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Michael M. O'Connor
University of Washington School of Medicine

JAMA. 1998;280:854-855.

On Thursday evenings countless medical students nationwide set aside their course notes to watch the latest episode of ER, the popular NBC television drama that chronicles the lives of fictional emergency department personnel at a Chicago teaching hospital. The program's frantic style blends medical terminology with theatrical scenarios as upbeat background music and shifting camera angles mesmerize viewers. Unquestionably more intense than a textbook, ER captivates medical students with its synthesis of medical realism and modern-day drama. This brainchild of Harvard Medical School graduate Michael Crichton certainly entertains viewers, but one could contend that students are actually studying—albeit not in the traditional, didactic manner.

Medical education has been described as a process of socialization in which students are taught to acquire the beliefs and behaviors that will identify them as physicians.¹ Likewise, television has also been described as a medium that molds viewers' attitudes and behaviors, thereby shaping their social identity.² Medical students' reactions to televised medical dramas like ER suggest that they may incorporate the attitudes and beliefs of physicians on television in much the same way they acquire the qualities and behaviors of physicians through their experiences in patient care.

ER uniquely contributes to the genre of medical dramas that spans decades: Ben Casey and Dr Kildare in the 1960s, Marcus Welby, MD, and M*A*S*H in the 1970s, and St Elsewhere and Trapper John, MD, in the 1980s.³ The hospital scenes in ER occur on an elaborately realistic set where the medical team encounters emergency medicine cases ranging from drug overdoses and rape victims to motor vehicle crashes and gunshot wounds. The 1997 season premiere went so far as to present the show as if it were a medical documentary.

The cast of ER physicians includes, among others, Mark Greene, the cynical emergency medicine attending physician; Kerry Weaver, the utilitarian emergency medicine attending physician; Peter Benton, the taciturn senior resident in surgery; Doug Ross, the soft-spoken pediatric emergency fellow; and John Carter, the enthusiastic emergency medicine resident. Goggles, latex gloves, white coats, and surgical scrubs are the modern armor for these heroes battling in the trenches of televised medicine.

Given its tendency to glamorize the work of emergency department physicians, ER has the potential to bias students' career choices. Wallack and Bingle note a 2-fold increase in the number of fourth-year medical students at Indiana University enrolling in emergency medicine residency programs since 1994, the year ofER' s premiere.⁴ Nationally, applicants to emergency medicine residency programs have increased from 4% of total US senior students entering the resident match in 1994 to 5.2% in 1997.^5-6 While ER is obviously not the only factor influencing students' career choices, the program does shape the cultural image of emergency medicine physicians, perhaps creating a more appealing career path for the undecided medical student.

ER participates in expanding students' knowledge of clinical medicine by presenting a wealth of medical jargon and patient scenarios each week. Students update their medical vocabulary as they recognize the acronyms, drug names, and diagnoses being tossed around the fictional emergency room. Moreover, the characters on the show obtain patient histories, deliver tragic news to patients, and dispute the opinions of coworkers. Especially for medical students in their preclinical years, the televised physicians of ER may offer students their most vivid glimpse into the practice of medicine. Interestingly, the total time that a student could spend watching weekly episodes of ER over 4 years rivals the duration of a typical emergency medicine rotation at most schools.

Of course, a television drama has its limitations as a clinical teaching tool. ER uses physicians as writers and consultants in an attempt to reflect the actual practice of medicine, but some critics identify ER as a source of medical misinformation. Diem and colleagues and Markert and Saklayen^7-8 describe the disparity between cardiopulmonary resuscitation (CPR) long-term survival rates (67%) in the television programs ER, Chicago Hope, and Rescue 911 and actual CPR survival rates (14.7%) in the medical literature. The writer and producer of ER, Neal Baer, MD, acknowledges that while efforts are made to depict accurate and credible medical care, the show's dramatic foundation is primary.⁹

Superceding the show's educational role is its ability to shape medical students' perceptions of appropriate physician behavior. The ER characters may be mirrors for students wherein they validate desirable qualities, such as compassion, and also exhibit less appealing traits, such as competitiveness. Depictions of the controlling attending, arrogant surgeon, or blundering medical student are often realized on ER, forcing students to confront their own preconceptions of their profession. Some students may embrace these stereotypical portrayals wholeheartedly, whereas others may use them as points of reflection in forming a professional identity. The program ultimately exposes students to qualities that either reinforce or contradict the influence of real life physicians.

The popularity of ER among students raises interesting questions about the role of the media in shaping aspiring doctors' perceptions about their chosen profession. Does the show cultivate the development of spurious attitudes toward various medical specialties? Do ER physicians set the contemporary standard for the ideal physician? Although most will agree that ER provides a captivating escape from one's studies, a latent socialization force may also operate in tandem with its entertaining storylines. More importantly, the phenomenon of ER forces students to think carefully about the distinction between fantasy and reality in the construction of physicians' professional identity. If medicine lends itself so readily to television fiction, it is perhaps because the medical profession itself is built on social fictions surrounding the authority and functions of doctors.

REFERENCES
1. Baszanger I. Professional socialization and social control: from medical students to general practitioners. Soc Sci Med. 1985;20:133-143. FULL TEXT | WEB OF SCIENCE | PUBMED 2. Felson RB. Mass media effects on violent behavior. Annu Rev Sociol. 1996;22:103-128. FULL TEXT | WEB OF SCIENCE 3. Turow J. Playing Doctor. New York, NY: Oxford University Press; 1989. 4. Wallack EM, Bingle GJ. Cardiopulmonary resuscitation on television [letter]. N Engl J Med. 1996;335:1606. WEB OF SCIENCE | PUBMED 5. Randlett RR. Results of the National Resident Matching Program for 1994. Acad Med. 1994;69:508-510. WEB OF SCIENCE | PUBMED 6. Beran RL, Creighton KP. Results of the National Resident Matching Program for 1997. Acad Med. 1997;72:560-562. WEB OF SCIENCE | PUBMED 7. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television: miracles and misinformation. N Engl J Med. 1996;334:1578-1582. FREE FULL TEXT 8. Markert RJ, Saklayen, MG. Cardiopulmonary resuscitation on television [letter]. N Engl J Med. 1996;335:1605. FREE FULL TEXT 9. Baer NA. Cardiopulmonary resuscitation on television: exaggerations and accusations [editorial]. N Engl J Med. 1996;334:1604-1605. FREE FULL TEXT

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