Script Doctors

Since at least the 1950s, medical dramas have been a staple of television programming—and for good reason. Where else are the stark realities of life and death more vividly experienced than in the work of doctors and other medical professionals? Few television writers and producers have a background in medicine, though, so MDs have been enlisted as consultants to help lend these programs a sense of reality. To find out what it takes to help produce medical dramas that are both accurate and entertaining, we spoke with consultants from two of the most popular examples of the genre in recent decades: House and ER.

If you’re interested in working as a consultant on a medical show, it generally comes down to who you know. Harley Liker, MD, MBA, helped his friend and neighbor, television producer David Shore, sketch out the cast of characters for a new show Shore was developing that would center on solving medical mysteries—and ended up as a consultant on House from its first season on. Greg Moran, MD, who did a residency in emergency medicine and a fellowship in infectious diseases, started out feeding ideas for odd maladies to a friend from his residency program at USC who was a consultant on ER and went on to become a consultant himself for the show’s final five seasons. Compared with Liker and Moran, Lisa Sanders, MD, took a slightly unorthodox route to her position as a consultant on House: Her monthly Diagnosis column in the New York Times Magazine, which explains how physicians sleuth out difficult cases, was an inspiration for the show and has served as the basis for a number of its episodes.

Once on board, medical show consultants generally keep their day jobs. Although Moran’s friend, who got a film degree in addition to an MD, moved up the ranks and ultimately became an executive producer of ER, most consultants are strictly part-time. “It was a side thing,” says Moran, who is vice chair of emergency medicine at Olive View-UCLA Medical Center and a professor of medicine at UCLA. “It was a few hours a week.” When the work comes through, however, it has to be attended to quickly. “No matter what’s happening in my life, when a script comes, I have to drop everything and look at it, because I only have 48 hours to make suggestions on how to fix it,” says Sanders, an assistant professor of medicine in the internal medicine and primary care program at the Yale School of Medicine.

Medical consultants are just one part of a complicated apparatus, and their feedback can have significant consequences for others involved in making the show. “The scripts get moving pretty quickly, and there is a whole production cycle of when a script gets released to the time it needs to be revised to the time it gets to the actors to the time it gets to the special effects and props people so they can get what they need,” says Liker, who is an associate clinical professor of medicine at UCLA and provides concierge medical services through his company, Liker Consulting. “Say I had to give a writer a note or comment where I thought that the patient absolutely needed to have an MRI and imagine there wasn’t a reproduction of an MRI machine on the set and they are going to have to go out and get one—you can’t do that in a day.”

The basic role of the consultant is to help ensure that the medical details of each episode are accurate—pointing out when a drug that is only available orally is scripted to be delivered intravenously, for instance—and help the writers imagine how medical scenarios might play out. On ER, Moran would generally receive an outline of an episode script with broad sketches of what was to happen in each scene and then write a first draft of the medical sections. This might involve coming up with a plausible dispute between two characters over how to approach a particular case. On House, consultants vet scripts for medical accuracy and play a role in coming up with the ultimate diagnosis for each episode as well as the false leads that the physicians might pursue in trying to treat it.

“It’s a 60-minute show, and in the first 45 or 50 minutes, you basically want to distract the viewer,” says Liker. “Maybe it’s a pneumonia, OK, let’s treat it with antibiotics. Oh, we treated for pneumonia, but he’s not getting better, so maybe it’s something else. And I think they needed a lot of help with the something elses and how to step through to get to the end.”

When working on a television show, however, consultants learn to balance absolute verisimilitude against the need to tell a good story. One challenge is working with a limited cast, which means that characters might be shown performing a procedure that is far outside their normal area of practice. “For instance, you’ve got someone like Chase [on House] who is trained as a pulmonary critical care expert occasionally doing neurosurgery,” says Liker. “That would never happen. Only a neurosurgeon would do neurosurgery.” And, of course, there is House’s central character, the famously cantankerous yet brilliant Gregory House, MD, who cuts ethical corners, disregards patients’ treatment preferences, and berates colleagues and patients alike, all in the pursuit of the greater good. “In internal medicine, we spend a lot of time teaching our residents how to behave properly on the theory that if you’re good to your patients, you have a much, much better chance of getting the whole story,” says Sanders. “So there are a whole bunch of people who do primary care who just hate House because he has such a terrible bedside manner.”

Moran acknowledges that the drama was frequently amped up much higher on ER than it was in a real-life emergency room, but takes pride in how the show managed to have physicians and other medical staff use the sort of medical language they would in reality. “We would have to find a way to make it self-explanatory so the audience could tell what was going on, but we would use all the technical jargon,” he says. “That was just part of the feel of the show—that the docs and the nurses were speaking in the way that they would in the real world.” Another mark of ER’s realism: Some patients actually died. “That really is more reflective of the real-world situation,” Moran says. “A lot of patients do die. Clearly the outcomes on ER overall were better than in the real world, but they didn’t always have to have a happy ending.”

Sanders says that House’s writers and producers are generally eager to incorporate her suggestions for correcting errors to help make the show as accurate as possible, although there was one notable exception—the time she challenged a writer’s description of an infection in a man’s mouth as “bacterial vaginosis,” meant to imply that he had been engaged in oral-genital contact. “I sent this long email saying that, first of all, that organism doesn’t grow in the mouth, but even if it did, it wouldn’t be called ‘bacterial vaginosis’ because it’s not in the vagina, so it would be called oral stomatitis or something, and then I gave a few other suggestions that would convey that kind of contact in a funny way,” she says. “Twenty minutes later, the answer came back, and it was just one line: ‘Thanks, Lisa, but my way is funnier.’ And, you know, it was. I thought, ‘Oh, right, I get that.’ It’s nice to be accurate, but sometimes it’s also good to get off a really good joke.”

In the end, as Liker points out, the shows belong to the writers and the producers, not the consultants. “The writers come up with the ideas, and the medical consultants help them shape those ideas to create stories that will be compelling and as technically accurate as possible given the understanding that the show is a drama and not meant to represent pure reality,” he says. “It’s like somebody builds a beautiful car, and we shine the chrome to make it a little brighter, but we’re not building the car.”