Trauma: Life in the ER--education or entertainment? The patient's perspective.

Objectives: To determine whether patients felt that the show Trauma: Life in the ER has primarily educational or entertainment value. To determine if people felt that this show violated privacy.

Methods: Survey in an academic emergency department. Subjects were asked to participate in an initial survey, then asked to watch video clips from the show and complete a second survey.

Results: Three hundred ninety two participated in the initial survey. Fifty-six percent surveyed had seen the program, and of those, 55% stated that they watched the show for both educational and entertainment value. Of the initial participants, 267 watched the video and completed the second survey. Sixty-four percent stated that they would feel comfortable being filmed without prior permission. Eighteen percent of patients felt that the show violated patients' privacy.

Conclusions: Most patients felt that this show was educational and did not invade their privacy. The majority were willing to be filmed for this television show, even without prior permission.

Key Words: patient privacy, emergency department filming, consent

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The relatively recent obsession with reality television by the general public has resulted in an unprecedented level of access into what have previously been private medical situations. The Learning Channel's (TLC) Trauma: Life in the ER has spawned significant controversy due to questions regarding the process of consent and potential invasion of privacy. (1-3) A basis of the patient-physician relationship is the concept that privacy will be maintained. This relationship may be violated only if there is an overriding societal benefit, such as a case of suspected child abuse. Many would argue that even if there is a benefit to showing the public a more realistic view of what takes place in today's hospitals, it does not meet the level of a societal benefit that should allow the sacrifice of individual patient confidentiality. At issue is whether the presence of camera crews filming patients before obtaining consent is an unacceptable violation of patient privacy. The camera crews are present at the point that the patient enters the emergency department (ED). If the patient is awake, consent for filming is requested. If the patient is not able to give consent, but the case appears interesting, the patient may be filmed without consent. At some point, if the case is of interest to the producers of the show, the patient or family will be approached to obtain consent for use of the material. However, during the months that these camera crews are present in a given hospital, enormous amounts of footage are obtained, much without prior consent on the part of the patient or family. The camera crew itself serves no purpose in the care of the patient, and their presence can be viewed as a violation of patient privacy. Later review and editing of this footage further allows nonmedical personnel to view the physician-patient encounter with no consent on the part of the patient.

To date, most of the conversation about the ethics of filming patients has taken place in the medical community. Physicians have different views of this practice, some in favor, some adamantly opposed. (1-3) The voice of the public has been little more than "sound-bites" and anecdotal mention, (4,5) usually in favor of filming. The single study that considered patients' as well as physicians' opinions in regards to filming found that patients generally did not find filming to be an invasion of privacy, and it did not affect their satisfaction. (6) However, those patients that believed they might have been filmed were more likely to feel that their privacy was invaded. The numbers in this study were small, and this study did not ask patients about their general opinion of this show or whether they were in favor of filming.

At this point, regardless of personal opinion, the television show Trauma: Life in the ER continues, and additional medical reality dramas are being produced. The controversy in the medical community is well established, but the public voice has received little consideration. The purpose of this study was to assess more completely public opinion in regards to this type of television show. Specifically, we sought to establish whether people felt that some parts of the show were invasive to privacy. In addition, we attempted to determine whether patients felt that the show Trauma: Life in the ER has primarily educational or entertainment value.

Materials and Methods

This was a prospective survey of a convenience sample of adult patients and/or family members in the emergency department. Participants were verbally consented, and the study received IRB approval. The setting was a university ED that had previously been the site of filming for Trauma: Life in the ER and Resident Life. The authors enrolled adult patients or attendant family members who were present in the ED. Surveys were completed throughout different shifts (day, evening, nights, weekends) during the summer of 2001. Exclusion criteria consisted of the following: illness or condition that prevented participation and non-English speaking.

The following demographic information was obtained from all participants: age, sex, race, income, and level of education. Patients were initially surveyed about whether they had ever seen the television show Trauma: Life in the ER. If they indicated they had seen the show, several opinion-based questions were asked regarding whether patients viewed the show as education, entertainment, or both; whether they had seen something on the show that had changed their behavior; and whether they had seen something that they would find embarrassing if they were the patient being filmed. Examples were encouraged.

Next, the patients watched a 10-minute video of short clips from Trauma: Life in the ER episodes filmed in our ED a few years prior. The video had four patient encounters including a patient who had been badly burned in a dorm room prank, a badly injured unrestrained car accident patient, a hepatitis C-positive patient who had attempted suicide and ultimately died after a prolonged cardiopulmonary resuscitation, and a child who fell off his bicycle while not wearing a helmet. All of these cases would have been filmed without obtaining prior consent from the family or patient. In addition, several of the cases showed the patients in various states of undress.

After watching the video, participants were asked a series of opinion-based questions regarding what they had just seen. This section included questions such as whether they would have given consent to being filmed if they had been the patient in the video, and whether they would give consent for a relative if he/she were unable to consent. The patients were also questioned whether they felt that the show invaded the privacy of the patients in the video. Finally, the subjects were asked what value the show had, whether our institution should allow such shows to be filmed, and whether they felt that they had learned something by watching the video clips.

Data was analyzed with SPSS 10 (Mac) using [chi square] tests, t tests, and Mann Whitney U for data that was not normally distributed.

Results

Three hundred and ninety-two patients and family members participated in the initial part of the survey. Demographics of respondents are in Table 1. Fifty-six percent of respondents had seen the program, and 42% of those said they watched it weekly (33% watched 1-2 times a month, 25% watched rarely). Fifty-six percent of respondents watched the show for both educational and entertainment value, 17% for entertainment value only, 26% for educational value only. Survey responses are in Table 2. Forty-nine percent said they had seen something that would change their behavior in the future, and 62% said they had learned something helpful to them from watching the program. The most common changes participants would make were in the area of safety such as wearing seatbelts, helmets, or not drinking and driving (37 respondents). When asked what they had learned, 21 respondents noted they had learned how to do CPR or treat choking. An additional 17 noted other medical actions they had learned, for example, to wear a bike helmet and if there is a knife imbedded in someone they should not remove it. The remainder noted that they had learned specific medical information, such as stroke symptoms/treatment or had learned how the ER functions. Thirty-two percent of participants had witnessed something that would have embarrassed them if they had been the patient being filmed. The majority of examples given (24) were due to seeing patients undressed while on camera.

Two hundred sixty-seven participants watched the video and completed the second survey. Of these, 65% said they would have agreed to be videotaped for television if they had been one of the patients in the video. Most respondents (75%) were comfortable being filmed when consent was obtained before filming, and 64% said they would feel comfortable being filmed without prior permission. Eighteen percent of participants felt that TV shows like Trauma: Life in the ER violate patients' privacy.

Men were more likely to think the videotaping was an invasion of privacy [25% of men and 14% of women (P = 0.02)]. Women were more likely to feel that having a camera crew present might change the behavior of the doctor (54% of women and 46% of men). More men (86%) than women (75%) felt comfortable being filmed as long as permission was gained (P = 0.03). Other demographic factors such as age, ethnic or racial background, education, or income, did not affect responses.

Nearly all respondents (93%) thought that our hospital should allow real life TV shows to film at the hospital. When asked about the value of the show after viewing the clips, 96% noted educational value, 60% noted both educational and entertainment value, and 36% noted pure educational value. Most participants (88%) thought the show taught useful medical information.

Discussion

The debate regarding reality shows such as Trauma: Life in the ER has taken place primarily within the medical community. The pros and cons of such shows have been reviewed elsewhere. (3) The results of this survey support the view that patients perceive real life medical shows such as Trauma: Life in the ER to have some educational value. Our patients felt that they were watching the show for both entertainment and educational purposes, and they also felt that they had learned things by viewing the video and the show itself. However, the patients also recognized that there were some embarrassing moments on the video, and a minority of patients would not want to be videotaped. In general, our patient population had a much more positive view of filming compared with the views of physicians which have been previously published in the medical literature. (6)

The medical reality show format appears to be flourishing with new shows airing every year, so the question of whether these shows will continue appears to be moot. The issue may be how to meet the needs of a public that appears to be interested in the format of reality medical entertainment, while better protecting the privacy of the individual patient who is about to be filmed. Clearly, when possible, the patient should be asked if they are willing to have cameras present during their care. This allows the majority of patients who do not mind being videotaped to participate in something that they appear to enjoy.

There has been concern that patients under duress may not be able to give adequate consent (7); however, obtaining true informed consent is difficult to achieve in patient care, whether or not a patient is perceived to be under stress. The difference between consent for a procedure and consent for being filmed is that a procedure is done as an intervention to prevent the progression of a medical condition with the goal of improving outcome, whereas there may not be any clear positive outcome in the taping of a patient encounter. However, 72% of the patients in this survey felt that they learned something such as CPR or wearing helmets from watching the video. If the public can be educated in regards to public health measures and other steps to better health, perhaps something positive may result from the unfortunate situations that some people encounter. As well, individual testimonies from some patients that have been taped have been very positive. (5) Whatever position is taken in this debate by physicians, it may be reasonable to allow patients and families to make their own choice about participation in these types of television shows. It is worth making this point because some physicians have proposed that these types of shows be abolished. (1)

Concern must still remain for the patient who is unable to immediately give consent to filming because of age or severity of injury. The process of taping the patient encounter usually means that one or two extra people are in the room operating the cameras. After the taping, one must assume that others view the sequence for its desirability for the show. Thus, a group of people who have no role in patient care are witness to the intimacy of the physician-patient encounter. This type of patient is perhaps the most vulnerable to an inappropriate invasion of privacy when camera crews enter without prior consent. Yet, one has only to look around the trauma bay during a resuscitation to see the number of non-medical people who are present. These observers may be allowed because they are "interested in medicine," and it is considered beneficial to try to attract young people to the medical profession. In other words, these observers are allowed to view a physician-patient encounter so they might learn what it is like to be a physician. One might question whether these examples are markedly different from the potential benefit of creating a more educated public regarding certain health issues, particularly if the public generally has a positive view of medical reality shows. If patient privacy must be so closely guarded, it should be done with equal intensity to all types of voyeurism, both those that physicians agree with and those they do not.

Privacy within the patient-physician relationship is critical to ensure trust. Reality shows may intrude on this boundary and yet arguments can be made for and against this practice. Based on this survey, we feel that the public has a positive opinion regarding these shows and decisions regarding the fate of medical reality shows should include the public voice and not be made solely by physicians. If these shows can help educate the public regarding public health measures as well as to realistic expectations of the medical process, there may be a significant public good that results. However, until this public discourse occurs, protection of individual privacy should remain a priority. At institutions that allow taping, a burden should be placed upon the producers of these shows to minimize the number of people who view the videos of patients that have not yet consented. One example would be to allow a single camera person in the room to obtain footage on an unconscious patient. After filming, no one would be allowed to view the footage until the patient or family has consented to further viewing. At this point, the film could be reviewed by others to determine whether it is desirable for use in the television show. These actions might help protect the 18% that felt these shows are an invasion of privacy.

Several limitations exist in this study. This was a survey that asked theoretical questions regarding whether patients would be willing to be videotaped. Their responses might have been different if the possibility had been real rather than theoretical. While patients felt that they learned something from either watching the show or watching the video tape, there was no method to determine if they actually changed their behavior. Further research should also be done on those patients that have participated in the show to ensure that they do not later regret their decisions.

In conclusion, previous authors have denounced any medical reality shows, citing concerns regarding confidentiality and physician-patient relationships. However, many patients feel the show has educational value and were supportive of filming the show at our emergency department. Most people indicated they would be willing to be taped if they were injured. Fewer people were concerned about violations of privacy.

References

1. Geiderman JM, Larkin GL. Commercial filming of patient care activities in hospitals JAMA 2002;288:373-379.

2. Geiderman JM. Fame, rights, and videotape. Ann Emerg Med 2001;37:217-219.

3. Iserson KV. Film: exposing the emergency department. Ann Emerg Med 2001;37:220-221.

4. Foubister V. Acting in the ER. AMA News March 27, 2000.

5. SoRell R, Scheck A. Cameras in the ED: fame or invasion of privacy? Emergency Medicine News 2001:23;18-19.

6. Rodriguez RM, Dresden GM, Young JC. Patient and provider attitudes toward commercial television film crews in the emergency department. Acad Emerg Med 2001;8:740-745.

7. Smithline HA, Mader TJ, Crenshaw BJ. Do patients with acute medical conditions have the capacity to give informed consent for emergency medicine research? Acad Emerg Med 1999;6:776-780.

Robin R. Hemphill, MD, MPH, Sally A. Santen, MD, Cindy M. Spanier, MD, and Nicholas D. Fletcher, MD

From the Departments of Emergency Medicine, Pathology and Orthopedics, Vanderbilt University Medical Center, Nashville, TN.

Reprint requests to Dr. Robin R. Hemphill, Department of Emergency Medicine, VUMC, 703 Oxford House, Nashville, TN 37232. Email: [e-mail]

Accepted September 13, 2006.

RELATED ARTICLE: Key Points

* Many physician groups have concerns regarding the filming of the patient encounter.

* Most patients feel that this show is educational and does not invade their privacy.

* The majority would be willing to be filmed, even without prior permission.

Table 1. Demographics of respondents

Mean age                                39 years (SD 14)
Women                                   56%
Race
  African American                      54%
  Caucasian                             68%
  Other                                  2%
Education (GED or high school diploma)  54%
Income
  <$20,000                              31%
  $21-50,000                            35%
  >$50,000                              37%

Table 2. Survey responses questions:

                                                                 No
If you watch the show Trauma: Life in the ER:          Yes  No   opinion

Have you ever seen something happen to a patient that  49%  46%  3%
  changed the way that you might act in the future?
Have you ever learned something that was helpful to    62%  29%  6%
  you?
Have you ever seen something that if you were the      31%  65%  1%
  patient you would be embarrassed by?

Responses after viewing video clips from Trauma: Life in the ER

Do you feel that you learned something from this       72%  28%  1%
  video?
If you were one of the patients in the video would     65%  32%  3%
  you agree to be video-taped for television?
Do you feel that these real-life TV shows violate the  19%  78%  3%
  patient's privacy?
Do you feel that having a camera crew present during   42%  54%  4%
  patient care will change the way your doctor
  behaves toward you?
If this ED was being taped for a real-life TV show,    75%  19%  6%
  would you feel comfortable being video taped if the
  camera crew asked your permission?
In the case of the man in the car accident, the man    64%  32%  4%
  was unconscious. The man was filmed without his
  permission. Permission was asked later. Would you
  be comfortable being filmed in a case like this
  without permission?
If one of the people in the video clips was your       49%  42%  9%
  relative, would you agree to let them be
  videotaped?
Do you think that real-life medical TV shows teach     85%  12%  3%
  people useful medical information?
Do you think that this emergency department should     93%   2%  5%
  let real-life TV shows such as Trauma: Life in the
  ER film here?
In the video did you see something that if you were    22%  78%  0%
  the patient you would be embarrassed by?