PIO FORUM

by Joann Rodgers

A Reality Check On "Reality TV"

Joann Rodgers

When The Johns Hopkins Hospital opened its doors in 1889, the trustees arranged for illustrated articles in the local press to promote the event. Just how they did so is lost to time, but they clearly had figured out the unmatched benefit of third-party validation when trying to build public confidence in academic medicine.

I mention this historical note for two reasons: 1) it largely explains why, 110 years later, Hopkins PIOs and officials said "yes" to an unprecedented request from ABC News and 2) it might serve to illustrate the only reason any research-based institution would grant relatively unfettered access to television cameras in search of "reality" programming. Namely, if we want to have credibility, to inform the public debate, to offer more than lip service to the public's right to know how it's money is spent, to demonstrate how our institutions work in their best interests, to lose the label of arrogance that feeds public distrust, and to have a voice in what is said about us, we must willingly give voice to others, even when we cannot be ventriloquists.

By now, millions have seen the six-part, prime-time ABC News documentary Hopkins: 24/7 that aired last fall and an additional 10-part series produced from the outtakes by ABC for the Discovery Health Channel. The documentary earned ABC News the Society of Professional Journalists 2001 award for documentary journalism. Critics cheered the "emotional honesty," "eye-opening heroism," and "courage" of the series, contrasting the worth of true documentarian reality with the rat-eating survivors of so-called reality TV.

Each episode used storytelling craft to draw indirect visibility for medicine's hot-button issues and did this so successfully that the series generated invitations to Hopkins leadership and faculty to testify before Congress and other bodies on the Patient Bill of Rights, Balanced Budget Act relief, the unintended consequences of managed care, and increased support for research and graduate medical education.

A commercial meatpacker offered to provide a better system for transporting livers and lungs to our operating rooms after one episode dramatized the race to get a quickly deteriorating organ to a donor, seven bodies were donated for anatomy classes, the Washington Post's health editor invited the dean of the Medical School to participate in an online forum on health care costs, and the series spawned entire Nightline and Oprah! programs focusing on public policies relevant to academic medicine.

To get this bully pulpit, Hopkins agreed to ABC's request to give 25 videographers and producers around-the-clock, unhindered access to Hopkins research, teaching, and patient care activities for three months. Hopkins secured from ABC legal and ethical protection of our patients' privacy, but we would have no right of review. It took a flood tide of e-mails and memoranda, and nearly three months of meetings and negotiations one ABC executive likened to the Mideast peace process, to get the operation running, but like those trustees of yore, Hopkins understood the value.

Yet even among those who found ABC's portrayal of academic medicine "heroic," as the producers have described it, hard questions remain for any academic medical center or research university asked to join in such a venture: How can a place allow such extraordinary access to television journalists and still protect patients' privacy, confidential discussions, and unintended deficiencies that could bring unwanted scrutiny and liability? Are the hundreds of hours spent by public affairs personnel, lawyers, deans, students, faculty, and security officers worth it? Isn't it risky to expose institutions to intense scrutiny when regulators and politicians are already watching our every move? Given the complexity of institutional life, can PIOs expect journalists, even a network "A" team, to pay attention to what "counts?" In sum, why should anyone take the risk at all?

Since Hopkins: 24/7 aired, I've logged a lot of hours in meetings and on the phone with colleagues in institutions, ranging from hospitals, to City Halls to Airport Authorities, all trying to decide whether to participate in 24/7-style programming.

Degrees of risk aversion drive an institution's final answer. But I hope most PIOs would agree that participation carries the potential to give science-based institutions a colossal platform for advocacy and bankable credibility to spread around. Instead of hunkering down, or grousing about widespread media and public ignorance of our institutions, we can opt to manage, rather than avoid, the risk involved and let people see our wares and warts. If we do our pre?production work earnestly and wisely, we can influence, although not control, the final product, and if we do our post-production work well, we can leverage what people view to better explain our problems and our suggested solutions to the public.

Neither ABC News producers nor JHM PIOS and officials were entirely soothed by the official joint terms of agreement that defined some boundaries and put some limits on access and equipment. To every degree possible, ABC crew members obtained written consent from patients and/or families or guardians for videotaping and broadcast prior to taping (Hopkins received a copy). If, due to emergent or other extenuating circumstance, prior consent was impossible, ABC secured consent at the "earliest opportunity." And ABC agreed that in no case would it broadcast or otherwise disseminate any material showing an identifiable patient videotaped at the hospital without having obtained that patient's consent, or consent from a designated family member. ABC and Hopkins agreed to a joint authorization for release of information and development and release of media materials. (Lawyers for Big Media are even more risk averse than lawyers for Big Medicine.) The form explained in detail what the ABC series was after; made clear that ABC owned all rights to the material and that there would be no financial compensation (for Hopkins or patients) for appearing. Because we did not (we could not) escort the 25 cameras around the clock for three months, corporate security provided photo credentials and ID access cards to the ABC crew that contained both ABC and Hopkins logos.

But the key to success was the mutual commitment to get to "yes," no matter how many lawyers, ethicists, security officers, deans, corporate officers, public affairs staff, and meetings it took. A path between offices of Hopkins lawyers and the ABC team became well worn during weeks of negotiations to maintain regulatory and legal protections for Hopkins and ABC's unwavering resistance to "stage" the news. ABC's look under the tent included what is believed to be the first time cameras have been allowed to film a Mortality and Morbidity (M&M) conference in which physicians openly attack each other's clinical decisions in order to bring to light errors and teach each other vigilance. That "Middle East peace process" also broke through the traditional view that no psychiatric patient could provide informed consent to participate in publicity. Some could and many did. Animal research labs also were open to ABC, although it quickly became clear-and one of the few mutually held grave disappointments-that prime-time commercial television did not lend itself well to pictorial representations of basic research in vitro or in vivo.

So here's the reality check on reality TV requests: If your institution is asked to participate, will you be able to get "real" science on prime time? Probably not. In Hopkins: 24/7, bench science was all but absent in the final cut of the prime-time series, despite hours and hours of tape shot in an effort to offer the scientific backstory to clinical advances. Some ground was made up in the Discovery Health series, which featured translational research and medical education, but not all.

Will you get richer if you participate? Nope. The benefit to the bottom line is marginal, at best. Despite the enormous visibility of our cancer research and care on the documentary, for example, only a dozen or so small donations were made and although, more than 1,000 people called to seek care as a result of the programs, the long wait for appointments and beds was such that we questioned the clinical marketing value of the project. Institutions searching for ways to market services or lecture the public into throwing financial support their way won't find pay dirt at the end of a TV camera.

Will you be able to protect privacy in a way that satisfies everyone? No. We may wonder why people want the world to see them with gunshot wounds inflicted because they were arrested as a suspect in a crime, but in the age of Jerry Springer, to construe this as a violation of patients' privacy probably fails the silly test. But some will so construe. Additionally, the issues of patient privacy and confidentiality raised by some who saw the ABC series triggered new rule-making by the Joint Commission on Accreditation of Health Care Organizations which, if strictly interpreted and adhered to, make it impossible to ever again permit some of the access ABC News had by placing an outright ban on shooting in advance of written consent unless the news organization turns over its tape to the institution until consent is granted. That's a non-starter for credible news organizations.

Are there some good reasons to participate in this kind of programming? Sure. Because science-based institutions are accountable for their claims on the public pocketbook. Because, as our colleague Rick Borchelt told the National Science Board last February, "better public understanding of [science] is a defensible goal in and of itself in a democratic society, whether or not such familiarity leads to better public advocacy for funding of research or other institutional benefits." And because such documentaries can display concern for issues critically important to the academic, scientific, and clinical enterprise. Hopkins: 24/7 gave prime-time attention to such themes as urban health care, the plight of the uninsured, and underfunding of teaching and research.

Are the risks of trying to work it out with real reality TV worth it? If expectations are as realistic as the likely outcome, absolutely. And nobody has to eat rats.

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Joann Rodgers is director of media relations in the Office of Communications and Public Affairs at Johns Hopkins Medicine.