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SCRIPTDOCTOR: MEDICINE IN THE MEDIA Fact-checking Fiction

By Andrew Holtz, MPH tice medicine. But then he became a Andrew Holtz, MPH, is a former CNN Medical Correspondent full-time writer on the staff of House. young doctor and an older and the author of “The Medical Science of House, M.D.” This He also sits in on the filming of many of man step through the buzzing column examines mass media programs, particularly the medical scenes, but it is a nurse activity of a hospital emer- entertainment TV, for insight into popular perceptions, so that who has the lead role in monitoring A gency department. The older rather than merely wincing at distortions or accuracy on the House set. man sits on the edge of an empty bed oversimplifications in the portrayals of medicine on these “She is the one who is there for all and the doctor pulls up a chair. The shows, health care professionals can learn something from the medical scenes. She makes sure doctor quizzes his patient, trying to media professionals about the way that medical and health they are holding the scalpel correctly, figure out why he had a bad reaction topics are presented. or a patient is draped correctly, or peo- to his medication. It turns out the man Send questions to him about how the media treat ple are wearing gowns when they had switched drugs on his own, using medical topics or suggestions for future columns about a should be wearing gowns, or that when some leftover pills from a friend. they are in x-ray that they are wearing particular show or topic to discuss to [email protected] Taken aback, the doctor asks the man protective lead aprons, that type of why he would risk his health by taking thing,” Dr. Foster said. someone else’s medicine. It’s ironic that a nurse is the prima- “I’ve got no insurance. You know This isn’t an ER; it’s the set of ER, see that the right equipment is used at ry on-set medical adviser for House. The how much these drugs cost?” the elder statesman of primetime med- the right time in the right way. Having show has been criticized by nurses for Then they get up and do it again. ical dramas. Each movement, each an on-set medical adviser is one of the often portraying them as little more And again. word of the “doctor” and his “patient” ways medical shows work to assure than housekeepers and rarely showing are scripted by writers, and then played accuracy. nurses providing direct medical care. out in from of the cameras and crew At ER, MDs have always been in In each scene, it is not only the squeezed between the ER beds and the mix. One of the first writers was actions and words of the actors that Having an on-set medical nurses station. But just behind the cam- Neal Baer, MD, who eventually rose to must be checked for medical accuracy; adviser is one of the era, alongside the director, there’s a become an executive producer of the bedside monitors, screens, x-rays, and chair for someone who wouldn’t be on show. Dr. Baer introduced other physi- other images added to the visual flavor ways medical shows work the sets of most other TV shows. cians to Hollywood, including his med- of a show can also introduce errors. The occupant of that chair is an ical school friend David Foster, MD. If the actors are talking about a sus- to assure accuracy. MD. He is listening to the pronuncia- Dr. Foster worked with ER and picious mass on a lobe of a patient’s tion of medical jargon and watching to other shows, while continuing to prac- lung, then the image they are huddled

“I would argue that we need to ized: “For now, in fit patients, most of NSCLC exercise some degree of caution. There us would recommend cisplatinum- continued from page 51 are several inconvenient truths regard- based doublets. Despite a median age The next Intergroup trial ing CALGB 9633. The three-year dis- of 59 to 62 in trials, older patients often in early-stage NSCLC who constituted a very small minority ease-free survival still favors adjuvant benefit. Preoperative adjuvant chemo- of enrollees, the data are far shakier, Dr. treatment, as does three-year overall therapy is still being investigated,” he (ECOG 1505 study) will Langer said. survival. There is a nine percent abso- said. “As of 2006, we have observed a lute difference in recurrence and death The next Intergroup trial (the take bevacizumab, which clear-cut benefit for adjuvant cisplatin- rates. Median follow-up is still under Eastern Cooperative Oncology Group has shown a benefit in based therapy, particularly in Stage II five years, and I would argue, too, that 1505 study) in early-stage NSCLC will and Stage III NSCLC. In one primary this is probably the second premature take bevacizumab, which has shown a advanced disease, and trial—CALGB 9633—devoted to Stage reporting of this trial. While 150 deaths benefit in advanced disease, and look at IB NSCLC and in subset analyses of were needed for analysis, only 131 that in combination with chemotherapy look at that in combination other, larger trials that included Stage deaths have occurred.” versus chemotherapy alone, he said. with chemotherapy versus IB as well as earlier stages, the evidence Carboplatin-based therapies do for benefit in Stage IB NSCLC is not offer advantages, though, he said: “The ‘Premature to Criticize Trials chemotherapy alone. compelling. This general reservation is best results obtained in Stage IB have of Carboplatin amplified by the LACE meta-analysis. been attained with carboplatin-paclitax- “Under these circumstances, it may el, not cisplatin. The subset analysis in Asked for his opinion, A. Philippe “The results are underpowered because be necessary to repeat controlled, ran- four-cm tumors still demonstrates a Chahinian, MD, Professor of Medical there were only 170 patients per arm, domized trials in Stage IB NSCLC com- survival benefit. This has not been test- Oncology at Mount Sinai School of which is well below expected because paring standard chemotherapy to ed in Stage IIB-III in the adjuvant set- Medicine in New York City, said, “I early results were positive. observation. Finally, advanced age is ting, so the absence of data does not agree that carboplatin in not dead. It is “The differences in disease-free not an impediment to standard adju- prove absence of benefit. And finally, a premature to criticize trials of carbo- survival were very large. The three- vant therapy in fit individuals.” substantial percentage of adjuvant platin. year survival is still significant. More patients are poor candidates for cis- “If you look at Stage IIIB or IV dis- importantly, for the largest tumors, Some Dismiss Role of platin-based therapy because of age ease, carboplatin does as well as cis- there was a significant favor in overall Adjuvant Carboplatin and various comorbidities.” platin, or the difference is extremely survival in the paclitaxel group.” Clinically, statistically significant small. Based on results in advanced CALGB is still a positive trial, he “A lot of my colleagues have taken overall survival benefits have been stages of disease, carboplatin is not said, and deserves to be confirmed with great delight in looking at these data observed with platinum doublets in inferior to cisplatin.” an appropriately powered trial with and dismissing the role of carboplatin Stage II-IIIA disease overall in three to The CALGB trial is important larger numbers of patients and com- in the adjuvant setting,” Dr. Langer four cycles, he said, noting that Stage IB because it was specifically designed for pared with cisplatin and vinorelbine in O said. treatment still needs to be individual- Stage IB disease, Dr. Chahinian said. an adjuvant setting. T PAGE 53 / JANUARY 25, 2007

around better have a shadow in that Zwerling’s professional experiences “Hollywood, Health & Society” both patients receive kidneys. The writ- area, or viewer complaints are sure to and reading, including 20 or so medical (HH&S) Program at the Norman Lear ers wanted to explore a conflict be- follow. These medical images usually journals each month, but also stories Center at the USC Annenberg School tween two physician characters on the come from real patients, with any iden- gleaned from focus groups and panels for Communication in Los Angeles. show about some of the ethical chal- tifying information stripped off or of physicians and patients, and material The program was created by the lenges that might arise with such organ altered. culled from newspapers, magazines, Centers for Disease Control and Pre- donation match-making. “There are a number of places that and elsewhere by a full-time researcher. vention and is now also funded by the “To really get all the lowdown on provide de-identified x-rays and other National Cancer Institute and other fed- paired organ exchange programs, images,” Dr. Foster says. “For the gen- Hollywood, Health & Society eral health agencies. HH&S put [Dr. Zwerling] in touch with eral things, say you need a chest x-ray, Program at USC ER called on HH&S after reading Dr. Jim Burdick, who is the head of the there a number of prop houses in Los about paired kidney exchange pro- Johns Hopkins paired exchange pro- Angeles that have that sort of thing; a When writers at ER and other medical grams, for example. In these programs, gram,” Dr. Sachs says. normal head CT scan or something like shows need a specific medical question a patient who has a willing donor who Over the past year, HH&S has that. When we are looking for some- answered, they’ll turn to specialists, is not a match is connected with an responded to more than 200 inquiries thing particular, say an angiogram of including those suggested by the appropriate patient-donor pair, so that (continued on page 54) an aorta that’s not quite so common, we will often go to medical centers and ask their department of radiology if they have that type of image that they could provide for us.” Neal Baer, who helped lead Dr. Foster from the exam room to the writ- ers’ room, is now executive producer of Law & Order: Special Victims Unit. But his departure from ER did not leave that show doctor-less. Emergency med- icine specialist , MD, has been involved with the show for over a decade. Pediatrician , MD, has been writing for ER for four years.

“Human drama is the point of all the steps taken by entertainment TV shows to ensure medical accuracy. When it’s done right, then the story rings true.”

“Joe Sachs and I still do shifts,” Dr. Zwerling says. “And so sometimes we will have a story that is really moving to us. We will change all the details so that the real-life person would never identify themselves on screen. Also, we have colleagues who will call us up and give us a great story.” Those colleagues include two med- ical consultants who are full-time emer- gency medicine physicians. Dr. Sachs says the non-MD writers lean on them for stories that are not only medically accurate, but support their primary objective: telling good stories. For example, when one of the primary characters on ER, Dr. , played by Maura Tierney, returns from maternity leave, she is nervous about her ability to jump back into emergency medicine. “So that is when the medical assignment comes in: What is some- thing truly amazing and incredible that Abby can do on her first day back, that you’ve never seen before on ER after 13 seasons! So that’s when everybody looks at me and says, ‘OK, what’s Abby gonna do?’ At that point, I have to go to the well of our medical database,” Dr. Sachs says. The well includes his and Dr. PAGE 54 / JANUARY 25, 2007

ScriptDoctor tain viewers. A visit to the ER writers’ “real” J.D. by the writers, who depend continued from page 53 room will be featured in a future col- on him to fill the medical blanks in their umn. scripts. “A nurse is the primary “HH&S briefings are one of a hun- Early in the series, which is now in on-set medical adviser for from TV writers and researchers at nine dred ways that we stock our pond,” Dr. its sixth season, the writers often just broadcast and cable networks. And Sachs says. left placeholders in their scripts like House—rather ironic they’ve connected the staff at those “medical jargon here.” since the show has been entertainment programs to about 150 Medical Comedies “Now we are a little bit better experts at the CDC, NCI, and other about calling J.D. as we are writing our criticized by nurses for agencies, medical centers, and organi- Even primetime comedies that milk scripts, and saying, ‘OK, I’ve got this zations. hospitals for laughs employ physicians. guy, and I need to have a disease where often portraying them HH&S also makes house calls, Indeed, at the popular series Scrubs, the he would be really, really sick and he meeting with writers and producers to lead character is not the only named might die, but he’s not going to die, and as little more than introduce health topics and new infor- J.D. Dr. John Doris, a fraternity brother it’s got to be in his liver area, because housekeepers and rarely mation that may both inform and enter- of the show’s creator, is known as the we don’t want his face to look bad, and showing nurses providing direct medical care. The nurse is there for all the medical scenes, monitoring such things as making sure that scalpels are held correctly, or a patient is draped correctly, or people are wearing gowns when they should be wearing gowns, or that when they are in x-ray that they are wearing protective lead aprons.”

he’s got to be able to tell a joke once in a while. Now what would that be?’” says supervising producer Janae Bakken. Bakken says that in order to learn about medical reality before spinning their humorous yarns, the show’s writ- ers are required to read books about medicine, including the wrenching por- trayal of medical school in the 1970s, The House of God by Samuel Shem. And before each season, each writer has to interview at least three doctors. A Scrubs episode recently honored with a Sentinel for Health award by the HH&S program grew out of a TV docu- mentary program on partial liver trans- plants that a writer had seen.

‘They Call Me Mellow Yellow’

“They call me Mellow Yellow,” were the first words said, or rather sung, by the patient with hepatitis in that episode, titled “My Chopped Liver.” The show explored the human drama and comedy to be found in a story of a brother giving part of his liver to his deathly ill sibling. As the story was told, the recipient recovered nicely, but the donor was hit with life-threatening complications. Meanwhile, the show’s main character, J.D., was dealing with his own ques- tions about altruism. “How can you do an episode about giving part of yourself to a friend?” was the task Bakken says the writers faced. “And then you parallel that personal (continued on page 55) PAGE 55 / JANUARY 25, 2007

Stabilizing Bone after Vertebral Fracture Leaves Room for Meds

By Robert H. Carlson ing concern are the timing of kypho- plasty and bisphosphonate-generated AN ANTONIO, TX—Verte- “Patient pain is related to the tumor and the bone brittleness. broplasty and kyphoplasty pre- mechanical instability, and radiation will not address And so far the technique does not sent a great opportunity for appear to be appropriate for solid S oncologists treating cancer- those—you want to reestablish stability. On the tumors. related vertebral pain because treat- “Those are troublesome—that has ment medication can be added to the other hand, reestablishing stability without controlling yet to be worked out,” Dr. Lane said. cement. the tumor is of no advantage either—that’s why we’re “With a liquid tumor, the balloon can That add-on benefit might not have displace the tumor and fit into it, occurred to those who originated the looking for some sort of combination approach so whereas a solid tumor would work as a procedures, but it does make sense, barrier for the balloon.” said a speaker here at the International we can control the tumor as well as regain the He said the surgeon could “power Meeting on Cancer Induced Bone stability for the vertebral body.” past” the solid tumor and get support Disease. for the vertebral body, but that would “Nobody said what to put in the not displace the tumor very well. cement,” said Joseph M. Lane, MD, Professor of Surgery at the Hospital for inject cement directly into a myeloma kyphoplasty in the 1990s. Vertebro- Special Surgery in New York City. lesion to stabilize the bone. Kypho- plasty is more common performed, Surgeons using vertebroplasty plasty changes the dimensions of the originally by neurosurgeons and ortho- bone—an orthopedic balloon is inserted pedists but nowadays by interventional into the fractured bone and inflated to radiology oncologists as well, Dr. Lane reduce the fracture and correct the noted. alignment. After that the balloon is Kyphoplasty’s advantage over ver- removed and the cement put in. tebroplasty is that vertebral augmenta- Dr. Lane said he and colleagues tion with the balloon tamp partially have been adding a monthly dose of restores vertebral height, decreases zoledronic acid to the cement in certain kyphosis, and relieves pain. cases, which he said results in local con- “There is no question that vertebro- trol of the bone as well as providing plasty reduces pain about the same as systemic treatment. kyphoplasty and increases mobility “In our studies we have found that because of pain relief, but there is no up to 10 percent replacement [of reduction of fracture as with kypho- cement with an agent] will not weaken plasty,” he said. “The issue is, how Robert H. Carlson the cement, so there is an enormous important is it to correct the volume of space available to put mater- alignment of the spine?” Denis R. Clohisy, MD: “The major ial in,” he said. He noted that multiple determinant of whether to use

Robert H. Carlson Vertebral fractures occur common- myeloma studies by his group kyphoplasty or vertebroplasty ly during treatment for show that kyphoplasty can should be the safety and risk side multiple myeloma, as the restore up to 50% of a patient’s Joseph M. Lane, MD, said he and of one treatment versus the other.” colleagues have been adding a monthly combined tumor resorption height, reduce kyphosis by dose of zoledronic acid to the cement in and the drug-related osteo- about 50%, and significantly certain cases, which he said results in porosis combine to gener- improve pain relief and function local control of the bone as well as ate low energy fragility (Lane JM, et al: Clinical Orthopedics and “I suspect some other adjuvant providing systemic treatment. “In our fractures, Dr. Lane Related Research 2004;426:49-53) technique will have to be used such as a studies we have found that up to 10 explained. These can result Complications of kyphoplasty are laser technique to dissolve the tumor percent replacement [of cement with an in pain, deformity, gait minimal, he said, but issues of remain- and create a cavity,” he said. agent] will not weaken the cement, so abnormalities, pulmonary there is an enormous volume of space compromise, and increased Always Biopsy available to put material in,” he said. risk of falls. “Patient pain is related Vertebral fractures occur Dr. Lane warned clinicians to never do to the tumor and also to the commonly during either procedure without first doing a mechanical instability, and radiation biopsy. will not address those—you want to treatment for multiple “One of every 80 people who have ScriptDoctor reestablish stability,” Dr. Lane said. had a kyphoplasty or vertebroplasty for “On the other hand, reestablishing sta- myeloma, as the combined osteoporosis had underlying lym- continued from page 54 bility without controlling the tumor is tumor resorption and the phoma,” he said. of no advantage either—that’s why Even if the diagnosis of cancer has story of J.D. helping a friend out giving we’re looking for some sort of combina- drug-related osteoporosis been made, a biopsy before these proce- up something of himself, with the story tion approach so we can control the dures allows the oncologist to reassess of a patient and his brother. [The partial tumor as well as regain the stability for combine to generate the treatment protocols based on the liver donor] doesn’t want his brother to the vertebral body.” low-energy fragility efficacy of treatment. know he’s feeling so sick, because that Dr. Lane added that clinical trials The biopsy also may show the wouldn’t be altruistic,” Bakken says. are needed to determine whether fractures. These can opposite—that there is no tumor in the And that human drama, leavened putting agents in to protect the bone fracture. “Just because your myeloma by comedy in this case, is the point of and/or treat the tumor should be stan- result in pain, deformity, patient has a fracture does not necessar- all the steps taken by entertainment TV dard practice. gait abnormalities, ily mean there is tumor there,” he said. shows to ensure medical accuracy. Early on, patients with myeloma When it’s done right, then the story Kyphoplasty Restores Height pulmonary compromise, will get fractures from the tumor. But rings true. once they are in remission for several Stay tuned next time for “HH&S Vertebroplasty was developed in and increased risk of falls. years and they get a fracture, frequently O makes a Hollywood House Call.” T France and Spain in the 1980s, and (continued on page 56)