| The Hollywood Issue | Spring 2009 |
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Tales Out of School The final gurney has crashed through the doors of Chicago’s County General Hospital. We’ll see no more zaps with the defibrillator, no more I was a fourth-year medical student planning on doing a residency in pediatrics at Children’s Hospital Boston when I received a script that Michael Crichton ’69 had written while a Harvard medical student. The document had lain buried in a file cabinet for nearly a quarter century until a member of Steven Spielberg’s production team rediscovered it. Spielberg, who remembered it fondly as a movie script he once considered directing, decided it would make a great television show. John Wells, a childhood friend of mine who had hired me to write an episode of China Beach before I had enrolled at HMS, was slated to produce the script. He sent it to me to find out whether it still reflected life in the emergency room. Crichton had indeed captured the essence of the drama of an ER. At any moment anyone can burst through the doors with any sort of calamity: a teen with a gunshot wound; a pregnant woman with a distressed fetus; a man with a pole plunged through his chest. I immediately called Wells and said, “This is my life!” Although we no longer used glass IV bottles or chloramphenicol, Crichton had gotten it right. So I left Boston for what I thought would be two months to break stories with the new team of writers on ER. Doctors as Storytellers I soon found that my experience at Harvard had prepared me for television writing in unexpected ways. During my student years the curriculum was the New Pathway, which emphasized problem-based analyses of real patient cases, the doctor–patient relationship, and the social context of medicine. To make a proper diagnosis, I learned to poke and prod for the narrative thread of a patient’s complaint and to examine that patient’s habits, history, and hopes. I learned to appreciate the complexity of the doctor–patient dynamic. And I learned to anticipate the thorny ethical issues that can arise suddenly to complicate treatment. Thinking about patients’ stories as unfolding narratives helped me become a better doctor. My search for the nuances in those stories made me more empathetic. And telling my patients’ stories—even by writing notes in their charts—helped me understand those patients more deeply. Refining my storytelling skills as a doctor also helped me improve as a writer—and provided me with stories to tell. In fact, many of the stories I wrote for television were inspired by the patients, medical students, and attendings I met at Harvard. I had arrived at Warner Bros. Studios in Burbank, California, armed with more than a hundred stories based on my life as a medical student—some humorous, some odd, others tragic. Those became the sources for ER episodes. I quickly learned, though, that they weren’t enough; we would burn through at least half a dozen stories each week. In one early episode, for example, Noah Wyle’s character, John Carter, was challenged by his attending to name the capital of what was then known as Zaire. He did and was allowed to join the surgeons at the operating table. But that wasn’t enough. The chief of surgery then quizzed him: “What are the borders of the Triangle of Calot?” And Carter replied, “Cystic duct, common duct, and the liver.” Impressed, the chief of surgery allowed Carter to hold the retractor. Both moments were rooted in the real-life experiences of classmates at Harvard’s teaching hospitals. In fact, a certain surgical attending at one of the Harvard-affiliated hospitals always asked that question. On the show, one of the attendings prepped Carter before he entered the OR, telling him to remember three things: cystic duct, common duct, and the liver. Carter didn’t understand the significance of her advice at the time, but he appreciated her coaching when it came in handy. Details like this one transformed the audience from mere viewers to insiders who shared the joke. Another show during ER’s first season provides details only someone trained as a doctor would know: When Carter performs his first lumbar puncture, the nurse tells him that his resident will give him a bottle of champagne if the tap is clear. Carter nervously inserts the needle; later, when the lab results come back, he is elated to learn that the tap had no red blood cells—and he gets his bottle of bubbly. Stories like these opened a window onto the culture of becoming a doctor and became integral to the show’s success. Before ER, staff writers of medical shows would use consultants to salt the scripts with occasional clinical details. ER changed that. Crichton’s training had helped him set the stage for a show that would take us into the lives of doctors as no show had done before. And executive producer John Wells decided the best way to realize that concept would be to employ real doctors as writers for the show—a television first, to my knowledge. It’s an approach I call anthropological television. To write the kinds of stories ER presented, to provide the cultural minutiae that go into making a physician, one would have to be an ethnographer living among medical students and doctors. Or one would simply need to be a doctor. Wells chose the latter. Not only was I one of the first two doctors to write on a television drama, but I was also the first—and likely the only—medical student. To help ensure the show’s veracity, we had emergency physicians working on the set of every episode; they taught the actors Noah Wyle and Eriq LaSalle how to suture by having them practice on chicken parts, pigs’ feet, and eventually prosthetic devices. The actors’ suturing skills eventually surpassed mine. This approach to scripting a television show not only gave viewers a fresh take on the world of medicine, but it also had lasting effects on other television shows. Today, few medical shows on television are without a doctor–writer on staff. House, MD is a wonderful example. My closest friend in medical school, David Foster ’95, is the show’s doctor–writer, the creative force behind those rare cases we loved learning about, but seldom saw, as medical students. But the trend toward enlisting the help of experts isn’t limited to medical dramas. CSI: Crime Scene Investigation and its offshoots have forensic experts writing on their shows, just as legal shows now employ lawyers. Audiences have learned to crave authenticity. Programming Notes It quickly became clear that viewers weren’t watching ER just for its entertainment value. During the two years I finished my last clerkships, I shuttled between coasts, in Boston when ER was on hiatus and in Los Angeles when the show was filming. It was while I was in Boston that I witnessed the strong effect ER was having on medical students. Thursday night viewing clubs had formed; medical students would gather to watch the show and test themselves by trying to make diagnoses before ER’s physicians could. The experience may have even influenced their career paths; studies show that applications to emergency medicine residency programs increased after ER came on the air. ER was popular with the public, too. One episode—in which Doug Ross, the dedicated yet emotionally flawed pediatrician played by George Clooney, saved a boy trapped in a storm drain—drew a 45 share, meaning that 45 percent of the television sets in use in the nation were tuned in to ER. Today’s top-rated American Idol draws numbers that pale in comparison. But people didn’t simply watch ER—they learned from it. For a Kaiser Family Foundation study published in Health Affairs in 2001, we surveyed a random sample of ER viewers about an upcoming episode on human papilloma virus and cervical cancer. Before the show aired, 9 percent of the study participants knew the virus caused cervical cancer; a week after the show aired, 28 percent could correctly state that relationship. Back then, 30 to 40 million viewers were watching ER, which translates into at least 8 million people learning about human papilloma virus—the first step toward prevention. The Health Affairs study also showed that about one in seven viewers had contacted a doctor or other health care provider about a health problem after seeing an episode of ER. The ER scriptwriters took the Health Affairs findings seriously. In fact, during the show’s infancy a New England Journal of Medicine article had taken us to task for showing unusually high rates of success in cardiopulmonary resuscitation. In reality, CPR works infrequently, and, when it succeeds, it’s often accompanied by serious sequelae. After that article was published, we tried to make the show as accurate as possible, although we continued to take dramatic license with the time it takes to get lab results. ER also educated viewers on social issues. We delved into many of the controversies surrounding medicine today: cost, privacy issues, access, the impact of new technologies. And we were the first prime-time television show to present a main character with HIV, Jeanie Boulet, portrayed by Gloria Reuben. Before ER, diagnoses of HIV infection were presented as death sentences; we showed that someone with the virus could lead a full life. My work on ER taught me how powerful doctors’ stories can be, how they move people to tears—and even to action. I’ve been lucky to be able to take personal stories that have challenged my way of thinking, angered me, or shaken me to my core and use them as inspiration for ER and for the show I now write and produce, Law & Order: Special Victims Unit. I’ve witnessed, for instance, too many children rushed to emergency rooms with gunshot wounds. My role as a writer has allowed me to transform this personal experience into a public story: I’ve written several episodes of ER and SVU about gun violence. I know such stories have had an impact, not only from the studies we’ve done, but also from the many times people have told me that a story from ER or SVU made them see the world differently or compelled them to consider another point of view. Live It, Write It, Share It All doctors have stories from our practice of medicine that we just can’t shake. But we don’t need to be television writers to bring those stories to the public. Outlets for storytelling are legion. We can write op-ed pieces, present on grand rounds, testify before legislatures, host blogs, teach, compose poetry. I have, in fact, turned to the Internet to share another story that has moved me deeply: the crisis of 15 to 20 million children orphaned by AIDS in Africa. With partners from Venice Arts, a nonprofit organization that introduces children to photography and filmmaking, I’ve visited Africa several times to teach photography to HIV-infected mothers in Cape Town, South Africa, and to AIDS orphans in Maputo, Mozambique. We post their photographs online so the women and children can share their stories with people worldwide. And we present this work to policymakers and to college students to stimulate action. I believe I have a responsibility as a physician to alert people to the orphans’ plight. But it isn’t my responsibility alone. And it isn’t my opportunity alone. Each of us has stories to tell. And when we share them, we can begin to change the world. Neal Baer ’96 has been executive producer of Law & Order: Special Victims Unit since 2000. Before that, he served as a staff writer and eventually executive producer of ER. To learn more about his photography project in Africa, The House Is Small but the Welcome Is Big, visit www.thehouseissmall.org. Photo caption: ER took a prime-time leap when Jeanie Boulet, a physician assistant on the show, tested positive for HIV. Like many real people who were then living with the virus, Boulet sought treatment privately, fearful of coworker reactions and career-ending workplace repercussions. Photo: Warner Bros. |
emergency tracheotomies, no more pace and pathos. After 15 years, ER, the television series set in that fictional hospital, has ended—and Thursday nights will never be the same for me.
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