The results of this study show that medical students are very high consumers of medical television programs, which confirms the findings of Czarny et al.  Female students were more likely than males to watch Grey's Anatomy (and its spin off, Private Practice), as in Czarny et al.'s  study, which perhaps reflects role modelling in that students may be more likely to watch a show featuring a protagonist of the same gender. Another similarity between our research and Czarny et al.'s  study was a high recall of ethical issues in both samples, although our sample showed a higher proportion of students watching medical programs and recalling ethical issues. The popularity of Scrubs, one of the most frequently watched of any medical program, and certainly the most popular of all shows to watch with fellow medical students, confirms both anecdotal evidence from the students of their enthusiasm for the show, and the qualitative results from this study, which are not reported here.
Our results showed no statistical association between year of enrolment and perception of accuracy. This finding differs to the American study, which noted that students with clinical experience tended to rate the shows more negatively (in both medicine and nursing). Yet this was not the case in our research. From this we might conclude that these students begin their studies from a more critical perspective about the realism of medical television programs, or, conversely, that medical television programs do not greatly influence their beliefs and expectations about the medical profession, or not in ways that our study could measure. Indeed, students gave a very low ranking to medical television shows as sources of learning about ethical issues, which implies that they do not believe the television programs influence them. However, this finding is at odds with the students' high consumption of these shows, recall of ethical issues portrayed, and beliefs about the professionalism on the shows. Indeed, the majority of students believed that all ideals of professionalism were depicted positively in medical programs. This finding is concerning given that previous research points out some of the negative aspects of these television shows, such as high levels of unprofessional behaviour , medical paternalism in House , stereotypes of gender in Grey's Anatomy , and the absence of nursing staff [12, 16]. Given that ethical and legal principles are regularly abandoned in favour of drama in these programs, it is surprising that the majority of students felt that overall medical shows portrayed professionalism well. It may be that students do not realise the extent to which they are influenced by medical programs, even in subtle ways.
This research has implications for the educational setting. Anecdotally, teaching staff can be anxious about the impact of how the fictional world of medicine intrudes on and influences the real one. The high number of students who could remember ethical issues from the medical programs confirms the suggestion that there may be benefit in using the shows in tutorials or lectures as case studies or examples for students in medical education. Goodman  notes that television programs may be worthwhile tutorial teaching tools to assist in medical students' learning. As Spike  points out, television programs adhere to the classic Hollywood paradigm of a morality tale and may therefore be valuable aids to teaching students key lessons about ethics and professionalism, and in some ways can fill a gap where medical education does not adequately cover issues of ethics and professionalism in curricula. Our results show that a majority of students will discuss the medical and ethical issues raised in television programs with family and friends and each other anyway. If medical educators are willing to consider televisual texts as pedagogical tools, such as using specific scenes to illustrate particular lessons or to provoke debate, this may assist students to develop the analytical tools to not simply discuss the programs with others but to critically engage with the programs. There can be value in adopting a more inclusive approach to popular culture in medical education, to encourage critical thinking about ethical issues in medical practice.
Our research confirms, however, that there are negative features of medical television programs in the context of realism. In our study, students rated nine of the fourteen named ethical and medical issues as poorly represented in the shows, which reinforces that there are many important issues treated inappropriately on television. Yet the fact that students rated the realism negatively shows that they are able to engage critically with the programs to some extent. This is an important point. Students do not automatically acquire the skills to critically analyse texts such as television shows, and there is the potential for students and others to passively consume these programs. Although some researchers highlight the advantages of engaging with students via a medium they understand and enjoy, other commentators are dismissive of the benefits of using such a tool. For instance, Trachtman  questions medical television programs as teaching tools because of the "intrinsic flaws" in their presentation of ethical dramas (p.9). Trachtman  rightly points to the competing demands of realism and televisual narrative structure that can compromise medical authenticity. Not just ethics but practical skills can be a problem of realism in these programs. Deficient resuscitation skills have been linked to students absorbing inaccurate techniques from television programs such as ER . Our results show that students rated ER highly for its perceived realism, which is perhaps due to its age - which may be likely to bestow more credibility given it was a long-running program - and its focus on a team of doctors working on cases, rather than one or two dominant characters and medical cases as on more recent programs. Whatever the flaws of realism in these programs, however, they do not negate the possible value of using televisual texts as point of departure exemplars for medical students. Indeed, it may be precisely because of their flawed realism that they are vital to use in discussions with students to lead to an understanding of best practice.
One of the strengths of this study is in its attention to popular images of medicine, an area that is often overlooked in research about medical practice, policy, and education. It is difficult to measure the influence of popular culture on medical students and the general public, yet this study demonstrates that students are not only very high consumers of popular television images of medical worlds but also highly attuned to the potential relevance to their studies as measured by their awareness of the ethical and medical issues portrayed in the programs. However, this study was confined to one university in Australia and did not compare other student groups outside medicine. Many of our students are from culturally and linguistically diverse backgrounds (Table 1) and therefore may not reflect other medical student groups in Australia. Surveying medical students in other parts of Australia would provide valuable comparative data. Further research could also elucidate some of the contradictions that arose in our findings, such as the lead character of House nominated as both negative and positive role model. It may be that students who believe House is an appealing role model do so because of specific positive characteristics (for example, his intellect and commitment to solving medical mysteries) rather than - or despite - his negative traits (his contempt for patients). As Wicclair  points out, this determination to finding medical solutions may be part of the show's appeal. Given the problem-based learning format of medical education for these students, this may well be the appeal for them as well. Future research could address these areas in more depth.