Two articles summary
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Journal of Broadcasting & Electronic Media/March 2009
The Effects of Viewing Grey’s Anatomy on Perceptions of Doctors and
Patient Satisfaction
Brian L. Quick
The present investigation applies cultivation theory to describe the role of
viewing Grey’s Anatomy on patients’ predispositions. Results demonstrate
that heavy viewers of Grey’s Anatomy perceive this program to be credible.
Credibility was positively associated with a perception that real-world doctors
are courageous. A direct association did not emerge between Grey’s Anatomy
viewing and a perception that doctors are courageous, although an indirect
effect emerged, mediated through credibility. A positive association emerged
between perceptions that doctors are courageous and patient satisfaction.
Results are discussed with an emphasis on the role of entertainment programs
in cultivating patients’ predispositions about medical doctors.
Until recently, a shortcoming within the doctor-patient literature was a dearth of
theoretical models to explain the complexities that underlie this unique relationship.
The doctor-patient relationship does not occur in a vacuum, thus, attention to envi-
ronmental factors influencing this relationship is of interest to health communication
research. Street’s (2003) ecological model takes a step in this direction by advancing
an approach that takes into account multiple contexts impacting the healthcare
provider-patient relationship. In doing so, the model illustrates how the media,
organizational, cultural, and political-legal contexts each impact the doctor-patient
relationship, which has received a wealth of coverage during the past 30 years. At
the heart of the concept is the relationship between the healthcare provider and
patient. In examining the interpersonal context in which this relationship occurs,
Street identifies partner and relationship perceptions as cognitive-affective influences
for both doctors and patients.
In applying the ecological model to patients’ perspectives of doctors, the focus of
this investigation concentrates on the media context. Research examining television
representations of doctors is not new to the literature (Chory-Assad & Tamborini,
Brian L. Quick (Ph.D., Texas A & M University) is an Assistant Professor in the Department of Communi- cation at the University of Illinois at Urbana-Champaign. His research interests include message processing of persuasive health messages and the effects of media coverage of health issues.
This article was submitted and accepted under the editorship of Donald G. Godfrey.
© 2009 Broadcast Education Association Journal of Broadcasting & Electronic Media 53(1), 2009, pp. 38–55 DOI: 10.1080/08838150802643563 ISSN: 0883-8151 print/1550-6878 online
38
Quick/ECOLOGICAL MODEL 39
2001; Pfau, Mullen, & Garrow, 1995; Turow, 1989; 1996; Turow & Coe, 1985;
Volgy & Schwarz, 1980). Extant research successfully traced historic portrayals
of television doctors (Turow, 1989; Turow & Coe, 1985), while others performed
systematic content analyses to examine doctor portrayals on television (Chory-Assad
& Tamborini, 2001; Pfau et al., 1995); however, less is known about the influence
of television in shaping patient perceptions of doctors (Chory-Assad & Tamborini,
2003; Pfau et al.; Volgy & Schwarz, 1980), particularly within the context of a single
medical drama.
This investigation extends this line of research by examining the influence of
exposure to Grey’s Anatomy, spanning Season 2 and the first five episodes of
Season 3, on viewers’ perceptions of real-world doctor’s courage along with how
this perception is associated with patient satisfaction. Grey’s Anatomy was selected
due to its popularity and uniqueness. Nielsen Media Research rankings 2005–
2006 indicate that Grey’s Anatomy (Season 2) had an average of 19.9 million
viewers per episode, giving it a #5 overall ranking. Perhaps a major reason for
the show’s popularity among viewers rests in the diversity of the cast (Deimen,
2006; Reddy, 2007). The surgical interns and staff at Seattle’s Grace Hospital are
ethnically diverse, which is in stark contrast to most television shows that do
not adequately represent minorities (Deimen). Another factor that makes Grey’s
Anatomy different is the constant depiction of risky and complicated surgeries.
Deimen writes, ‘‘Due to the nature of their internship, they [surgical interns] are
constantly pitted against each other for the juiciest and most complicated surgeries’’
(p. 2). While the ecological model identifies the influence of the media within the
healthcare provider-patient relationship, the manner in which this occurs is not
explicated. Prior to making an argument for applying cultivation theory within the
context of a single program across 32 episodes, a brief history of television portrayals
of medical doctors is provided.
Television Portrayals of Doctors
The portrayal of doctors on television has shifted significantly during the past
60 years (Chory-Assad & Tamborini, 2001; Turow, 1989, 1996; Turow & Coe,
1985; Volgy & Schwarz, 1980). City Hospital, the initial doctor show launched
in 1952, portrayed doctors as omnipotent healers who represented the author-
ity within the hospital. Doctors throughout the 1950s and 1960s were charac-
terized as compassionate heroes dedicated to their patients (Turow, 1996). Au-
diences followed the likes of Dr. Ben Casey and Dr. James Kildare as they regularly
beat the odds and triumphed over illness to save patients. The 1970s introduced
doctors such as Dr. Marcus Welby who were on the cutting edge of medical
advances and, like their predecessors, always succeeded in improving the lives
of their patients. Volgy and Schwarz’s content analysis across a 4-week period
found that ‘‘not a single reference to physicians which could be described as a
negative statement toward the medical profession’’ occurred (1980, p. 152). At
40 Journal of Broadcasting & Electronic Media/March 2009
the end of the 1970s, the focus switched from patient illness to the difficulties
that come with being a doctor (Turow & Coe, 1985). Shows such as St. Else-
where and Northern Exposure, among others, began showing the stress and strain
of being a doctor (Pfau et al., 1995). By giving attention to the often unfavor-
able dispositions of doctors, media scholars feared that negative portrayals may
lead to doctor distrust (Pfau et al.). Although medical shows had begun to de-
pict doctors’ struggles, for better or worse, the majority of coverage remained
positive.
Most recently, Chory-Assad and Tamborini’s (2001) content analysis of 229
television physicians discovered that portrayals of doctors remained largely positive,
although these depictions were less favorable than portrayals a decade earlier
(Pfau et al., 1995). Specifically, Chory-Assad and Tamborini wrote that prime-
time fiction doctors ‘‘were often mean, unethical, incompetent, insubordinate,
and sometimes even criminal’’ compared to non-fiction portrayals within the
media (i.e., news broadcasts, magazines) (p. 514). ABC’s Grey’s Anatomy con-
tinues in this tradition by showing both positive and negative characteristics
of medical doctors. With that said, consistent with previous decades of doctor
portrayals on television, courageous acts performed by doctors on Grey’s Anatomy
abound in which they are forced to make critical decisions that determine
the fate of their patients. To provide illustrations of these valiant acts, two
episodes were randomly selected from Season 2 and the first five episodes of
Season 3.
In the episode entitled ‘‘Deterioration of the Fight or Flight Response,’’ three
courageous acts are performed simultaneously. First, Dr. Burke was shot outside of
the hospital. While treating Burke, viewers watch as Dr. Shepherd struggles with
the delicacy of dislodging a bullet from a friend, while at the same time performing
the surgery without damaging nerves that would prevent Burke from performing his
duty as a surgeon. While viewers witness this struggle, Dr. Addison has the daunting
task of telling Dr. Richard that his adolescent niece’s ovarian cancer has returned.
Meanwhile, viewers watch as interns Izzy, Cristina, Meredith, and George struggle
to keep a patient, Denny Duquette, alive after Izzy intentionally cut his LVAD
wire in attempts to improve the likelihood of him receiving a much-needed heart
transplant. In short, within a single episode, viewers see the courage needed to be
a medical doctor.
In another episode, ‘‘Raindrops Keep Falling on My Head,’’ viewers watch as Dr.
Addison Forbes Montgomery and intern Meredith Grey see Julie, a patient with twin-
twin transfusion syndrome (two twins connected by blood vessels in the placenta).
Addison performs surgery after she detects beginning heart failure in the twins.
After the surgery, viewers learn that the babies and Julie turned out fine. In the
same episode, viewers watch as Joe, the owner of a bar across from the hospital,
suffers from an aneurysm. In order to correct the problem, the doctors must perform
courageous acts (e.g., freeze his body, drain his blood, and stop his heart) within
45 minutes to save Joe. Joe survived the procedures. Despite their courageous acts,
the doctors on Grey’s Anatomy do not always succeed. In fact, often their patients
Quick/ECOLOGICAL MODEL 41
die. Although there is not always a happy ending, the doctors’ courageousness is
rarely questioned. In order to provide a theoretical framework to understand media
influence, cultivation theory is employed to address the underlying process in which
heavy viewers of Grey’s Anatomy develop beliefs and perceptions consistent with
television portrayals of doctors.
Cultivation Theory
Perhaps no theory has been as instrumental as cultivation theory in explaining the
long-term effects of repeated exposure to television images (Gerbner & Gross, 1976).
Cultivation theorists assert that over time, social reality and TV reality are blurred
among heavy television viewers (Gerbner & Gross, 1976; Gerbner, Gross, Morgan,
Signorielli, & Shanahan, 2002). The theory suggests that specific themes (e.g., crime)
cut across genre boundaries and pervade all programs. In making the case for
cultivation theory, researchers frequently compare perceptions between heavy and
light viewers. The preponderance of cultivation research suggests that heavy viewers
maintain perceptions that mirror television compared to light viewers in general. In
fact, the validity of cultivation research has been bolstered by meta-analytic research
that suggests Gerbner and colleagues’ prediction holds true (Morgan & Shanahan,
1996).
Despite evidence in support of cultivation, the theory has endured its share of
criticism (see Hawkins & Pingree, 1980; Potter & Chang, 1990). The assumption
that television viewing impacts perceptions is not disputed; however, the under-
lying assumptions of cultivation remain debated (for a review of these criticisms,
see Shanahan & Morgan, 1999). A major criticism of cultivation research rests in
Gerbner and colleagues’ belief that television messages are a cumulative mass of
messages with consistent storylines. That is, cultivation treats television messages as
a coherent system of stimuli spanning all genres and programs (Gerbner & Gross,
1976; Gerbner et al., 2002). As a result, cultivation researchers’ interests are in the
impact of total television viewing as opposed to genre-specific or program-specific
effects. While treating television messages as a coherent system was legitimate for
the late 1960s, the spawn of cable and satellite programming, an influx of programs
aimed at specific target audiences, along with technologies such as television digital
video recordings during the past four decades have certainly challenged cultivation’s
notion of a uniform storyline across genres and programs. Content analyses have
disputed the belief that television messages are uniform across genres and programs
(Hawkins & Pingree, 1980; Potter & Chang, 1990). In fact, Segrin and Nabi’s (2002)
study examining marital expectations found that relationship genre explained more
variance in eros and expectations for intimacy than total television viewing. Both
relationship genre and total television viewing explained a significant portion of
variance in fantasy rumination or marital intentions. Similarly, research found that
heavy viewing of TV news is associated with concerns about violent crimes (Romer,
Jamieson, & Aday, 2003), while others discovered that parents attending to media
42 Journal of Broadcasting & Electronic Media/March 2009
stories about child abduction cases experience more fright-related feelings than
light viewers (Wilson, Martins, & Marske, 2005). Wilson et al. also found that heavy
exposure to TV reality/dramas and attention to media stories about child kidnappings
are positively associated with concerns about a local threat. Finally, within the
context of doctor portrayals on television, Chory-Assad and Tamborini (2001) found
that visual and non-visual doctor portrayals varied in physical attractiveness and
interpersonal style across prime-time fiction, daytime soaps, network news, news
magazines, and daytime talk shows, although doctor competence, ethical character,
regard for others, and power did not vary significantly. Together, these studies
support the possibility of extending cultivation theory to examine effects within
specific television genres.
Although research supports the cultivation hypothesis with respect to total televi-
sion viewing (Morgan & Shanahan, 1996) and genre-specific programming (Chory-
Assad & Tamborini, 2003; Romer et al., 2003; Segrin & Nabi, 2002; Weaver &
Wakshlag, 1986; Wilson et al., 2005); however, examining cultivation within the
context of a single program (e.g., Grey’s Anatomy), albeit over 32 episodes, remains
uncharted territory. In fact, in several of the aforementioned studies, support for the
cultivation hypothesis was more robust for genre-specific compared to total televi-
sion viewing (Chory-Assad & Tamborini, 2003; Segrin & Nabi, 2002; Wilson et al.,
2005). Specifically, Chory-Assad and Tamborini found that exposure to prime-time
medical dramas among others predicted physician perceptions, but total television
viewing did not. Similar results were found by Wilson et al., although within a
different context, who found child news viewing to explain more variance than
TV viewing when it comes to fright-related feelings and concern for one’s safety.
Perhaps increasing the specificity of the cultivation hypothesis into a particular pro-
gram, over multiple episodes and seasons, will also support Gerbner’s hypothesis.
After all, Gerbner’s assumption about the nature of cultivation seems logical within
the context of Grey’s Anatomy. That is, heavy viewing of this program over the
course of 32 episodes would likely impact perceptions of real-world doctors among
heavy viewers of this medical drama.
Greenberg’s (1988) drench hypothesis is a competing framework to cultivation
theory. The drench hypothesis asserts that exposure to a dramatic program or
narrative can generate a significant impact on an audience. Whereas cultivation
can be characterized by a drip-drip-drip effect over a long period of time, the
drench hypothesis is depicted as an intense, immediate effect (Reep & Dambrot,
1989). Recently, Bahk (2001) applied the drench hypothesis to the movie Outbreak.
Bahk’s findings supported the argument that exposure to a dramatic stimulus can
elicit changes in health beliefs. While both frameworks offer insight into the present
study, examining the effect of Grey’s Anatomy viewing on perceptions of medical
doctors over 32 episodes better lends itself to cultivation than the drench hypothesis
for a number of reasons.
The present investigation is concerned primarily with how repeated exposure to
patterns communicated within a medical drama can impact and shape viewers’
perceptions of medical doctors. Arguably cultivation is not concerned with the
Quick/ECOLOGICAL MODEL 43
effects of a single program or particular genre, yet cultivation research is interested
in patterns and representations over an extended period of time (Gerbner & Gross,
1976; Gerbner et al., 2002). Grey’s Anatomy viewers have watched the everyday
operations of a teaching hospital unfold on their television sets. Exposure to pat-
terns of courage by these medical doctors may have cultivated similar perceptions
among viewers, but how these perceptions impact viewers over time is worthy
of consideration within a cultivation framework. Cultivation also acknowledges
that exposure impacts the cultivation effect. Specifically, heavy viewers are hy-
pothesized to provide answers consistent with television reality when asked about
real-world reality (Gerbner & Gross, 1976). Although this hypothesis rings true
for total television viewing (see Gerbner et al., 2002) and genre-specific view-
ing (Chory-Assad & Tamborini, 2003; Romer et al., 2003; Segrin & Nabi, 2002;
Wilson et al., 2003), conceivably cultivation theory is an appropriate framework
for a single show spanning 32 episodes. Therefore, portrayals presented across
32 Grey’s Anatomy episodes will likely impact viewers’ perceptions of real-world
doctors.
From a cultivation perspective, it is assumed that heavy viewers of Grey’s Anatomy
will maintain perceptions of doctors that are consistent with depictions of television
doctors on this television program. Moreover, cultivation researchers have argued
that a cultivation effect is most likely in medical contexts where viewers often have
limited experiences (see Gerbner & Gross, 1976; Morgan & Signorielli, 1990; Pfau
et al., 1995). Not surprisingly, media scholars have found that television viewing of
medical shows impacts patient perceptions of doctors (Chory-Assad & Tamborini,
2003; Pfau et al., 1995). Additionally, limited experience inside a teaching hospital
will likely enhance the credibility of the program, which can impact one’s social
judgments (Busselle, 2001; Busselle & Greenberg, 2000). For instance, perceiving
television to be realistic enhances the accessibility of television images in audiences
(e.g., shootings, Americans having extramarital affairs) (Busselle). In this same man-
ner, perceiving Grey’s Anatomy to be realistic will likely make television depictions
of doctors on this program more accessible to viewers and subsequently impact
viewers’ perceptions of real-world doctors. Medical dramas such as Grey’s Anatomy
can shape perceptions about doctors by giving viewers insight into the behind
the scenes and day-to-day operations of a teaching hospital, which few patients,
particularly college students, have experienced first hand. Put another way, average
college students presumably have little experience inside emergency rooms and
thus, are likely to perceive Grey’s Anatomy depictions of surgeons operating in this
environment as accurate due to their inexperience in this context. With that said,
the first hypothesis is advanced,
H1: The viewing of Grey’s Anatomy is positively associated with perceived cred-
ibility of this program.
As alluded to earlier, cultivation research asserts that a cultivation effect is most
pronounced in contexts in which the audience is unfamiliar (see Gerbner & Gross,
44 Journal of Broadcasting & Electronic Media/March 2009
1976; Morgan & Signorielli, 1990; Pfau et al., 1995). That said, studying the culti-
vation effects of a program such as Grey’s Anatomy, which has attracted a college-
student audience, is reasonable. Few students have spent extensive time in a teach-
ing hospital. Not surprisingly, media scholars have found that television viewing of
medical shows impacts patient perceptions of doctors (Chory-Assad & Tamborini,
2003; Pfau et al., 1995). With inadequate examples to compare the validity of the
programs’ everyday portrayals, audiences are likely to perceive the depictions on
Grey’s Anatomy to be realistic. Following these surgical interns as they seek out
the most daring and complicated surgeries, audiences are likely to perceive these
doctors to be courageous. In turn, if viewers of Grey’s Anatomy perceive these TV
doctors as courageous, then they will also perceive real-world doctors as being
courageous. After all, research indicates that perceiving a message to be credible
can make television images more accessible and ultimately can impact one’s social
judgments (Busselle, 2001; Busselle & Greenberg, 2000). With this in mind, the
second hypothesis is advanced.
H2: Perceived credibility of Grey’s Anatomy is positively associated with per-
ceived courageousness of real-world doctors.
Reviews of doctor portrayals on television demonstrate that TV doctors are coura-
geous. Consistent with depictions of TV doctors on other medical dramas over
the years such as Dr. James Kildare, Dr. Ben Casey, and Dr. Marcus Welby, the
cast of Grey’s Anatomy display their bravery through their courageous maneuvers
in difficult situations. For these reasons, to provide a direct test of the cultivation
hypothesis, a positive association is expected to emerge between exposure to Grey’s
Anatomy viewing and a belief that real-world doctors are courageous.
H3: The viewing of Grey’s Anatomy is positively associated with perceived coura-
geousness of real-world doctors.
In addition to testing for a direct effect between Grey’s Anatomy viewing with
perceived credibility and perceptions that doctors are courageous, an indirect effect
connecting Grey’s Anatomy viewing and perceptions that doctors are courageous
through the program’s perceived credibility is examined. Media effects researchers
have encouraged research to examine both direct and indirect effects (Holbert &
Stephenson, 2003; McLeod, Kosicki, & Pan, 1996). Inadequate attention to indirect
effects could certainly camouflage the relationship between two variables of interest.
In this spirit,
RQ1: Does perceived credibility of Grey’s Anatomy mediate the relationship
between Grey’s Anatomy viewing and perceived courageousness of real-
world doctors?
Quick/ECOLOGICAL MODEL 45
Research argues that glamorizing the profession on medical dramas is a contribut-
ing factor to increases in applications to medical resident programs, which increased
from 4% in 1994 (the year ER began) to 5.2% in 1997 (O’Connor, 1998). In essence,
O’Connor argued that students watching weekly episodes of ER over 4 years is com-
parable to a medical student’s time spent in a typical emergency medicine rotation.
Taking into account television depictions of physicians along with physicians’ and
public perceptions of physicians, Pfau et al. (1995) found that television portrayals
and public perceptions of doctors’ interpersonal style and physical attractiveness
were more favorable than physician perceptions. Interestingly, network television
depictions and public perceptions toward doctors’ character and power were more
negative than physician perceptions. These studies suggest that viewing medical
dramas can impact perceptions. Within the doctor-patient literature, a commonly
employed measure for patient outcomes is satisfaction (Brown, Stewart, & Ryan,
2003).
Research has found that patients satisfied with their interactions with doctors are
more likely to adhere to a prescribed treatment regimen (e.g., Brown et al., 2003).
Patient satisfaction has received extensive attention in the literature. For example,
Roter et al. (1997) conducted an extensive analysis of patient satisfaction across 13
locations within North America. Their team found that patients were most satisfied
when the doctor discussed biomedical and psychosocial issues equivalently. Per-
ceptions that a doctor will perform courageous acts in order to save or significantly
improve the quality of life for a patient will reasonably be positively associated with
patient satisfaction. Thus,
H4: Perceived courageousness of real-world doctors is positively associated with
patient satisfaction with their real-world doctors.
In sum, H1 through H4 present a structural model featuring both direct and
indirect effects between Grey’s Anatomy viewing, an evaluation of the credibility of
this medical drama, patients’ perceptions that doctors are courageous, and patient
satisfaction. Specifically, heavy viewers of Grey’s Anatomy are hypothesized to
believe the show is credible (H1 ). A belief that Grey’s Anatomy presents a credible
portrayal of doctors is hypothesized to be positively associated with a perception that
real-world doctors are courageous (H2 ). To provide a direct test of the cultivation
hypothesis, Grey’s Anatomy viewing is hypothesized to be positively associated with
perceived courageousness of real-world doctors (H3 ). Along with testing a direct ef-
fect between Grey’s Anatomy viewing and perceptions of real-world doctor courage,
an indirect effect between these variables was assessed as mediated through program
credibility (RQ1). Following extant research on doctor-patient communication, a
positive association between perceiving a doctor to be courageous and patient
satisfaction was hypothesized (H4 ). The hypothesized structural model is depicted
in Figure 1.
46 Journal of Broadcasting & Electronic Media/March 2009
Figure 1
Hypothesized Structural Model
Method
Participants and Procedures
Students in a communication class at a large Midwestern University recruited five
students to complete the paper and pencil survey for extra credit. This recruitment
strategy was employed because it offers a broader range of participants than limiting
a sample to students enrolled in communication classes (see Kramer & Hess, 2002).
Students returned the survey to the principal investigator within 1 week. Participants
(N D 269) ranged in age from 18 to 46 (M D 20.72, SD D 2.04). The majority of
participants, 95.5%, identified themselves as White or Caucasian, while 1.1% were
African American, and 3.4% were other. Most participants were female (65.1%). In
terms of watching Grey’s Anatomy during Season 2 and part way through Season 3,
a total of 32 episodes, the majority of participants watched several episodes (M D
12.77, SD = 14.25). In fact, 78 participants reported watching all 27 episodes from
Season 2 and the first five episodes of Season 3, while 95 had not seen one episode.
Measures
In order to prevent the likelihood of an ordering effect, participants first completed
a series of items pertaining to their perceptions of real-world doctors’ courageous-
ness and patient satisfaction among others. To avoid an ordering effect, participants
indicated their television viewing habits along with their perceived credibility of
Grey’s Anatomy at the end of the survey. Additionally, given the nature of the
recruitment strategy, it was important to limit the number of survey items in or-
der to increase the validity of the responses. As a result, scales to assess Grey’s
Anatomy viewing, perceived Grey’s Anatomy credibility, doctors’ courageousness,
and patient satisfaction were developed.
To ensure that these measures empirically held together, an exploratory factor
analysis with principal axis factor extractions, promax rotations with Kaiser normal-
izations, and a convergence rotation set at 25 iterations was performed. Five factors
emerged with eigenvalues of greater than 1. Specifically, the following eigenvalues
were obtained: perceived doctor courageousness (4.39), perceived Grey’s Anatomy
credibility (2.29), and patient satisfaction (1.08).1
Quick/ECOLOGICAL MODEL 47
Grey’s Anatomy Viewing. In determining how frequently participants watched
Grey’s Anatomy, participants were asked, (a) ‘‘During the second season of Grey’s
Anatomy, how many episodes did you watch on TV?’’, and (b) ‘‘So far this season,
how many episodes of Grey’s Anatomy have you watched on TV?’’ The sum of both
items resulted in the Grey’s Anatomy viewing variable (M D 12.77, SD D 14.25).
Grey’s Anatomy Perceived Credibility. To determine the perceived credibility
of Grey’s Anatomy, the following stem was used, ‘‘In general, images and story-
lines communicated in medical dramas like Grey’s Anatomy are .’’
Three semantic differential scales with the endpoints not realistic/realistic, not cred-
ible/credible, and not believable/believable were used on a 5-point scale. The three-
item index was reliable (˛ D .88, M D 2.75, SD D .94).
Perceived Doctor Courageousness. Perceptions that doctors are courageous was
measured on a Likert scale ranging from 1 D Strongly disagree to 5 D Strongly agree,
participants responded to the following seven items: (a) In general, physicians are
heroic; (b) In general, physicians are brave; (c) In general, physicians are daring; (d)
In general, physicians are courageous; (e) In general, physicians are superhuman;
(f ) In general, physicians are brilliant; and (g) In general, physicians are clever. The
7-item scale was reliable (˛ D .84, M D 3.25, SD D .64).
Patient Satisfaction. On a 1 D Strongly disagree to 5 D Strongly agree Likert
scale, participants indicated their overall satisfaction with doctors in general by
responding to two items: (a) ‘‘In general, I am satisfied with my physician,’’ and (b)
‘‘On average, my physician satisfies my health needs.’’ This 2-item index formed a
reliable measure (˛ D .79, M D 3.99, SD D .78).
Results
Structural equation model (SEM) using EQS 6.1 was employed to test the fit of the
hypothesized model. In testing the hypothesized model, Grey’s Anatomy viewing
was specified as a single-item observed variable, while perceived credibility, doctor
courageousness, and patient satisfaction were each treated as latent composite vari-
ables (see Holbert & Stephenson, 2002; Stephenson & Holbert, 2003). To determine
the adequacy of the hypothesized model, the Chi square goodness-of-fit test (�2 ),
Comparative Fit Index (CFI), Standardized Root Mean Squared Residual (SRMR),
and Root Mean Square Error of Approximation (RMSEA) were used as indicators.
To provide a conservative test of cultivation theory, it was decided that total
television viewing, which represented the sum of hours watched on the average
weekend and weekday, along with participants’ biological sex and the number
of doctor visits during the past year should serve as covariates while testing the
48 Journal of Broadcasting & Electronic Media/March 2009
Table 1
Means, Standard Deviations, and Correlations for Variables
(N D 269)
Variables 1 2 3 4
1. GA Viewing 1.0
2. GA Credibility .33 1.0
3. Courage .13 .25 1.0
4. Satisfaction .02 .08 .27 1.0
Mean �.02 �.01 .00 .00
Standard Deviation 14.16 .93 .63 .78
Note. GA D Grey’s Anatomy.
hypothesized model. In doing so, Grey’s Anatomy credibility, doctor courage, and
patient satisfaction were regressed on each of the covariates using SPSS software.
Then, the unstandardized residuals for these variables, which represent the variance
not explained by the covariates, were saved and transferred to EQS for the structural
equation analyses (e.g., Stephenson & Palmgreen, 2001). In this way, the variables
depicted in the structural model are not affected by any systematic effect due to the
covariates.
The Mardia’s normalized estimate was examined and was not determined to be
problematic at .80. The results indicated that the hypothesized structural model was
consistent with the data, CFI D 1.0, SRMR D .01, RMSEA D .00 (CI: .00, .05), �2
(2, N D 269) D .19, p D .91. See Table 1 for correlations, means, and standard
deviations (after controlling for the covariates) for this model’s variables and Figure 2
for path coefficients.
The first hypothesis predicted that viewers of Grey’s Anatomy would be likely
to perceive the show as credible. Following cultivation theory (Gerbner & Gross,
1976; Gerbner et al., 2002), heavy viewers of television are more likely to adopt
worldviews that mirror those portrayed on television. A positive association was
anticipated and found between exposure to Grey’s Anatomy and perceptions of this
show’s credibility, ˇ D .35, p < .001.
Figure 2
Structural Model
Note. *** D p < .001.
Quick/ECOLOGICAL MODEL 49
A cultivation effect is believed to be most pronounced within contexts where
viewers are unfamiliar with the content being portrayed on television (see Chory-
Assad & Tamborini, 2001; Gerbner & Gross, 1976; Morgan & Signorielli, 1990; Pfau
et al., 1995; Volgy & Schwarz, 1980). Due to the unfamiliarity of life inside a teach-
ing hospital, it was hypothesized that for viewers perceiving the presentations on
Grey’s Anatomy to be credible, a perception that real-world doctors are courageous
would follow. Hypothesis 2 received empirical support, ˇ D .28, p < .001.
Following the frequent portrayal of doctors performing heroic acts throughout
Grey’s Anatomy, it was hypothesized that heavy viewers of Grey’s Anatomy would
likely perceive real-world doctors to be courageous. Hypothesis 3 did not receive
empirical support, ˇ D .04, p > .05.
A positive association was hypothesized between perceived real-world doctor
courageousness and patient satisfaction. Patients want doctors that are willing to do
whatever it takes to improve their health. Hypothesis 4 received empirical support
in the hypothesized direction, ˇ D .33, p < .001.
Although a direct effect for Hypothesis 3 was not found, an indirect effect con-
necting Grey’s Anatomy viewing and perceived doctor courageousness as medi-
ated through perceived Grey’s Anatomy credibility was examined. Media effects
researchers have encouraged examining indirect effects to get at the why question
in quantitative research (Holbert & Stephenson, 2003; McLeod et al., 1996). In
response, a product of coefficient test for mediation was performed (MacKinnon,
Lockwood, Hoffman, West, & Sheets, 2002). In doing so, a z-score product for the
mediation of Grey’s Anatomy viewing on Grey’s Anatomy perceived credibility and
doctor courageousness was computed, (.02/.004) � (.18/.05) D 18. After consult-
ing Craig’s (1936) normally distributed variable table, Grey’s Anatomy perceived
credibility was determined to mediate Hypothesis 3 at p < .001.
Discussion
Street (2003) advanced the ecological model to provide a systems framework to
the healthcare provider-patient relationship. Within the model, Street acknowledged
the media as an environmental factor that influences patient predispositions prior to
an appointment with a doctor. Although the present investigation was not a formal
test of the ecological model, it applied cultivation theory to a single program across
32 episodes as opposed to total television viewing (Gerbner et al., 2002; Morgan
& Shanahan, 1996) and genre-specific programming (Chory-Assad & Tamborini,
2003; Romer et al., 2003; Segrin & Nabi, 2002; Weaver & Wakshlag, 1986; Wilson
et al., 2005), and advanced cultivation theory by providing partial evidence that
this framework can be applied to a single program over an extended period of
time. Results from this investigation are discussed below with an emphasis on how
these findings bolster Street’s ecological model, advance cultivation theory, and to
a larger extent, provide a linear framework from which to understand antecedents,
within a media context, to patient satisfaction.
50 Journal of Broadcasting & Electronic Media/March 2009
A research line that emerged more than four decades ago sought to understand
media portrayals of doctors (Chory-Assad, & Tamborini, 2001; Pfau et al., 1995;
Turow, 1989, 1996; Turow & Coe, 1985; Volgy & Schwarz, 1980). From this
research, readers learn that doctors historically have been portrayed on television
as omnipotent healers who overcome adverse conditions to triumph in the face of
adversity (O’Connor, 1998). Although content analyses of these medical portrayals
abound (Chory-Assad, & Tamborini, 2001), less is known about how these portrayals
impact patient perceptions (Chory-Assad & Tamborini, 2003; Pfau et al. 1995;
Volgy & Schwarz, 1980). Cultivation researchers argue that heavy viewers are
likely to perceive the world as it is depicted on television more than light viewers
(Gerbner & Gross, 1976; Gerbner et al., 2002). Although the bulk of research
favors a cultivation effect (see Morgan & Shanahan, 1996), Gerbner and colleagues’
hypothesis is stronger when audiences have little experience or exposure to the
phenomenon depicted on television (Gerbner & Gross, 1976; Pfau et al., 1995). For
these reasons, it was hypothesized that a positive association would emerge between
Grey’s Anatomy viewers and show credibility. The first hypothesis was supported,
which predicted that the number of Grey’s Anatomy episodes viewed would be
positively associated with the perceived credibility of the show. In other words, the
more people watched the show, the more realistic they perceived the program. This
finding was not surprising given the limited exposure that has been given to day-
to-day operations of teaching hospitals. For this reason, media are likely to affect
judgments when the portrayals are perceived as realistic (Bahk, 2001; Busselle,
2001; Busselle & Greenberg, 2000).
To examine the show’s influence on viewers’ predispositions, a positive asso-
ciation was hypothesized connecting Grey’s Anatomy credibility with real-world
doctors’ courageousness (Hypothesis 2). This hypothesized association between per-
ceived credibility and doctor courageousness was confirmed and sheds additional
light into how television viewing of Grey’s Anatomy can impact patient perceptions.
Consistent with portrayals of the doctors at Seattle’s Grace Hospital on Grey’s
Anatomy, it is not surprising that participants within this study perceived doctors
in general to be courageous. Episodes frequently depict doctors as performing a
risky procedure to save or significantly improve the life of a patient. Often, multiple
storylines represent doctors performing heroic acts to save or significantly improve
a patient’s life.
Gerbner and colleagues assert that cultivation effects span total television viewing,
not genre- or program-specific viewing (Gerbner et al., 2002). The rationale behind
this fundamental belief rests in the assumption that consistent storylines are present
across genres. Although this assumption has received its share of criticisms (see
Hawkins & Pingree, 1980; Potter & Chang, 1990), critics of this belief may be
right. Recent research suggests that genre-specific programs explain more variance
in outcome variables of interest than total television viewing (Chory-Assad & Tam-
borini, 2003; Segrin & Nabi, 2002, Wilson et al., 2005). These findings are not
surprising given the influx of more tailored programming due to channel increases
with satellite television. This investigation extends this research by narrowing the
Quick/ECOLOGICAL MODEL 51
scope of cultivation by testing the relationship between television viewing of Grey’s
Anatomy, across 32 episodes, on a host of outcome variables. Evidence did not sup-
port a cultivation hypothesis via a direct effect between Grey’s Anatomy viewing and
perceptions of doctors’ courageousness (Hypothesis 3); however, an indirect effect
between these variables mediated through perceived Grey’s Anatomy credibility
was found (Research Question 1). In a spirited call, Holbert and Stephenson (2003)
encouraged researchers to examine indirect effects when testing structural models.
Media effects researchers have encouraged examining indirect effects to unravel the
underlying mechanisms at work in examining media effects (McLeod et al., 1996).
In response to this charge, MacKinnon et al.’s (2002) product of coefficient estimate
was employed. Although a direct effect was not found, an indirect effect connecting
Grey’s Anatomy viewing and perceptions that real-world doctors are courageous
was supported. Additional research should continue to examine a cultivation effect
resulting from total television exposure, genre-specific, and exposure to a single
program over several episodes. Initial evidence did not suggest a direct link between
Grey’s Anatomy viewing and perceptions of doctors’ courageousness, but rather
perceiving the show to be credible mediated this relationship.
Hypothesis 4 predicted a positive association between doctor courageousness and
patient satisfaction. The strength of this association was robust. Put another way,
participants in this study perceived courage was strongly associated with patient
satisfaction. Perhaps the reason for the strong support for this hypothesis stems from
the similarity between perceived doctor courageousness and doctor competence
among participants in this study.1 Hall and Dornan’s (1988) meta-analysis (k D
107) discovered that patient satisfaction is a result of perceived doctor competence.
This is not surprising because there is comfort in knowing that a doctor will do
everything in his or her power to save or improve the condition of a patient. In
short, results from this investigation suggest that courageousness is closely linked to
patient satisfaction. Future research should examine patient perceptions of doctor
courageousness within the clinical context to see if these associations replicate.
With an overview of the major findings from this investigation, attention is turned
to the shortcomings of this study and the opportunities that remain.
Limitations and Future Research
The present investigation offers a glimpse of how viewing Grey’s Anatomy can
impact patient predispositions about real-world doctors. Although this study rep-
resents an initial attempt to better understand the role of Grey’s Anatomy viewing
on perceptions of doctors, this investigation raises more questions than it answers.
Future research should assess the role of medical dramas in changing, creating, or
reinforcing perceptions of nurses and hospital administrators. Along these lines, re-
search should also examine television portrayals of health insurance and malpractice
suits as well as other economical and political factors that impact the complexities
in the healthcare provider and patient relationship. Research should also make an
52 Journal of Broadcasting & Electronic Media/March 2009
effort to recruit from more heterogeneous populations. The generalizability of these
findings is hindered given the convenience sample employed to recruit participants.
Although many of these college students were heavy viewers of Grey’s Anatomy, a
random sample would enhance the external validity to these findings. Additionally,
a larger sample would increase the generalizability of these findings.
Future research should inquire about specific details derived from Grey’s Anatomy
viewers to ascertain how this program impacts their predispositions. The present
study addressed the more global question of whether viewing Grey’s Anatomy
impacts perceptions of doctors in general; however, identifying certain content
features from Grey’s Anatomy that impact perceptions of doctor courageousness and
perhaps other variables such as doctors’ character, interpersonal style, physical at-
tractiveness, social attractiveness, power, competence, and regard for others (Chory-
Assad & Tamborini, 2001; Pfau et al., 1995) would be a welcomed addition. On a
related note, understanding why and how these variables impact patient satisfaction
would enhance the understanding of media portrayals of doctors. For instance,
depictions of doctors as being courageous and heroic could logically result in this
program serving as a mechanism for social control. How viewers interpret these
behaviors and how it could impact patient adherence is worthy of future research.
Perhaps, relying on interpretive methods of data collection such as focus groups
and in-depth interview will provide answers to these important questions. Future
research should examine how heavy viewers of shows such as Grey’s Anatomy
perceive their role as patients within the doctor-patient relationship. Findings from
such a study would be valuable to research advocating patient training (for a review,
see Cegala & Broz, 2003). Finally, applying cultivation theory into other specific
programs, across multiple episodes, as opposed to total television viewing or genre-
specific programs should receive additional attention.
Conclusion
An advantage of the ecological model rests in its ability to identify environmental
sources such as the media that shape, reify, and change audience predispositions
about medical encounters with doctors. Findings from this investigation demonstrate
that heavy viewers of Grey’s Anatomy perceive the content to be realistic, which
leads to believing doctors are courageous, which leads to being more satisfied with
one’s real-world doctor. Given the limited exposure most patients have to these
behind the scene looks at doctors at teaching hospitals, accurate portrayals of this
context and settings is paramount. Additionally, portrayals of issues such as organ
donation present television producers with an opportunity to shed light into some
of the major problems facing society. Given the perceived credibility of Grey’s
Anatomy by its devoted viewers, public health advocates have an opportunity to dis-
seminate accurate health messages within these shows. Unfortunately, historically,
producing television shows for commercial and social reasons have been seen as
adversaries as opposed to complementary (Singhal & Rogers, 2002). Hollywood has
Quick/ECOLOGICAL MODEL 53
a tendency to sensationalize issues for improved audience ratings. In fact, a recent
content analysis of television portrayals of organ donation supported this claim
(Morgan, Harrison, Volk Chewning, DiCorcia, & Davis, 2007). As a result, these
researchers encouraged organ donation advocates to influence the entertainment
industry to present accurate depictions of health. In sum, this investigation provided
a testable theoretical framework to bolster Street’s (2003) ecological model. As
a result, this investigation provides a better understanding about the underlying
process by which the media infiltrates patients’ predispositions about doctors in
general via exposure to Grey’s Anatomy.
Note
1Initially, doctor courageousness and competence were believed to be separate concepts. Although two factors emerged between both sets of items, results from the factor analysis revealed that only one item loaded on perceived competence, thus it was dropped.
References
Bahk, C. M. (2001). Drench effects of media portrayals of fatal virus disease on health locus of control beliefs. Health Communication, 13, 187–204.
Brown, J. B., Stewart, M., & Ryan, B. L. (2003). Outcomes of patient-provider interaction. In T. L. Thompson, A. M. Dorsey, K. I. Miller, and R. L. Parrott (Eds.), Handbook of health communication (pp. 141–162). Mahwah, NJ: Lawrence Erlbaum Associates.
Busselle, R. W. (2001). Television exposure, perceived realism, and exemplar accessibility in the social judgment process. Media Psychology, 3, 43–67.
Busselle, R. W., & Greenberg, B. S. (2000). The nature of television realism judgments: A reevaluation of their conceptualization and measurement. Mass Communication & Society, 3, 249–286.
Cegala, D. J., & Broz, S. L. (2003). Provider and patient communication skills training. In T. L. Thompson, A. M. Dorsey, K. I. Miller, and R. L. Parrott (Eds.), Handbook of health communication (pp. 95–120). Mahwah, NJ: Lawrence Erlbaum Associates.
Chory-Assad, R. M., & Tamborini, R. (2001). Television doctors: An analysis of physicians in fictional and non-fictional television programs. Journal of Broadcasting & Electronic Media, 45, 499–521.
Chory-Assad, R. M., & Tamborini, R. (2003). Television exposure and the public’s perceptions of physicians. Journal of Broadcasting & Electronic Media, 47, 197–215.
Craig, C. C. (1936). On the frequency function of xy. Annals of Mathematical Statistics, 7, 1– 15.
Deimen, J. (2006). Grey’s Anatomy. The Urban Wire. Retrieved March 5, 2008, from http:// www.theurbanwire.com/stories/index.php?optionDcom_content&taskDview&idD549& ItemidD67.
Gerbner, G., & Gross, L. (1976). Living with television. The violence profile. Journal of Communication, 26, 182–190.
Gerbner, G., Gross, L., Morgan, M., Signorielli, N., & Shanahan, J. (2002). Growing up with television: Cultivation processes. In J. Bryant and D. Zillmann (Eds.), Media effects: Advances in theory and research (2nd ed., pp. 43–67). Mahwah, NJ: Lawrence Erlbaum Associates.
54 Journal of Broadcasting & Electronic Media/March 2009
Greenberg, B. S. (1988). Some uncommon television images and the drench hypothesis. In S. Oskamp (Ed.), Applied social psychology annual: Television as a social issue (Vol. 8, pp. 88–102). Newbury Park, CA: Sage.
Hall, J. A., & Dornan, M. C. (1988). What patients like about their medical care and how often they are asked: A meta-analysis of the satisfaction literature. Social Science and Medicine, 27, 935–939.
Hawkins, R. P., & Pingree, S. (1980). Some processes in the cultivation effect. Communication Research, 7, 193–226.
Holbert, R. L., & Stephenson, M. T. (2002). Structural equation modeling in the communication sciences, 1995–2000. Human Communication Research, 28, 531–551.
Holbert, R. L., & Stephenson, M. T. (2003). The importance of analyzing indirect effects in media effects research: Testing for mediation in structural equation modeling. Journal of Broadcasting & Electronic Media, 47, 556–572.
Kramer, M. W. & Hess, J. A. (2002). Communication rules for the display of emotions in organizational settings. Management Communication Quarterly, 16(1), 66–80.
MacKinnon, D. P., Lockwood, C. M., Hoffman, J. M., West, S. G., & Sheets, V. (2002). A com- parison of methods to test mediation and other intervening variable effects. Psychological Methods, 7, 83–104.
McLeod, J. M., Kosicki, G. M., & Pan, Z. (1996). On understanding and misunderstanding media effects. In J. Curran & M. Gurevitch (Eds.), Mass media and society (pp. 235–266). London: Edward Arnold.
Morgan, S. E., Harrison, T. R., Volk Chewning, L., DiCorcia, M., Davis, L. (2007). Entertain- ment (mis)education: The framing of organ donation in entertainment television. Health Communication, 22, 143–151.
Morgan, M., & Shanahan, J. (1996). Two decades of cultivation research: An appraisal and meta-analysis. In B. R. Burleson (Ed.), Communication yearbook, 20, 1–45. Newbury Park, CA: Sage.
Morgan, M., & Signorielli, N. (1990). Cultivation analysis: Conceptualization and methodol- ogy. In N. Signorielli & M. Morgan (Eds.), Cultivation analysis: New directions in media effects research (pp. 13–34). Newbury Park, CA: Sage.
Nielsen Media Research (2005). Your guide to local reports and services, 2005. O’Connor, M. M. (1998). The role of the television drama ER in medical student life: Enter-
tainment or socialization? The Journal of the American Medical Association, 280, 854– 855.
Pfau, M., Mullen, L. J., & Garrow, K. (1995). The influence of television viewing on public perceptions of physicians. Journal of Broadcasting & Electronic Media, 39, 441–458.
Potter, W. J., & Chang, I. C. (1990). Television exposure measures and the cultivation hypoth- esis. Journal of Broadcasting & Electronic Media, 34, 313–333.
Reddy, M. (2007, November 11). Muslims on TV, no terror in sight. The New York Times, p. 30.
Reep, D. C., & Dambrot, F. H. (1989). Effects of frequent television viewing on stereotypes: ‘‘Drip. Drip’’ or ‘‘drench’’? Journalism Quarterly, 66, 542–550.
Romer, D., Jamieson, K. H., & Aday, S. (2003). Television news and the cultivation of fear and crime. Journal of Communication, 53, 88–105.
Roter, D. L., Stewart, M., Putnam, S. M., Lipkin, M., Jr., Stiles, W., & Inui, T. S. (1997). Communication patterns of primary care physicians. Journal of the American Medical Association, 277, 350–356.
Segrin, C., & Nabi, R. L. (2002). Does television viewing cultivate unrealistic expectations about marriage? Journal of Communication, 52, 247–263.
Shanahan, J., & Morgan, M. (1999). Television and its viewers: Cultivation theory and research. Cambridge, UK: Cambridge University Press.
Singhal, A., & Rogers, E. M. (2002). A theoretical agenda for entertainment-education. Com- munication Theory, 12, 117–135.
Stephenson, M. T., & Holbert, R. L. (2003). A Monte Carlo simulation of observable-versus latent-variable structural equation modeling techniques. Communication Research, 30, 332–354.
Quick/ECOLOGICAL MODEL 55
Stephenson, M. T., & Palmgreen, P. (2001). Sensation seeking, perceived message sensa- tion value, personal involvement, and processing of anti-marijuana PSAs. Communication Monographs, 68, 49–71.
Street, R. L., Jr. (2003). Communication in medical encounters: An ecological perspective. In T. L. Thompson, A. M. Dorsey, K. I. Miller, and R. L. Parrott (Eds.), Handbook of health communication (pp. 63–93). Mahwah, NJ: Lawrence Erlbaum Associates.
Turow, J. (1989). Playing doctor. New York: Oxford University Press. Turow, J. (1996). Television entertainment and the US health-care debate. Lancet, 347, 1240–
1244. Turow, J., & Coe, L. (1985). Curing television’s ills: The portrayal of health care. Journal of
Communication, 35, 36–51. Volgy, T., & Schwarz, J. E. (1980). TV entertainment programming and sociopolitical attitudes.
Journalism Quarterly, 57, 150–155. Weaver, J., & Wakshlag, J. (1986). Perceived vulnerability to crime, criminal victimization
experience, and television viewing. Journal of Broadcast & Electronic Media, 30, 141–158. Wilson, B. J., Martins, N., & Marske, A. L. (2005). Children’s and parents’ fright reactions to
kidnapping stories in the news. Communication Monographs, 72, 46–70.
