 Dr. Williams is a physician, clinical medical ethicist, green writer and filmmaker. September served as part of the inaugural team opening the Tuskegee University National Center for Bioethics and Research in Healthcare. And she was the census first physician ethicist and communication specialist. Along with feature film scripts and shorter pieces, she is the writer, director of the medically based short film, shared decisions and the feature lens documentary, a conversation on moral intuition and when we were asked. And today, Dr. Williams is going to speak about, if I can find it, yes, transplant and prime time television. Thank you very much. Hi. I also need to learn how to use this equipment a little bit. And I'm going to do you the favor of turning my timer on. How many of the people here knew Dr. Mark Sloan? Dr. Mark Sloan passed a few weeks ago after having had a horrible car accident. He died in the hospital that he worked in, in the presence of his family and loved ones, with his attending physician having prepared the family for the removal of his ventilator because he was brain dead, and with arrangements being made for his organs to be actually donated there in his own hospital. So this talk is dedicated to Dr. Mark Sloan because in 1992, when I started studying film, there was no way that we would see that scenario on television as we did on Grey's Anatomy last month. So this is just to let you know that things can change in medicine. Things can change drastically, only in our dreams what we imagine that such a thing would happen. Different people will recognize different people that are here. I want you to think about the fact that television is very much like film, but it has a different means of production and a different means of distribution. As you know, there are a number of good books out about bioethics and film, none of which existed when I first started studying film and looking at the impact on bioethics. Stephen Tullman was very instrumental in making sure that I pursued this goal as a clinical bioethicist, but also as a creative person. Sandra Schapze's book is more philosophical. I love it and have reviewed it for the journal Bioethical Inquiry. The Picture of Health is a book that many people who are members or former fellows of this center have participated in. Irini Martinez has a chapter in it. Annette Dula has a chapter. I have a chapter in it. Ron Miller was very involved with the early parts of the organization of the book. And additionally, there are a beautiful, beautiful piece by Al Johnson, early in the book, looking at issues around Frankenstein. And that brings us back to where we are now. What I wanted to do here, and I can barely see this myself. I hope it looks better for you. What I wanted to do was to explain to you that I was driven to do this particular topic. Because in 2010, the Annenberg-Norman Lear Center for Hollywood Health and Society launched a campaign with the Screenwriters Guild of America, the Writers Guild of America, where they asked for additional storylines to be developed based on organ donation and transplant. Now, this is particularly significant because those of us who write know that it will never show up on the screen if you don't write it. And it probably won't show up on the screen even if you do write it, right? So it was a targeted intervention. And they did sessions for information called You Want a Piece of Me. And they had different people come and be involved. Neil Baer, who is a physician, pediatrician, screenwriter, and one of the all-time best showrunners in history, who was part of the initial, he was the voice of Carter in ER, was participating in this project and as a participant in Hollywood Health and Society. So they approached us to do this. And when I say us, I was there not as a bioethicist, but as a writer. And that is the point of this talk. It looked like 26% of the public has cited entertainment television as an important source for them, for health information. This information comes from a very nice study that was done called How Healthy is Primetime Television. It was done by Health and Society and by the Kaiser Foundation. And what's happened is that I use that as a model for looking at bioethics content in medical television dramas. It turns out that clinicians are often used as consultants in television programming. However, we are rarely, if you are a clinician who is a physician, you are rarely used as a bioethicist even if you are one. What buys you access as a consultant is not being a bioethicist, but you're tromping all over that. And there are very few bioethicist physicians who do that kind of consulting. The objectives of this talk are to consider the influence of television communication science methodology, screen grammar, and narrative on bioethics literacy in the general population. The question, it questions whether the number of episodes depicting organ transplant donation increased in quantity or bioethics quality after the initiation of the Annenberg Norman Lear Center Health, Hollywood Health and Society campaign. It also is an attempt to use the depiction of the informed consent process as it's consistent with the common rule, which people who are involved in transplant here will know that, and the general rules around scarce resource ethics as a proxy for bioethics content because you gotta have something to look and watch for on the screen. And also I wanted to look at and compare the number and quality of depictions of informed consent within the two years after the initiation of that, so before and after. So there are a couple of things that you still have to consider which is that TV is important. It's often a primary source. You have to understand that in the US, the work that was done by the Kaiser Foundation actually found that 61% of primetime television shows, the top 10 television shows over six years actually had health lines in them. There were storylines that dealt with health and 32% of those included strong educational content. Some was moderate, some was strong and that's by where it sat in the thematic stories of television. Six out of 10 episodes had at least one health storyline. Some episodes had more than one health storyline. So television shows, this is important, television shows targeting African American and Hispanic audiences are exposed to fewer health storylines than our viewers overall. So this is another area that may be affecting health disparities. So if you have a television show that is on TNT that is not supposed to be targeting a white audience but a black audience or a Spanish audience, there's gonna be less health storylines written into them. A couple of things about the medical TV genre. Medical TV genre is a very specific thing and when you're writing for it, it's very specific and it's kind of annoying because you wanna go off and do all kinds of interesting things and they won't let you. Basically, it's a subset of professional TV. It's primarily set in a clinical environment. So this is an important thing. It looks like a hospital. It looks like a clinical environment. We're all sitting in a room that doesn't look like that right now, right? We are all in a medical people but it doesn't look like that. It has to do typically with vocational things, surgery, procedures and new technology. The personal lives of medical professionals are very important and this is filling in a hole in patients' understandings about doctors. So everybody's got a doctor. That's their primary socialization with doctors. There's a secondary socialization that they don't have real access to but they think that they do because they see our private lives on television. Yet we see them naked all the time, right? Characters also navigate complex, often ambiguous ethical terrain and this is very seriously talked about in the writer's room. Which of these ethical terrains are going to be run through? You also need to know that the structure of a medical drama and all dramas on television, the one-hour structure has an A storyline, a B storyline and a C storyline. So anytime you watch a one-hour program, you will see these three structures that are there. In the A storyline, you see the most change or the most challenge for the main character of the storyline who is always a doctor or the major clinician. In the B storyline, a greater character but not the main character will be dealing with a lesser storyline and very often the transplant patient sneaks in at that point. And then the C storyline will be a storyline that may be a minor storyline that ends with that episode where it may be carried through and become a major storyline later on. And there's some examples of that. But in general, the structure of those storylines and the structure of those characters and the structure of the genre actually looks a lot like the Aristotelian plot curve that has to do with all narratives. And it's very like that because the Greek narratives were basically melodramas where people went to work through the emotional issues that they had to do that they wouldn't touch in real life, right? But they could go there except that the Greek dramas were two hours long and these are generally one hour long. You also need to understand that the Nielsen ratings are very, very important. They're important because the entire purpose of network television and to some extent to cable television, the entire purpose is to get advertising dollars in. So the higher your Nielsen ratings, the more likely you are going to actually get more advertising dollars in. But what this means is that the genre is shaped by the interest of the population of people who are watching it as demonstrated by their viewership of the first broadcast of the episode that they're looking at. So to shorten all of this stuff up, what you need to know is that a rating is easily converted into the number of people who saw the show and first broadcast. So when somebody gives a rating of, you know, 8.5, that means 8.5 million people saw that show. So if you want to talk about throw in terms of places that bioethicists might want to spend some time, that would be important. Now these ratings were originally done only to look at broadcast television. There is a new metric called the C3 metric which was launched in 2007 which begins to take into account ratings in relationship to the average commercial minute in live programming plus three days of digital recorder playback. How many people in this room have a device on their person or next to them that they can watch a television show on right now? Come on, come on, okay? You could watch an episode of Grey's Anatomies while I'm talking to you, right? During the session. So what I wanted you to understand is the medical TV drama has been around for a while and some people with different age groups in this room will recognize different medical TV shows. I want to point out a couple of them. Ben Casey, which started in 1961 was a very important show because it was sort of the first time where you got into a gritty hospital situation. Everybody wasn't all polished up at that point. The next one is Marcus Welby, okay? Which was for the very first time in history took a medical television show to the top of the mark in terms of ratings. Mash many people have seen and are still seeing. St. Elsewhere's was a very important show. The few things that I wanted to look at were a little bit different. Marcus Welby dealt with transplant by 1972. Mash dealt with transplant by 1979. St. Elsewhere's dealt with transplant by 1983. So these are episodes that were already there. What I did was I looked at a specific inclusion criteria that allowed me to look at shows as a well-informed bioethicist with a clinical background, with a screenwriting background. And it's a single observer looking at these shows for the content that had to do with informed consent being depicted on the screen or the actual words that are involved in that content being there. But I did want to look at shows before and after the intervention of the Annenberg Foundation. So it turned out, luckily, that there were actually only five shows that met that criteria in the time period that I was looking at. Otherwise, I would have been watching even more of them. So the specific depictions I were looking for in relationship to the common rule were that a patient's impending death was announced that potentially the hospital or a doctor was going to inform the local organ procurement organization that this was happening. The organization would subsequently go and get permission for the transplant because that's the way the bylaws of the hospitals that I have worked in are, that you speak to the person, but the actual consent is not taken by a physician and there are reasons for that that we can, in terms of coercion, and that the donation procedures have been explained properly to people. There are other things that I looked at too in terms of the ability to consider scarce resources, which are often described in the evaluation process, benefit, quality of life. If you're drinking, we're probably not gonna give you that organ so you need to commit to not doing that. Issues that had to do with urgency were often expressed very particularly. Everybody was into urgency. And I was particularly interested in the quality of informed consent around medical risk and around psychological risk. I really honed in on this idea of having a third party step in, like an organ procurement organization coordinator to do the informed consent because it's never hardly seen in my experience on television so I wanted to do a more global thing. The things that were magenta on the top are the things that were done better or more before the intervention and the things on the bottom are the things that seem to be, that's a small sample. We've got 38 shows that we're being looked at but there seems to be a trend there. You also need to realize that shows get canceled. House went out because house, even though it started with 19 million, 19 million viewers on its opening day, it's all time low was 8.69, it was approaching half of its viewership so that's when you get gotten rid of pretty much. There were 18 episodes of Grey's Anatomy because shows that deal with trauma centers in ER actually have more storylines that deal specifically with transplant as well as 13 episodes of a show called Three Rivers which you probably have never seen because it had one season but it was about transplant. It turns out, and then there were other shows. Hawthorne which is really about a nurse who acts as a peer with physicians because she's a department head which is what's always happening in the hospitals I've been in and also there were 13 episodes of private practice. I have the list of episodes if anybody wants them sort of tagged by organ and by theme so that if you want to use them for teaching you can do that. Finally, this is what I found that there are 38 prime, out of these 38 shows, about 52% broadcast before the intervention and 47 within two years after a percent afterwards. There was a quality of informed consent that was using these 17 observations that I had decided to use based on how they really fit into disclosure and the things that we know. It's one of those things where a clinical ethicist knows it when they see it. You know when you see the proper informed consent pieces there and depict it. Whether it's a medical student doing it or you're doing it yourself. What I found was that really that before the intervention about 24% of the parameters were met in the shows and after the intervention it looked like about 58.9% of them were met. So the intervention counted which is not a big surprise because in the rest of the world people are using television radio narrative to do public health and other things around these things and there are narratives that are not public service announcements primarily. So this is a very general thing. So I think the informed consent bioethics parameter improved despite the presence of bioethicists by actually having people look deeper into the issues and information surrounding transplant when they were writing storylines. It doesn't keep the shows in the air however. So what I want you to know is that more than 80% of medical students actually when they're surveyed and nursing students watch medical television dramas. So it's important that you have a sense of how people do that and what they think about these things. And I also want you to know that the five shows that I reviewed have an average combined viewership of nine million people per episode at the time of the original broadcast. So on the day of the original broadcast that's what it comes out to. So those who are not involved in whether or not people watch TV and I have to say that Mark had as much to do with my interest in this work as Steven Thulman did because Mark didn't watch a lot of TV back in the day. He was good with films. But I think this is an important area. The question that I've been asked is what would I do with this? Well I have to thank the people at the Annenberg Foundation and the Norman Lear Center for helping me to understand how they figured out the health themes before and encouraging me to go ahead and have a look at some of this stuff so that I can now take it back to them and say, hey, I think we need some bioethicist on your list so that you can do this better and we can all do it better. So thanks.