| The Hollywood Issue | Spring 2009 |
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Special Effects Several years ago, my husband and I were eating breakfast with our friend Rob LaZebnik, a Hollywood scriptwriter, when my husband asked Rob whether he was working on a new pilot. Rob blushed. “I’ve been meaning to ask you two…” he said. “Well, if this is in any way disturbing…I want to write a doctor show whose lead character is based on Alice. You know, a hypergraphic neurologist at a Boston teaching hospital who’s a bit crazy. Kind of House meets Ally McBeal.” My first thought was, Oh no, poor Rob, what a bad idea. It’s true what he said the other day, that comedy writers over 40 are dog meat. My second thought was, A TV show all about me? Whee! My husband’s first and second reactions were identical: dismay. My eagerness trumped my husband’s wisdom, and I soon found myself helping with the script, inventing neurological cases for the brilliant protagonist to solve. I also tried to cut down on unnecessary medical jargon that crept into the dialogue, such as not saying “upper extremity” when “arm’ would do. Rob resisted my editing. “People love the jargon,” he said. “That’s the lesson Hollywood learned from ER.” I later realized that the actors liked using the jargon for the same reason medical students do: it makes them sound like real doctors. Rob had warned me that most pitches never turn into scripts, most scripts are never sold, and most purchased scripts are never filmed. So I was surprised to find myself having to ask my department chair, during my yearly review, to hold her thought; my agent and my entertainment lawyer were on the line to discuss how much to ask for the rights to my life story. During the process of casting “me,” the producers reviewed dozens of audition tapes. One woman both looked and acted remarkably like a neurologist—remarkably like me, in fact, in a suitably dry performance. I was relieved when the casting agents chose someone less authentic. Several colleagues have asked me whether it felt degrading to be played by a tall blonde with legs from here to tomorrow. Maybe if I hadn’t been so lucky with this particular actress, Ever Carradine, it would have been. Instead, I learned from her. At first I learned how to act like a good doctor; in the end, I learned how to be a better one. Charm School The Madness of Jane featured the fictional Jane Conway, a quirky neurologist who festooned her office with Post-It notes, built odd contraptions to help her patients, and diagnosed rare diseases based on only a few symptoms. The show was neither a soap opera nor a sitcom, but a serious exploration of the personal foibles of doctors. Ever, a member of the Carradine acting dynasty, brought special insight to the role. Not only are her in-laws doctors, but a family member’s serious illness had recently exposed her to a range of doctors’ performances. Before I met Ever, Rob called with a warning. “I don’t want to freak you out,” he said, “but Ever’s been cyberstalking you, watching clips of documentaries where you were a talking head, to pick up your mannerisms.” That was bad. What if she succeeded and turned herself into an authentically wooden neurologist? Luckily, she merely grafted some of my more harmless traits, like toe walking, onto her own set of more expressive behaviors. Ironically, I had already been trying to incorporate Ever’s mannerisms into my encounters with patients. In her audition tape, to convey therapeutic concern, she had used gestures more fluent than any I had in my own repertoire. Her smile when a treatment worked, for instance, looked pleased for the patient, not just pleased at her professional skill. I began to try it out on the wards, with good effect. Life imitating art imitating life. During the filming, my role resembled that of a neurology attending: I showed “residents” how to hold their brain stimulators properly, and I corrected their jargon. (“ ‘Subthalamic,’ not ‘subthalamic,’ darling.”) Life-and-death decisions, though, were left to the director. Life and art blurred further in that the filming took place in a real hospital that turned artificial each weekend: a Veterans Administration outpatient center that emptied itself out to rent to dozens of medical shows. When I saw extras sitting in the clinic waiting room for their next scene, I kept mistaking them for real patients. Oh, poor woman, I thought when I spied one middle-aged woman in a bad wig, she must be getting chemo. An instant later, I remembered, Duh. She’s an extra. Another instant later, noticing that the other extras’ wigs were skillful enough to look real, I realized that her bad wig was intentional—she was meant to look like a woman with a bad chemo wig. Art imitating art imitating life. In the pilot’s main medical plot, a Vermont maple sugar farmer’s brain stimulator was reset after he was shocked while trying to dive under an electrified fence on his farm. A typically unrealistic Hollywood storyline, except that it had really happened to one of my patients. The television version ended up less bizarre than the true version. What was sobering about the show was not the ways in which it was less than real, but the ways in which it was more than real. In particular, the actors playing doctors had notably better bedside manners than many real doctors. They made eye contact with their patients, spoke at a comfortable pace, and, when the patients complained of pain, focused on the complaint rather than changing the subject. Also revealing was the director’s custom of shooting important scenes as many as twenty times in a row. While some of the actors duplicated their lines and gestures as accurately as automatons for each take, the better actors tried something new each time. I thought about my own limited repertoire. During initial patient visits, for example, I made the same joke every time I pulled out my reflex hammer; my flexibility extended only so far as to ensure I never repeated that joke on follow-up visits. Get Your Act Together The good actors’ ability to modify their behavior contrasted sharply with an event on my neurological service that happened soon after the show’s pilot was shot. One of my senior residents was giving a death talk to the family of an elderly woman with multiorgan failure. The family members were dramatically upset. Earlier, when we had told them that the woman’s prognosis was poor, one daughter had fainted and another had begun dry retching over a trash can. The resident’s obvious discomfort was natural, but it wasn’t helping. He folded his arms tightly and drummed his fingers against his chest as he gazed over the family members’ heads toward the door. The daughters asked more insistently whether we had done all we could—a natural response to a doctor who was signaling that all he wanted was to be done with them. Finally I couldn’t resist his signals either, and I sent him off on an errand. He shot out the door, and the family members relaxed almost immediately. They were not, fundamentally, upset with us. They were just upset. Afterward I discussed the room’s heightened drama with the resident. I suggested, in what I hoped was in a non-confrontational way, that in future situations he might avoid crossing his arms and drumming his fingers. He seemed to find my advice reasonable, but added, “I could never do that. When I’m nervous, I cross my arms.” I showed him a simple alternative, sitting with his palms held loosely open on the table. That gesture, the universal human “Look! No weapons!” signal of non-aggression, works as well when dealing with angry patients as it does with your boss. “Oh, I wouldn’t feel comfortable doing that!” he said. “I have to cross my arms.” Mirror, Mirror In medical school, doctor–patient courses that teach the art of medicine often use the literary arts as a model. Lecturers hope that by assigning, say, Tolstoy’s short story “The Death of Ivan Ilyich,” they can teach students to read a patient like a book. Perceptiveness doesn’t inevitably lead to altruistic action, though. Indeed, feeling a patient’s suffering too much can make an empathic person want to flee rather than to stay and help. And even the most polished phrases of compassion lose their power when a doctor recites them rapidly while gazing at a computer screen. Instead, the true art of medicine is more dramatic than literary, as the disproportionate number of doctor shows suggests. Real medicine’s use of ritualized lines and gestures, operating theaters, and costumes—the scrubs and the johnnies—are much more than conventions. Their dramatic symbolism can give doctor–patient contact an emotional meaning that transcends the notion of cure. Their ceremonial quality, by shaping the patient’s expectations, can even be part of that cure. Doctors don’t like to think of medicine as theater, though. Drama’s status as a low art, overly emotional and deceptive, can discomfort the academic psychiatrists who tend to teach the bedside-manner courses. Quoting dialogue from an episode of House, MD doesn’t produce the same air of gravitas as quoting passages from a Walker Percy novel. A major force that keeps doctors from acting well is that we like to think we are above acting. Historically, as academic medicine became a scientific pursuit and doctors wanted to distinguish themselves from the quacks who cured with their flamboyant bedside manner alone, physicians in the academies adopted an undramatic aloofness that has persisted to this day. When medical ethicists talk about deficits in bedside manner, they often present them as manifestations of the pressures on doctors’ time or of the pain that an empathic bond with a patient can inflict. But we sometimes choose to act brusquely because that’s how brilliant, scientifically driven diagnosticians are supposed to act. Subconsciously, many of us believe that empathy is the nurses’ job, or we save it for terminal patients for whom we have nothing more potent. Yet science can now demonstrate the benefits that warmer doctor–patient interactions can bring. The placebo effect that can be achieved, for instance, when doctors’ behavior makes patients expect to get better, is nearly as helpful as the workings of many of the most expensive drugs. Sympathetic human interaction produces real changes in the subcortical regions of adult brains and causes permanent changes in the DNA transcription of children. Television medical dramas, despite their often soapy quality, have real-world relevance: They reflect and shape how patients play the sick role and how they expect doctors to behave. An episode of ER, for example, stressed the role of physicians as patient advocates when surgeon Peter Benton fought a colleague over the importance of following a safe surgery checklist; his insistence on using it ended up saving his one-time protégé John Carter from kidney failure. Teaching students the art of medicine as drama has another problem besides our fear of the theatrical as false. Acting skills are difficult to teach. Performance gives introverted premeds stage fright, whereas literary contemplation of another’s suffering can be done in the privacy of one’s own head. Neither working doctors nor trainees receive much visual exposure to good role models of empathic action. Feedback about behavior is even rarer and generally comes long after the patient has left the room. The actors on Rob’s show, unlike my residents, received immediate feedback after each shoot. The director would call out advice such as, “Too weepy! This isn’t Beaches.” After the next take, “Too dry! Too Helen Mirren in The Queen.” Or: “Hey! We’re not doing Flatliners here.” The Science of the Art Recently, though, actors have been giving medical students feedback about how to become better doctors. The Objective Structured Clinical Examinations, or OSCEs, use actors as standardized patients to help assess the clinical performances of fourth-year medical students. These tools are popular with both students and faculty. By presenting communication skills as concrete abilities that can be tested, these exams make even the most hard-nosed students take bedside manner more seriously than doctor–patient courses—with their emphasis on emotional exchanges between doctors and patients—have done. And the actors, many of whom have by now observed hundreds of students, are perceptive in their feedback. In the hierarchical world of medicine, though, students focus more on what faculty examiners say. The “patient’s” words are given about the same weight as the opinions of real patients. The emphasis of these exams is not on training but on testing students’ abilities. And they occur only a few times a year, as actors are expensive. Less cumbersome help with the art of acting well may come from unexpected sources, the very forces that bedside manner is traditionally meant to combat—science and technology. The explosion of social neuroscience research is starting to provide a bottom-up approach to playing doctor that complements art’s top-down one. Studies of the facial expressions of emotions have turned the ability to produce a smile that looks real rather than ingratiating from an art to a science. (It’s all about activation of the orbicularis oculi. Social smiles involve only the mouth; emotional ones crinkle the eyes as well.) Medical education has made increasing use of high-tech simulations to teach skills learned best by performance, such as putting in central lines. The logical next step would be to construct multimodal simulations of human interaction that will allow students to learn how not to hurt patients’ feelings by a technique other than learning from their mistakes. Human-interaction simulators are already in use with populations that range from Asperger’s patients who need to understand how their disquisitions affect their listeners, to police officers who want to detect lying, to shy people who wish to speak more comfortably in public. The simulations that Asperger’s patients use allow concentrated practice and feedback. Likewise, doctors could learn to reinforce such basic communication skills as maintaining eye contact, pausing to allow patients to ask questions, and avoiding jargon. Medical students are eager to use clinical simulators. Doctors, however, are not. They don’t want to take time away from their real patients to play doctor to fake ones. And now they may not need to: Recent developments allow the rapid feedback about performance that simulations can provide—but in the real world, without slowing actual clinical encounters The MIT Media Lab has developed a number of such devices. One is a beeper-sized box called the Monologue Monitor that analyzes the wearer’s speech patterns. Speakers who drone on without interruption get a discreet zap from their monitor, prompting them to pause so their listener can respond. Another device analyzes the listener’s face for signs of puzzlement or negative emotion and signals any such sign to the speaker. It’s tempting to think that while these machines may help awkward computer scientists, they have nothing to offer socially sophisticated physicians. Surely we can recognize boredom when it stares us in the face. Perhaps that’s true—but many of us have learned not to look. While rapid behavioral feedback devices lack the subtlety of literary analysis, the empathic errors that we doctors make are often equally unsubtle ones of haste and habit. A number of studies show that doctors lose rather than gain empathic sensitivity during their training. In one study, for example, researchers used functional MRI to show that after two years of training, doctors had lost the activation in brain empathy areas that was seen in the healthy controls. Their medical education had helped them achieve dispassionate brain activity similar to that seen in people with Asperger’s. Prompt, Please Our adventure with the TV pilot had a happy ending, if not quite a Hollywood ending. As Rob had predicted, the pilot wasn’t picked up. He returned to his job on The Simpsons, where he makes ten times more money than he would have made from the new show. Ever has a job with another TV series, filmed in Boston. And I was saved from the temptation of turning my office into the equivalent of the “real” Cheers bar, where I would have likely sold reflex hammers that played the show’s theme song whenever you rapped someone’s knee with them. I kept my job and perhaps gained some wisdom. How much wiser am I? I learned a little about the art of acting well—and about the reasons doctors often choose not to behave artfully. Hollywood also taught me that medical shows can’t teach doctors everything they need to know about acting well. Those shows are, after all, trying to model themselves on the worst of our manners as well as the best—as the protagonist of House demonstrates so vividly. Science itself may soon help us improve the art of medicine. Advances in behavioral therapies are starting to help people with Asperger’s interact with others more effectively; perhaps they can help doctors do so as well. In learning to help those who struggle with how to feel and act, we may end up learning how to heal ourselves. Alice Flaherty ’94, PhD, is an HMS assistant professor of neurology at Massachusetts General Hospital. Photo caption: The life of neurologist Alice Flaherty formed the basis for a proposed television series, The Madness of Jane. Ever Carradine (far right) was cast in the lead role. Also pictured are, from left, Erick Avari, Jeff Bryan Davis, and Brittany Ishibashi. Photo: Courtesy of Lifetime Television |
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