Doc Shows Give Wrong Health-Care Diagnosis

Pity the Clintons and their supporters in the health-care debate. Now they even have part of the new prime-time television lineup against them.

Despite misfires with network medical dramas in recent years, NBC and CBS are again taking a stab at behind-the-scenes views of doctors’ work with “ER” and “Chicago Hope.” Critics have lauded both programs for acting and writing; “ER” has been a ratings winner. For health-care reformers, though, neither show can be good news. It would not be surprising if people who watch them end up wondering what the reformers’ fuss is all about.

Consider how both shows act out the state of health care in America. Here are three propositions that those who are trying to reshape medicine accept as gospel. Look at what “ER” and “Chicago Hope” have to say about them.

Proposition 1: Many major U.S. hospitals are suffering deeply under the weight of uninsured individuals who are flooding emergency rooms and filling expensive beds .

What suffering? Both of these TV citadels look and sound great. Floors shine, walls look modern, equipment is terrific, the morale impressive. The E.R. in “ER” is a busy, even frenetic place, but the program does not reflect reformers’ claims that lines are unbearable, infectious diseases rampant, demands overwhelming.

The one mention of scarcity in “ER’s” first four episodes turned out to be more the prelude to a surprising romance than a medical point. A female E.R. doc exchanges angry words with the male director of the psychiatric ward about his refusal to admit a welfare patient. But the psychiatrist argues that the ambiguity of the patient’s problem, not the cost of care, is the relevant roadblock. Anyway, the entire issue disappears into a startling scene where the two physicians who argued are shown sharing a bed.

“Chicago Hope” uses the issue of money to heighten drama fairly frequently, but money always loses. In one episode, the hospital’s budget director and some of the board of directors prattle on about the high costs of certain uninsured surgical procedures that a surgeon wants to perform. In the end, though, the medical director overrules them by saying angrily that he will recoup the million-dollar cost from the research grants of some of his fancy physicians. It seems that there is always some pot of gold to help a patient’s rainbow.

Proposition 2: Uninsured Americans, especially disadvantaged minorities, suffer due to lack of care . Not in these shows. Both are veritable melting pots of ethnicities. But nobody asks anybody for insurance cards and health professionals who don’t treat all people equally get in trouble.

In “Chicago Hope,” for example, a resident is reprimanded severely by a surgeon for hesitating to deal with a bleeding white prostitute who admits being HIV positive. Not only does the resident apologize, but the surgeon tries to help the prostitute fight infection by carrying out a hugely expensive experimental bone marrow transplant. At the end of the episode, she is lying on a gurney next to a middle-aged black man who also has undergone a hugely expensive experimental operation to give him an ape’s heart until a human donor can be found. Equal-opportunity care-giving here.

Proposition 3: To maximize the value of scarce medical resources, high-tech medicine must be de-emphasized in favor of primary physicians and managed care .

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Here, of course, is where debates about various health-care proposals run rampant. Is it good that government and corporate policy-makers want teaching programs to turn out fewer specialists and more family practitioners, general internists and general pediatricians? Should we be comfortable that companies are channeling their employees into health maintenance organizations, where primary physicians are coordinators of care and gatekeepers to specialists?

In “ER” and “Chicago Hope,” there is no debate. For these shows, high-tech, hospital-based medicine is not just the best medicine, it is the only medicine worth dramatizing. In their worlds, primary-care doctors simply don’t exist and HMOs hardly rear their heads.

What counts in “ER” are multiple crises that shift back and forth with pulsating MTV-like tension at the edge of chaos, when life hangs in the balance and cost is a dirty word. In “Chicago Hope,” what counts is the gleaming operating room where state-of-the-art doctors use state-of-art machinery to advance science, along with their egos.

“ER’s” physicians never deal with health maintenance organizations or any other type of insurance company. One way or another, their patients show up and receive help. As for “Chicago Hope,” one gets the sense that this is a place where other specialists who have run out of options send their patients. Somehow the hospital gets paid.

Yet “Chicago Hope” did build part of an episode around the problem that a gifted neurosurgeon has with an HMO. The patient, a friend of the surgeon’s secretary, goes to him for a second opinion about a huge tumor at the front of her brain. Confident that the HMO’s neurosurgeon cannot perform the operation successfully (though he says he can), the Chicago Hope doctor offers his service. The HMO refuses to use him, however, even when the doctor volunteers to reduce his fee to the HMO’s rate. The HMO’s executives, it turns out, do not want to set a costly precedent where their patients take surgery outside the plan.

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Finally, the HMO neurosurgeon admits his insecurity regarding the procedure, and Chicago Hope’s lawyer threatens to help the patient mount lawsuits if anything goes awry. The managed-care firm allows the right doctor to perform the operation, and it is totally successful.

Despite its upbeat ending, the story is likely to scare the pants off HMO members. Yet it fits comfortably into the general philosophy that “Chicago Hope”--and “ER”--act out about medical care in the United States: that, at its best, it is a high-tech battle between knighted physicians and disease; that it is generally available to people when they need it and that administrators and policy-makers simply ought to give doctors the right tools and get out of the way.

These are highly controversial notions, greatly at odds with the conclusions of most contemporary health policy analysts. It is difficult to know whether the story lines that convey them reflect a principled stand on the health-care debate by the programs’ creators and producers; more likely, they flow out of a long history of doctor-show plots, from “Ben Casey” to “The Bold Ones,” from “The Lazarus Syndrome” to “MASH” and “St. Elsewhere.”

The traditional TV-doctor formula may well have a great heritage of engrossing drama. Yet it carries in it the beliefs and challenges of an era that no longer exists. From a ratings standpoint, that may not be a problem. To groups trying to educate the public about ways to address the difficulties of a new medical environment, it is a major problem indeed.