Healthy viewing: the reception of medical narratives
Address for correspondence: Solange Davin, Flat 1/L, 15 Eskdale Street, Glasgow G42 8UD e-mail: firstname.lastname@example.org.
Abstract This paper draws on two reception studies. One focuses on an American medical drama which respondents perceived as entertainment but also as a reliable source of information from which they collected medical and social data by using emotional and ludic strategies. The second compares parallel illness narratives in a soap opera and a documentary. Soap operas were described by informants as good pedagogic tools because they attracted large audiences and promoted identification and repetition which enhance learning. On the other hand, they criticised the documentary for being incomplete and artificial. The conclusion argues that viewers are media-literate, astute and insightful. They produce sophisticated, subtle interpretations which cannot be predicted by content analyses of programmes alone. More reception research is therefore needed, particularly since television is increasingly omnipresent and provides a considerable portion of the public's medical knowledge.
Introduction: screening medical narratives
When Norman Felton was put in charge of development at the CBS network in 1959, one of his aims was to create a medical drama. But senior executives at first rejected the idea. ‘Sick people in hospital is something you don’t want to put on television. People have enough trouble during the day!’ they objected1. They could not have been more mistaken. Medical dramas won instant acclaim, and, 50 years on, the genre has reached epidemic proportions. From selfless surgeons to egotistical consultants to emergency room anti-heroes, physicians occupy a place of honour on the small screen. In Great Britain, the US drama Dr. Kildare remained in the top 10 favourites for five years in the 1960s (Philips 2000), Peak Practice, made by the British network ITV, reached ratings of 13 million (Hallam 1998) and Casualty, the BBC1 flagship medical drama, first made in 1986, continues to attract over 10 million followers, according to the BBC (news.bbc.co.uk/1/hi/entertainment/tv_and_radio/1749007.stm). Medical themes have also been popular in the UK in factual genres, from the 1958 ground-breaking documentary Your Life in Their Hands through well-known series like Horizon and Panorama to the sarcastic 1990s Trust Me I’m a Doctor (all BBC programmes). Yet the reception of (fictional and factual) health and illness narratives on television has been neglected by researchers. Little is known about the responses of these substantial audiences to images of sickness2 despite the fact that television is known to be a prime source of medical information for the public (Karpf 1988, Kitzinger 1998). How televised representations of health and illness contribute to spectators’ knowedge thus needs urgent attention, particularly as the medium is increasingly prevalent. This paper begins to fill in the gap by reporting on two reception studies, one of the American drama ER and the second of parallel illness storylines in a documentary and a soap opera, whose purpose was to collect hitherto-lacking data on the interpretations3 of medical narratives on television.
ER as a source of medical information
The first study presented in this paper draws on letters received in response to advertisements in British and French television magazines4 asking viewers why they watched ER, a wording which enabled respondents to discuss the broadcast in their own terms. One hundred and 33 women and 62 men replied, of whom just under half were British, aged between 12 and 84 and from a diverse range of backgrounds – students, unemployed, doctors, nurses, clerks, housewives, etc. (including six viewers who disliked ER). The data were analysed manually. After repeated readings, an open coding procedure (Strauss and Corbin 1990) was applied in order to generate themes grounded in the letters rather than imposed a priori. The categories which emerged were further scrutinised in order to discern similarities and differences between interpretations, and sub-classifications were drawn accordingly. The limitations of the study are acknowledged – more women than men participated and self-selected informants may respond differently from a random sample. The aim of the project was to examine responses to medical narratives in the light of recent reception studies demonstrating the complexity and subtlety of viewers’ interpretations (e.g.Hill 1999,Turnock 2000).
ER is a fast-paced American medical drama which follows the lives and loves of a group of health professionals working on an emergency ward in Chicago. It was conceived in the late 1970s by Michael Crichton, best known for his films Jurassic Park and Coma. Although he never practised, Crichton is a qualified physician and the first ER scenarios were inspired by his casualty training. In its first season ER was hailed as the highest-ranking drama in US media history with 35 million viewers (Pourroy 1996). It has since become a quasi-cult show in over 60 countries, including the UK with more than four million fans (reported in Radio Times) and France with five million (http://www.t7j.com/audiences.php).
Most viewers, as may be expected from its international fame, described ER as quality entertainment, perhaps the best medical drama yet. They enjoyed its swinging rhythm of action and emotion, triumph and defeat, chaos and calm, joy and sorrow:
Each episode seems to take you on a roller-coaster ride, laughing one minute, crying the next … It shows life at both ends of the spectrum (British woman, 53, housewife).
They tried to predict forthcoming plots and wrote their own happy-ending scenarios. They looked forward to their weekly meetings with regular characters and to the gradual discovery of their complex personalities:
I am interested in all the characters because we discover new facets in each episode. He who seemed perfect shows weaknesses and he who seemed abominable is ‘redeemed’. . . (French woman, 27, teacher).
But ER is no mere distraction. In line with the current infotainment trend, it was simultaneously perceived by informants as a trustworthy source of information on topics which they were eager to know more about, from ‘the intricacies of the profession, what goes into the training, the ethics, the negligence, the politics, etc.’ (British woman, 38), to ‘what an operation looks like’ (French man, 62, hotel manager). In addition, a dozen informants explicitly thought of the drama in terms of a documentary:
We find it a very realistic series, that is, in the sense of ‘documentary’, which is very rare and interesting (French woman, 49, switchboard operator).
This should not be surprising since ER has many attributes usually associated with documentaries: the scripts are written by doctors who also supervise the filming, the medical stories are based on real emergency cases reported by health professionals, the main actors have familiarised themselves with real casualty procedures, the medical equipment is genuine, and the Steadycam cameras give an impression of impromptu, of real life (Pourroy 1996).
What did viewers learn from a popular entertainment show to which they attributed informative properties? Although the production team refused to indulge the public's unquenchable thirst for medical knowledge and to provide explanations for the medics’ actions (Pourroy 1996), just under half the informants reported acquiring data on physiology, symptoms, diseases, treatments, the practice of medicine:
A cancer can cause a broken leg, I did not know that at all (French woman, 19, Baccalaureate student).
Some believed that the production team wanted to raise awareness of health risks old (drug abuse, smoking, HIV infection) and new, and remembered some of the dangers brought to their attention:
I liked the episode where a student gets a shock allergy from latex gloves. It informs you about an increasingly common allergy (French woman, 48, GP).
Moreover, like Casualty, ER may ‘help to prepare viewers for the experience of witnessing such scenes, or for going into hospital themselves’ (Buckingham 1997: 224):
I had never seen such glasses. Now if I go to casualty I won’t be surprised if they wear glasses or a green or blue gown or gloves (French man, 27, computer programmer).
This information-gathering process is not specific to ER. Medical knowledge is extracted from other fictional broadcasts. Kingsley (1993) reports that some fans diagnosed their own diseases from Casualty and claims that it has taught millions about the ins-and-outs of medicine. Incidental findings show that soap operas can convey useful data: a woman became pregnant after hearing about ovulation prediction kits in the US soap All My Children (Rogers 1995). The famous American serial Dallas provided details on amniocentesis (Rapp 1988) and the British soap opera Coronation Street on mental illness (Philo 1996). Guidance about drugs and safe sex was gleaned from a range of soaps by Willis's (1990) adolescents. The pedagogic potential of fiction has been acknowledged and legitimised by the use of soap operas in health promotion campaigns (see below) and in schools (Grahame and Simons 1998), of police series for police training courses (Simon and Fejes 1987), and of ER in universities:
My neighbour, who did his internship at [name of hospital], told me that tutors recommend ER and discuss the episode the following day (French woman, 41, sales assistant).
Some medical dramas have (had) educational ambitions (and so have British-made soap operas, as will be seen below). The mission of early British ones was to help ‘overcome the pre-war attitude of the public to hospitals as institutions, as places to be avoided at all costs’ (Karpf 1988: 183), with positive results: Emergency Ward 10 was praised by the British Medical Association for helping allay these fears (Kingsley 1988). From the beginning, Casualty has included medical and first-aid hints and its motto has been ‘educating while entertaining’ (Kingsley 1993: 86).
These objectives match viewers’ taste for such mélanges. From the farmers who, in 1950, chose a format of soap opera to receive agricultural advice (a choice which led to the creation of the ongoing BBC radio soap The Archers) (Kingsley 1988) to the young people who, more recently, called for information about contraception and safe sex to be disseminated in soap operas (BAC 1999), viewers – particularly adolescents who seem strongly resistant to didactic approaches (Gavin 2001) – have consistently restated their preference for ‘edutainment’ (e.g.Bouman, Mass and Kok 1998). For many, a good series is one which simultaneously ‘entertains and addresses their problems’ (Elkamel 1995: 228).
ER as a vehicle for social knowledge
It is not only medical knowledge which was acquired from ER. Social concerns have long been a key attraction of ‘professional dramas’ (dramas whose main protagonists are lawyers, doctors, police officers) (Dientsfrey 1976), and ER is no exception. Viewers were alert to the social issues evoked in the show. First, they learnt about the organisation of health care. The informants who addressed the subject compared the day-to-day functioning of US and British/French health systems. They were especially struck by the differential roles of the emergency wards:
Many of the non-urgent patients would not be in casualty in England. They would have gone to their GP (British woman, 38, legal secretary).
At a broader level, some informants contrasted the Welfare State ethos of free care for all to the American health market where a few underfunded state hospitals are the only provision available to the many without private insurance:
They show the problems of social cover in the US, the lack of money in hospitals, the treatments chosen because they are cheap, the patients sent away because they cannot pay for their treatment … (French woman, 33, travel agency clerk).
These informants agreed that the former is superior, with one striking exception:
Whoever has been to casualty in France can only wish they could go to Chicago to be treated. They don’t have to wait for hours … (French man, 23, architecture student).
Second, because ER takes place in a state hospital, it is ideally situated to reveal aspects of American society which are commonly erased from entertainment. Around a quarter of respondents, observing the ongoing flow of unemployed and/or homeless patients taking refuge in ER, commented on this depiction of poverty, violence, exclusion, and contrasted it to the socially and economically healthy country portrayed in ‘Beverly Hills-style serials like Dallas’ (French woman, 44). ER was praised for its ‘non-PC approach’ (British woman, 36, nurse) which discloses the flip-side of Dallas-Dynasty's America:
We keep seeing patients who need help from social services, children's bodies full of bullets, abused children. It seems to me that ER is a rich and realistic portrait of American society (French woman, 17, high school pupil).
A few informants feared that these images of healthcare rationing and of daily hardship for the less wealthy may prove to be a preview of their own country when these problems reach the European side of the Atlantic.
These remarks add a political touch to the reception of ER which echoes that produced by the young EastEnders viewers who interpreted the long-lasting BBC1 soap opera in political/ideological terms even though the ‘kinds of judgements which are invited are more frequently moral rather than ideological ones – that is, judgements which relate to the rights and wrongs of individual behaviour, rather than to broader social issues’ (Buckingham 1987: 174).
In view of the linking of ER to documentaries, it seems somewhat ironic that respondents in a follow-up project should express scepticism towards the genre. The objective of this study was to compare the reception of medical narratives in a fictional storyline (‘Peggy's breast cancer’ in EastEnders, Peggy being a long-standing central character) and in a factual narrative, a 50-minute Channel 4 documentary following a patient and her husband through the stages of her fight against breast cancer.
Advertisements were placed in several locations (libraries, shops, etc.) and 24 British women were recruited and interviewed individually5 after viewing the programmes. The interviews were ‘ethnographic’, as defined by Spradley (1979), conversation-like, encouraging informants to speak in their own words and to broach topics of interest to them rather than those pre-determined by the researcher. Interviews were taped and transcribed verbatim and submitted to the same coding procedures as the ER data. The study was the first of a series examining men and women's responses to fictional and factual television narratives of (male and female) cancers and was designed to explore women's interpretations of portrayals of breast cancer. Men's responses are therefore not included.
Despite documentaries’ traditionally high status (somewhat tarnished in recent years by several ‘faked documentary’ scandals (see Maddox 1999)), most informants were cautious. Their circumspection was based on two objections. Documentaries6 are misleading: first, because the camera, often seen as a mechanical, neutral device, as the eye-which-never-lies, does indeed lie: it lies by omission, by not telling the whole story, by presenting snippets of a broader picture, portions of which are erased. Thus they are incomplete, partial (in both senses of the term) constructions:
She did not fall to pieces or apparently she did not … But you don’t know if she is schooled beforehand or if it is edited. We don’t know about the editing and we are left with the positive bits (Teacher, 36).
Secondly, the presence of cameras is enough to lure even the most genuine protagonists into being tempted to playact, to adopt a false persona:
It is a realistic documentary but you are aware that the family was being watched. Hence they are not quite being themselves. I wonder what goes on off camera (Receptionist, 52).
Most women repeatedly wondered about the ‘off camera’ and ‘the editing’, sometimes speculating as to what had (perhaps) been removed from the screen, and documentary images were said to be fragmentary and artificial. They cannot be taken for a full and faithful reproduction of real life. These arguments were corroborated by the husband of the patient who features in the documentary, who agreed to discuss the making of the programme (16 May 2000):
It is a story. There is so much selection of material … They filmed 60 hours over four months. So it's only part of the whole story [ … ] There were cameras outdoors and inside. I could not see them but it was very artificial. I was very conscious of them. It was almost like acting . . .
Thus, viewers were critical of the documentary genre but not of the documentary side of ER. This may be because the former's reputation for objectivity and honesty raises both viewers’ expectations and their vigilance and propensity to look for flaws, as this quote from the second study suggests:
I know that it is a documentary and that they say what they think is the case but I am more inclined to question it because I know that doctors have different viewpoints. While, funnily enough, when it comes to EastEnders, I did not think that at all. I just felt ‘that's what they say’. There is a difference. With documentaries you are more likely to question things because it's a different process when you watch documentaries. And I think it calls for different kinds of responses. A soap you will accept more easily (Company director, 64).
Anticipating entertainment from ER, viewers, surprised and delighted to find useful material, may therefore be more lenient. Thus, form and content are intertwined: expectations about form may affect the perception of content. This phenomenon was also visible when viewers criticised ER excesses (notably the ‘unbelievable number of serious cases in each episode’ (British woman, 53, housewife) and the speed at which they were treated) but discounted their implausibility on the grounds that these exaggerations were not due to mistakes, sloppiness or deception, but were necessary if the requirements of good drama are to be met. In spite of these recurrent unrealistic elements, ER therefore remains realistic.
This is not to say that viewers dismissed documentaries. But, although only four informants mentioned using documentary information, it is worth noting that two reported conducting a verification procedure beforehand:
I changed my diet and my family's diet, all on the basis of information from television, mostly documentaries about how things affect you. You consider what they say and you go to the sources to confirm your impressions and then you change. That's my experience (Office administrator, 49).
Continuous serials as a pedagogic resource
Soap operas began on American radio in the 1930s. Sponsored by manufacturers of domestic products eager to target housewives, they soon acquired a ‘feminine drivel’ label which followed them when they appeared on television7. In contrast, in British public service culture, many soaps have had (partly) pedagogic objectives (see Anger 1999, Buckman 1984). The radio soap The Archers was sponsored by the Department of Agriculture and designed to disseminate farming advice (Kingsley 1988). Tony Holland, the EastEnders script-editor, was adamant that ‘we are not going to duck any social issues. Our stories would deal with all the contemporary problems of London's East End’ (quoted in Geraghty 1994: 34), and many have indeed figured in the serial, from abuse to xenophobia through sickness (schizophrenia, HIV/AIDS, spina bifida, depression, infertility, alcoholism, cancer, etc.). Equally, Phil Redmond, the creator of Brookside, a soap produced by the British network Channel 4, aspired to ‘contribute to any continuous social debate . . .’ (quoted in Gottlieb 1993: 40). In the 1990s, Brookside became the backbone of the literacy campaign of the British Department of Education (Grahame and Simons 1998).
Some stigma still surrounds soap operas, as this quote suggests: ‘I dismiss Casualty as a soap with all these sentimental stories, not a medical drama’ (British woman, 23, shop assistant), but most respondents in the second study gave them more credit than they gave documentaries. They believed soaps to be an effective vehicle for communicating (health) advice:
Getting information through the soaps is a good way of doing it. It's a sort of health education, if you like. With information about illnesses (Teacher, 53).
One must be wary, however, of lumping programmes into genres, and of attributing to them a priori properties. Not all programmes are equal. One viewer in this study trusted EastEnders more than Coronation Street which, she thought, treated all subjects in a trivial and caricatured fashion (but of which she nevertheless remained a devoted fan). In terms of health promotion, such questions need to be tackled at the formative research stage.
Furthermore, informants can be ambivalent. One woman, talking about soaps in general, claimed that networks are too preoccupied with ratings to worry about accuracy (‘If they get desperate, if the ratings drop, they’ll put on anything’ (Administrative assistant, 44)), but was nevertheless convinced that they are good educative tools because they foster identification.
The ‘emotional’ information-gathering tactics of identification is one of four reasons given by interviewees for the usefulness of continuous serials. Soap opera characters were described as ‘very identifiable with’ by several women, a quality enhanced by regular viewing, some added, and which rendered the narratives closer and more relevant. Identification also occurred with ER. Twenty-three correspondents identified with medical students, with whom they felt a strong empathy due to a perceived shared status of newcomer on the ward:
Spectators are thrown into the whirlwind of the situations with the students. They could be the spectator who has crept inside the emergency department. Their beginners’ eyes are ours (French man, 19, college student).
Viewers and students alike were novices, ignorant of casualty practices, learning together through a process of trial and error, making mistakes together, failing and suffering (‘I suffered with him throughout his training’ (French man, 39) one person wrote), succeeding and rejoicing together. Thanks to these medics-to-be, thrilled spectators could join a (virtual) course in emergency medicine, penetrate into a hitherto mysterious hospital and discover how it functions:
We can go in the parts of the hospital which are prohibited to the public and to families, operating theatres and others (French man, 28, administration worker).
Emotional tactics may perhaps partly explain why some informants reported becoming aware through entertainment such as ER of issues like violence in the USA which have repeatedly made news(paper) headlines in recent years and which are therefore already well known.
This is especially pertinent to health promotion because, contrary to the long-held belief that new knowledge directly leads to behaviour modification (i.e. once informed that their conduct may be dangerous, rational listeners will stop/alter it), responses to health messages may have more to do with emotions than cognition (e.g.Frankham 1991).
ER viewers also made use of a ludic strategy8: a dozen people played games with the narratives, turning them into a mystery or a quiz. Once aware of patients’ symptoms/injuries, they attempted to predict the diagnoses, tests and treatments they would receive:
My favourite sport is to guess the diagnosis as soon as they admit them and tell us the injuries (British woman, 54, nurse).
In so doing, they collected material about symptoms and syndromes, the weaknesses of diagnostic techniques etc.
Secondly, these shows have vast followings (EastEnders, for example, with 17–18 million followers (Ruddock 2001, and ER with fans in over 60 countries) and exposure to messages is accordingly high. Further, their continuity requires multiple intersecting narratives, each episode chronicling a variety of plots. This mosaic style alleviates the impact of taxing illness storylines by adding a dose of light relief:
EastEnders was easier to take than the other one. It is putting its message across without being gruelling (Housewife, 54).
Finally, continuous serials include much duplicated material as characters consider and reconsider their plight, discuss it with friends, seek advice, etc. Many informants thought that repetition enhanced assimilation and recollection, a suggestion confirmed by research (e.g.Rogers and Singhal 1990).
One should also notice that all the viewers who broached the topic took it for granted that serious matters like sickness were addressed by the networks in a conscientious fashion, irrespective of genre. Many trusted producers’ and/or directors’ professionalism and sense of duty, and considered that broadcasting medical narratives without expert input and thorough research would be irresponsible and unacceptable:
They could not give false information about something as sensitive and important for women's health. They’d have to get it right. The research would have to be done. I believe what they say, I really do (Classroom assistant, 40).
This was endorsed by an EastEnders researcher whom I interviewed (9 November 1999 at the BBC Elstree Studios), who confirmed that although drama sometimes takes precedence over realism, oncology nurses and consultants were involved in the making of the ‘Peggy's cancer’ episodes:
For the Peggy story, we co-operated with [name of oncology hospital] and with cancer nurses and with [name of cancer charity]. Peggy's story is based on a case study [ … ] Sometimes it's a story decision, for example the waiting room where Peggy and Frank are alone, rather than a full room. This way we can focus on the characters. But we follow the medical guidelines. We did check the information.
Two viewers were more cynical. While believing that most medical information in the media is correct, they had little faith in producers’ integrity and/or respect for viewers. A more likely motivation, they suggested, was their fear of poor ratings and of court cases should the information prove incorrect. In a sense, it was ultimately on themselves, on the power of the public to forsake and/or take to task a network, that these informants’ confidence rested.
Moreover, there was no agreement about what EastEnders was meant to be communicating. As with ER and the documentary, contradictory opinions were articulated: some, for instance, claimed that Peggy's initial refusal of surgery and subsequent consent promoted patients’ choice and agency while others argued that it illustrated that doctors’ advice, especially in serious cases, should be adhered to, and that she had wasted precious time.
That such diversity in interpretations is unexceptional9 is illustrated by two further examples from the second study. When talking about the documentary, ten informants speculated about the (perceived) aloofness of the patient's husband when she broke the news to him that her cancer was spreading. They suggested diverse reasons for his detachment, reasons which reflected their differing perceptions (not least diverging perceptions of the two protagonists), experiences, opinions, beliefs, etc.: His remoteness befits his ongoing lack of support for his wife. He only expresses himself when directly questioned. He is unable to open up emotionally. He cannot handle the issue. He is worried that his wife cannot handle the issue. The ongoing strain has become overwhelming and he wants nothing more to do with the situation. He is embarrassed at being filmed in such an intimate situation. He is angry with his wife for consenting to filming.
Similarly, six women were puzzled by the patient's sudden decision to move house, of whom four imagined possible motivations, with equally disparate results: she wants to be busy so that she forgets about her disease; she needs a house with better facilities for when she becomes more ill; she would like to see her family settled before she goes; she wishes for a fresh start away from the home where she became sick.
Viewers’ attribution of pedagogic qualities to ongoing melodramas echoes the findings of health promotion campaigns in developing countries which have demonstrated their efficacy10. This success can be explained by the fact that they possess features known to promote learning (in addition to those cited above by informants – popularity, identification, repetition) which may be absent from large-scale publicity campaigns (see Davin 2000 for further details and references). For example, despite occasional frightening items, serials tend to have reassuring themes:
We love ER in a security way. We want to believe that it will be the same when we go to ER ourselves (French woman, 24).
Such a positive approach has been found more fertile than fear-inducing methods which have had poor overall results (Montazeri, McGhee and McEwen 1998). Furthermore, didactic exhortations, more often than not, fail to alter people's habits because they tend to be perceived as moral lessons and/or social control which prompt rejection (e.g.Plant and Plant 1994). Broadcasts like the 1990s series, moulded in postmodern uncertainty, encourage audiences to reflect on contemporary issues, to weigh the pros and cons of various solutions, to reach their own conclusions:
There is no demonstration. We are not told ‘such and such is bad’. We are shown facts and behaviours. It is for us to think about it (French man, 33).
Enabling spectators to engage in debate may have more impact than prescriptive messages: post-viewing discussions were crucial to the success of soap-supported campaigns in developing countries, as indicated by Singhal and Rogers (1999). Finally, (perceived) authenticity is key to viewers’ willingness to accept and take advice on board. Realism is the first requirement of good ‘edutainment’ (Elkamel 1995) and, as previously seen, many viewers have confidence in the realism of serials.
This dual role of hybrid broadcasts resonates with the ‘new’ theories of education (see Meyer 1997, MacMahon 1997). While the transmission of information (intended or not) is reminiscent of ‘old’ top-bottom ‘good Samaritan’ transfer models, the audiences in these studies are by no means empty vessels passively awaiting to be filled, but active interpreters processing and evaluating programmes in an intricate fashion. Their ability to be in two seemingly incompatible viewing modes at once – cognitive and emotional, distant and involved, informing and enjoying themselves – questions established dichotomies and befits the recent ‘travelling’ or ‘growing’ theories of learning which mix ‘couch’ metaphors (relaxed, undemanding viewers) and ‘desk’ ones (engaged, attentive viewers) (MacMahon 1997), and where programmes are ‘treats designed to motivate more than to instruct’ (Buckingham 1983: 97), to stimulate spectators to seek further knowledge about a topic. Some of these shows, like ER, are indeed inspiring:
I am fascinated by medical terms. I have the most incredible curiosity. I keep asking all sorts of questions to my medical student friends (French man, 26, translator).
This is particularly true of adolescents, some of whom were inspired to enter medical school:
My daughter has just started studying medicine partly because of the series, and she is not the only one [French woman, 49, pharmacist].
Similarly, registrations in law schools shot up after LA Law (Winckler 2002) and the number of men's applications to enter nursing schools raised dramatically following the portrayal of male nurses in Casualty (Hallam 1998).
The studies presented in this paper show that ER was perceived both as quality entertainment and as a reliable source of knowledge from which the public gathered medical and social information. Viewers used emotional (identification) and/or ludic (game-playing) strategies to collect this knowledge. In the second project, many informants described soap operas as efficient pedagogic tools because they reach massive audiences, they are ‘easy to take’ and they allow identification and repetition which enhance learning. On the other hand, most expressed caution about the documentary – and documentaries in general – which were criticised for being incomplete and artificial.
Despite their limitations, these findings indicate that real viewers do not resemble the caricatures of ‘passive, ignorant and undiscerning sponges’ (Gauntlett 1995: 10) which have informed some areas of Media Studies until recently (Gauntlett 1995). Real viewers are sophisticated, astute, insightful and media-literate. They produce complex, multi-layered, sometimes contradictory and/or unexpected interpretations. They ascribe their own genres to programmes. They read and use broadcasts according to their mood and wants at a particular moment. They generate meanings in their encounters with flexible texts, meanings which cannot be predicted by content analysis of broadcasts alone. The success of health promotion through continuous fiction is precisely rooted in a recognition of the public's impressive abilities and diversity. It is by empathising with characters, by assessing the dis/advantages of different courses of action, by discussing storylines with relatives and friends, by filling in the blanks, by creating narratives, by playing games with the stories, etc., that viewers engage with, and learn from, broadcasts.
Producers of early radio soaps and CBS executives had little insight into their public's tastes, and the situation has barely changed (e.g.Espinosa 1982, Gripsrud 1995). Equally, in academia, despite some reception research, knowledge of real viewers’ responses to the small screen remains limited. Like producers, who make gratuitous suppositions about imagined television consumers such as ‘the Huddersfield housewife’ (Karpf 1988: 228), scholars are prone to fabricate audiences from their own readings (the ‘viewer-in-the-text’) and/or from preset sociological categories (‘women’, ‘working-class people’, etc.). Furthermore, reception continues to be routinely overlooked in the social/human sciences. Cancer research is a case in point: lay conceptions of the disease (e.g.Payne 1990, Balshem 1993, Oakley et al. 1995) have been examined, and so have media discourses (e.g.Freimuth et al. 1984, Clarke and Robinson 1999, Seale 2001), but, with one exception (Henderson and Kitzinger 1999), the link between the two has been neglected – how do viewers use media representations to formulate their notions of cancer? The reception of health and illness narratives needs further research, particularly since viewers rely heavily on television for their medical knowledge, as noted in the introduction.
Finally, theories of reception may benefit from a multi-disciplinary approach (see Davin forthcoming, 2005). Media Studies do not have the monopoly of reception. Interpretation is a salient topic too in health promotion, in literary criticism, in the public understanding of science, and sociologists, psychologists and education specialists have paid attention to the phenomenon. ER fans, Shakespeare enthusiasts and health advice listeners all employ equally intricate reading and meaning-making processes. More co-operation and communication between fields which may at first sight appear largely unconnected would benefit scholars involved in reception research in all domains.
Norman Felton was interviewed in a documentary, Playing Doctor, part of a BBC1 ‘Docs on the Box’ week-end (09.06.1996).
Apart from Buckingham's (1997) book on young people's interpretations of diverse programmes which includes a few pages on Casualty, and Bouman, Mass and Kok's (1998) article on a Dutch ‘hospital serial’, no reception work on medical dramas is, to my knowledge, available (although one may arguably include the work of Tulloch and Moran (1986) on the Australian ‘rural medical soap’A Country Practice and of Tulloch and Lupton (1997), part of a small upsurge of studies prompted by the 1980s AIDS crisis and which also includes episodes of A Country Practice).The reception of documentaries has not feared much better. Few studies are available and they have primarily focused on social/environmental matters. Only Hoijer (1992) explored a Swedish science magazine on social/medical aspects of AIDS.
Although space lacks to address the topic, the definition of ‘interpretation’ is an important issue. There have been debates as to whether ‘interpretation’ is limited to denotation or whether it encompasses connotation and evaluation (e.g.Corner 1992). But, as Rorty (1989: 98) remarked, ‘there is no point at which you can draw a line between what we are talking about and what we are saying about it’. ‘Interpretation’ is used in this article in its widest sense.
This study began as a comparison of British and French viewers. Its rationale was less national identity than the differences between the number of, enthusiasm for, and familiarity with, medical dramas between the two countries (which have been relatively rare in France and, until ER, have attracted little interest), which suggested possible variations in interpretations. Cross-cultural differences, however, failed to appear. The themes evoked by British and by French correspondents, and their comments, parallel each other.Personal information in informants’ letters was sketchy. Nationality was not specified and was attributed according to the correspondent's address. Some respondents may therefore (conceive themselves to) be neither British nor French. However, in the Europe of 2002, the notion of national identity is increasingly blurred – what does it mean to be British, and what is, for example, the relation of Britishness to Englishness, to Scottishness, etc.? (my article at http://wjfms.ncl.ac.uk/ER.htm addresses both the lack of cross-cultural differences and national identity). Full details of the study are available in Davin (forthcoming, 2003).
Individual interviews avoid the risk of conformity inherent in group interviews (e.g.Kitzinger and Miller 1992) and ensure higher levels of privacy and confidentiality. They provide opportunities for probing ambiguous replies and for acquiring ‘thick’ knowledge, and they give informants scope to enlarge on their replies (Tulloch and Lupton 1997).As is common in media research, informants occasionally spoke in the ‘third person’ (Davison 1983), imagining how others might react. Most comments, however, remained rooted in the first person.
Although conversations began by focusing on the documentary in question, informants soon generalised to ‘documentaries’.
Many soaps also cover ‘masculine’ issues and try to appeal to both genders. Two celebrated British soaps, Brookside and EastEnders, have been described as ‘male soaps’ (see respectively Geraghty 1994: Chapter 8 and Kingsley 1988). In terms of reception, alleged gender differences may in part be due to methodology. For instance, while men admit to enjoying ‘women's shows’ in questionnaires (e.g.Tulloch and Moran 1986), they tend to deny it in peer groups (e.g.Buckingham 1997). New technologies may both motivate, and provide a justification for, men to take part in such studies. Most of the 62 men who answered the advertisement in the ER study did so by e-mail, and some stated that it was the e-mail address which had encouraged them to reply.
This is not to say that viewers do not use other strategies – they almost certainly do – but that identification and game-playing were the only two used and/or mentioned in these studies.
This diversity is partly due to the fact that texts are full of gaps (see Iser 1995). Viewers’ familiarity with media grammar ensures that most of these blanks are automatically filled in (notably space and time compression without which most programmes would be impossible – for instance, a character leaves home and in the next take is at the office. Viewers know that time has elapsed and that s/he has travelled). Other gaps (e.g. unstated reasons for characters’ actions) incite viewers to exercise their imagination, as can be seen in the examples in the main text.
See Nariman (1993) for the basic principles of melodrama-based health promotion, and Singhal and Rogers (1999) for a review of campaigns. These books also address the ethics of covert messages.