Vulnerable live patients, powerful dead patients: A textual analysis of doctor-patient relationships in popular Chinese medical dramas

Using Framing Theory as a theoretical framework, this study examined depictions of patients and doctor-patient communication in Chinese medical dramas. The textual analysis had two major findings. First, Chinese medical dramas extended the definition of “patient” to include family members, an outcome of the impact of Confucian ethics. Second, doctor-patient communication was found to be two-fold: conversations during interventions were typically paternalistic, while conversations about non-medical issues exhibited consumeristic features. Doctors’ unshakable dominance during interventions resulted from patients’ lack of awareness of their rights as independent individuals, while doctors’ vulnerable position in medical disputes resulted from systemic deficits in the current legal system. Both trends challenged the typical doctor-patient relationships described by previous literature. Instead of introducing ordinary people’s reactions to rare or extreme situations, these shows were found to emphasize people’s unusual reactions to ordinary situations. Overall, Chinese media dramas defined and presented inherent


PUBLIC INTEREST STATEMENT
This study examined depictions of patients and doctor-patient communication in Chinese medical dramas. The textual analysis had three major findings. First, Chinese medical dramas extended the definition of "patient" to include family members, an outcome of the impact of Confucian ethics. Second, doctor-patient communication was found to be two-fold: conversations during interventions were typically paternalistic, while conversations about non-medical issues exhibited consumeristic features. Doctors' unshakable dominance during interventions resulted from patients' lack of awareness of their rights as independent individuals, while doctors' vulnerable position in medical disputes resulted from systemic deficits in the current legal system. Finally, instead of introducing ordinary people's reactions to rare or extreme situations, these shows were found to emphasize people's unusual reactions to ordinary situations. Overall, Chinese media dramas defined and presented inherent problems in doctor-patient communication, elaborated the causes of most of these problems, and made moral judgments about these issues using vivid individual stories, but they did not attempt to offer solutions to these problems. problems in doctor-patient communication, elaborated the causes of most of these problems, and made moral judgments about these issues using vivid individual stories, but they did not attempt to offer solutions to these problems.

Subjects: Mass Communication; Health Communication; Broadcast Media
Keywords: doctor-patient communication; popular medical drama(s); Confucian ethics; framing theory; extended definition of patients The success of popular American medical dramas such as House, M.D. and Grey's Anatomy has inspired producers in different countries to produce local medical dramas. Within the past ten years, Chinese producers have adopted the genre and created their own popular medical dramas.
Although a considerable number of early Chinese medical dramas were criticized for being roughly produced and having low quality content, in recent years, scriptwriters began taking the genre seriously. For example, Liu Liu, the scriptwriter of Angel Heart (Xin Shu), spent two years doing fieldwork at a tertiary hospital in order to write a script that best reflected the medical discipline (Yang, 2017). Labelling herself as "a person who line-draws social problems" (shehui wenti de baimiao zhe) ("Chinese medical dramas lack depth", 2012), Liu Liu claimed that she attempted to use medical dramas to reflect social reality and to "diagnose the illness of our contemporary society" ("Media dramas-diagnose the society", 2014). Liu Liu was not the only scriptwriter who took a realist approach to medical controversies. Scriptwriters who took similar approaches created high-quality medical dramas that reflected the nature of the medical profession and the reality of the contemporary public health care system in China, and these realist medical dramas were well received by audiences (e.g., "Top seven medical dramas", 2017).
Medical drama has become a popular genre worldwide, but few scholars have systematically studied medical dramas produced outside the United States. My project explores medical dramas that were broadcast within completely different cultural and social contexts, expanding the scholarly work in this field. Various studies have suggested that exposure to medical dramas affects viewers' perceptions of doctors' personal characters (Chory-Assad & Tamborini, 2003;Stinson & Heischmidt, 2012), alters viewers' expectations of medical practices (Gauthier, 1999;Harris & Willoughby, 2009), shapes viewers' understandings of medical examination strategies (Lapostolle et al., 2013), and contributes to the formation of various myths (e.g., Chung, 2014;Quick, 2009). Due to its potentially powerful impact, the content of medical dramas is worthy of exploration.
The purpose of this paper is to explore depictions of patients and doctor-patient communication in Chinese medical dramas. Using framing theory, the project is a textual analysis of the five most popular medical dramas in China. The findings of this research project will introduce several important themes that were rarely found in American medical dramas.
The study has several theoretical and practical implications. From the theoretical perspective, by examining the content of non-Western medical dramas, Chinese medical drama case studies will further exemplify how popular culture reflects and reconstructs the interplay between culture, medicine, and communication. Of more importance, the study demonstrates the nuances and dynamics involved in doctor-patient communication, which has not been adequately addressed by the popular culture or health communication studies that were primarily conducted in a Western context. The findings of this study expand current scholarly work about the media's depictions of various controversies, such as patients' identities, doctor-patient relationships, and the cultural and political factors that contributed to the formation of a unique type of doctor-patient relationship. From the practical perspective, since all the medical dramas examined in this study were realist, the themes and issues revealed in the study were dramatic but symbolic representations of real-life problems. The information will help health communication campaigners and educators foresee the problems they might encounter in a Confucian society, understand the root of conflicts between indigenous values and conventional medical practices, and determine possible solutions to real-life dilemmas.

Framing
Ever since Goffman (1974) labeled "schemata of interpretation" as "frames", researchers have been developing framing theory. A frame is conceptualized as a "central organizing idea or story line that provides meaning" (Gamson & Modigliani, 1989, p.143). To be more specific, "frames are organizing principles that are socially shared and persistent over time, that work symbolically to meaningfully structure the social world" (Reese, 2001, p.5). Gitlin (1980) defined media frames as "persistent patterns of cognition, interpretation, and presentation, of selection, emphasis, and exclusion" (p. 7) that are viewed as constructing social reality (Scheufele, 1999). Synthesizing the ideas from these scholars, Hertog and McLeod (2001) concluded that framing a topic means determining its contexts, prescribing its major tenets, assigning roles to the individuals, groups and organizations that are involved in the issues, and defining the legitimacy of varied strategies for action.
Framing involves a psychological and a sociological process (Pan & Kosicki, 1993). The sociological process indicates how media frames are built by journalists and editors, and the psychological process explains how the audience interprets media frames. As a sociological process, framing is the construction of social reality, and mass media set the frames of reference that individuals use to interpret the world around them (Scheufele, 1999). According to Entman (1993), framing is achieved through the process of selection and salience. In other words, the mass media selects some aspects of a perceived reality and then makes a specific piece of information more noticeable, meaningful, or memorable to its audience. This research project attempted to reveal the common themes in doctor-patient communication that medical dramas selected, emphasized, and attributed particular meanings to.
The process of media framing suggests that mass media have four functions: 1) define problems; 2) diagnose causes; 3) make moral judgments; and 4) suggest remedies (Entman, 1993). The current project studied these four functions in medical dramas: what problems in doctor-patient communication did medical dramas reveal/define? What causes were identified? What moral judgments did the shows make? What remedies/solutions did they offer? fictional doctors and patients. Research found that the nonverbal behavior between doctors and patients was balanced: doctors and patients had equal speaking time, the same length of pauses, and were interrupted for an equal amount of time. Accordingly, simultaneous speech, an indicator of a dramatic struggle for power between speakers, did not appear frequently in Grey's Anatomy (Jason, Shian-Li, & Shelley, 2013).

The cultural context-Confucianism
Just as the idea of civil society is grounded in the Western social tradition (Tai, 2006), the conventional doctor-patient communication model is predicted and examined in a typical Western context. Both ideas encounter challenges when they are applied to societies with completely different cultural traditions. Hierarchical (Tu, 1996) and family-centered Confucian ethics (Bell, 2010) could challenge the scholarly interpretations of doctor-patient communication based on European and North American contexts.
The Asian cultural context was reflected in Japanese and Korean medical dramas. These shows depicted the highly collectivistic and hierarchical corporate cultures of East Asian. In addition to addressing medical issues, the struggle between pursuing medical professionalism and maintaining bureaucratic order has always been the focus of Asian medical dramas. Doctors in popular shows such as The Great White Tower, Nurse AOI, and Code Blue often struggled to overcome personal angst, patient idiosyncrasies, and bureaucratic hurdles (Khium, 2011).
The fundamental thesis in Confucianism stresses the arrangement of relationships between people, which is hostile to individual autonomy. There is no appreciation for the private self in Confucianism: individuals are identified as members of families first, prioritizing family interests over individual ones (Tu, 1996). Due to the vast impact of Confusion ethics in East Asian countries, especially China, family members have played a crucial role in making a wide range of medical decisions (Wang, Luo, & Fan, 2010). Therefore, in many cases, doctors in China had to talk to both the patient and their relatives in order to make medical decisions, which has made doctor-patient communication even more challenging.
RQ1. In Chinese medical dramas, to what extent were family members involved in medical decision-making and doctor-patient communication?

Doctor-patient communication described by health communication literature
Communication between physician and patient plays a crucial role in predicting the proximal outcomes, intermediate outcomes, and health outcomes of medical interventions (Street, Makoul, Arora, & Epstein, 2009). Typical communication behaviors include exchanging information, responding to emotions, managing uncertainty, fostering relationships, making decisions, and enabling self-management (Street et al., 2009). Emanuel and Emanuel (1992) developed four models to describe different types of physicianpatient relationships: the paternalistic model (also called the parental or priestly model), the informative model, the interpretive model, and the deliberative model. Each model featured unique patient values, physician obligations, conceptions of patient autonomy, and conceptions of the role of physicians. For example, in the paternalistic model, physicians acted like guardians and used their skills to determine patients' health conditions. Playing the role of the "parent", doctors prioritized patients' well-being and health over other values such as patient autonomy and choice. Even though the deliberative model in which the physician helped the patient "determine and choose the best health-related values that can be realized in the clinical situation" (p.2222) was considered the ideal physician-patient relationship, different models may be appropriate under particular clinical circumstances (Emanuel & Emanuel, 1992). Eckler, Worsowicz, and Downey (2009) proposed three models that explained the control and power in physician-patient communication: a paternalistic relationship in which the physician has a high level of control and patient has a low level of control, a consumerist relationship in which the patient has a high level of control and physician has a low level of control, and a mutual relationship in which both parties exercise strong control. All these models can be found in different types of doctor-patient communication.
RQ2. Which type of physician-patient relationship did Chinese medical dramas present?
RQ2a. Which group, doctors or patients, had more power in communication?

Methodology
The purpose of this study was to reveal the media depictions of doctor-patient communication in popular Chinese medical dramas. To answer the research questions, I conducted textual analysis of five popular Chinese medical dramas. The medical dramas chosen were Angel Heart, Surgeons, Emergency Room, The Doctors, and Inspire the Life. These medical dramas were chosen for the following reasons. First, all these dramas claimed that they attempted to reflect the "reality" of the current public health care system, differentiating them from typical "repackaged idol dramas" (e.g., "Chinese medical dramas", 2014) or "idol dramas in white clothes" (Yang, 2017). Second, all the shows were broadcast within the past seven years, sharing a similar time frame. Finally, these shows received high ratings and were popular with audiences. Basic information about these shows is listed in Appendix A. These shows were available on YouTube, and I downloaded all the episodes during the data collection process.
Textual analysis is defined as a type of qualitative analysis that studies the underlying meanings of a text, and the approach suggests that the latent meanings and implicit patterns of a text can be identified by coding it (Fursich, 2009). Textual analysis is often used to help researchers understand social processes and to generate theories about social life through "nonliving" materials (Hesse-Biber & Leavy, 2006). Interpretation of a text is the basic level of textual analysis, and the text in the current study is the conversations between doctors and patients in Chinese medical dramas.
Data collection and analysis followed the three steps recommended by Hesse-Biber and Leavy (2006): data preparation, data exploration, and data reduction. First, I transcribed the conversations between doctors and patients while I was watching the episodes. Each episode of these shows included multiple storylines, and it often took more than one episode to complete one patient's case. During the first stage of transcription, I labeled the conversations about the same case with unique markers such as patient's name. When I finished watching each show, I put those conversations about the same case together. Next, I used the constant-comparison method (Strauss & Corbin, 1998) to analyze the conversations sorted by case. I used different colors and numbers to highlight the arguments and themes that were mentioned repetitively in the dialogues. The universal themes were later developed into coding categories. Finally, I coded more dialogues according to the themes and categories identified in the previous step. The original transcripts in Chinese were used during the data analysis process. Conversations were translated into English when they were cited in the final paper.

Results
RQ1. In Chinese medical dramas, to what extent were family members involved in medical decision-making and doctor-patient communication?
In Chinese medical dramas, patients were most often involved in casual discussions with doctors in the ward, but they rarely appeared during formal meetings, such as the ones before surgeries.
Instead, patients' family members played a much more crucial role in the medical decision-making process. Therefore, the medical dramas have extended the definition of patients: in a typical Chinese doctor-patient relationship, the patient was conceived of as two groups, the "real" patient who needed intervention and their family members. Family members' deep involvement in the medical decision-making process deprived the patient of the right to make decisions. This phenomenon resulted from Confucian family ethics, which disregards the rights of the private self (Tu, 1996). The medical dramas presented the dynamics of and the possible consequences of this practice.
In most stories, only patients' close family members, such as sons, daughters, husbands, wives, and parents, participated in official meetings with doctors before surgery. They were the persons asked to make informed decisions and to sign consent forms. Whether the patients knew the truth depended on if their families were willing to tell it to them. In Angel Heart, for example, with only one exception, all the medical decisions about whether to undergo surgeries were made by family members. A typical scenario was that an old woman would be diagnosed with cancer and doctors gave her daughter the right "to decide whether to tell [her] mom the truth."

Your life? No, it's our life
Of more importance, patients did not have the absolute right to make medical decisions. When patients and their family members could not reach an agreement, whose request did doctors respond to? In most cases, doctors would try convincing them to reach an agreement. In a case on Angel Heart, family members decided to stop treatment due to the high cost, but the patient asked, "Are you hoping for me to die?" Even though the patient explicitly insisted that he would like to continue treatment, doctors had to convince his son first before continuing treatment. Similarly, Sun, a main character on Angel Heart, could not start preparing for an operation until a patient managed to convince her daughter to "let [her] mom take the risk." In some cases when doctors could not convince family members to reach an agreement, they prioritized family members' suggestions. The Doctors told a story about family member involvement and the subsequent consequences. Huan, a college student who received a kidney transplant two years prior, returned to the hospital when his transplanted kidney stopped functioning. From the medical perspective, Wu, an expert in kidney transplantation and the vice director of the hospital, suggested that Huan have a second transplant. Huan rejected the suggestion. He told Wu that he had suffered too much from the disease, and he understood that having another kidney transplant would only make him survive a few more years, which he did not consider worth spending all of his parents' savings on. Even though Huan clearly and explicitly rejected Wu's suggestion, Huan's parents kept begging Wu and insisted that they would "pay no matter how much it costs to save [their] son." Eventually, Wu disregarded Huan's unwillingness to undergo another surgery, and performed the transplant as Huan's parents' requested. Huan appreciated Wu's effort, but he was in so much pain that he tried escaping from the hospital after the surgery. In this case, the patient Huan had no power to decide whether to undergo the surgery. Even though Wu and Huan's parents made the decision for the sake of "extending Huan's life", Huan's own rights were completely ignored.
Both doctors and patients appeared to have gotten used to the fact that patients' family members have the right to make the final decision. Patients were allowed to make their own decisions only when their family members could not agree with each other. In The Doctors, Mei needed heart surgery to cure her illness. The surgery was high risk and even the most experienced surgeon, Zhong, had no confidence in its success. Informed of the high risk of the surgery, Mei's mon and dad could not reach a consensus. They argued with each other for days, until Zhong insisted that Mei's health status would worsen if they kept waiting. Zhong convinced Mei's parents to let Mei make the decision herself "since [they] can't convince each other." Mei was one of the few patients who made the decision for herself. However, the doctor's rhetoric was ironic: Zhong asked Mei to make the decision herself only because her family members could not reach an agreement. Letting the patient make her own decision was a backup plan, and everyone assumed that the family members were responsible for decision-making.
Family members did not appear to be aware that making decisions that were against the patient's will was harmful in nature to the patient. Instead, they considered it their responsibility to make sure that the patient acted in the ways they expected. In The Doctors, the Jin brothers decided to let their mother, Mrs. Jin, undergo a high-risk surgery. They believed that their mother was "a cowardly person" who "would certainly reject the high-risk surgery if she [knew] that the doctors will open her chest." Thus, they requested that the doctors hide the real "facts" about the surgery from Mrs. Jin. Unfortunately, during a regular conversation with the anesthetist before the surgery, Mrs. Jin realized that she would be undergoing a "bloody" and "scary" surgery. She was so shocked that she firmly rejected the surgery and requested to check out of the hospital. After many debates with her sons, she managed to do so. She died a few episodes later, and the Jin brothers regretted agreeing to let their mom check out: "It's my fault for letting her do what she wanted to do, otherwise she could have survived a few more years." The Jin brothers' reactions suggested that their attempts to make the decision for Mrs. Jin resulted from good motives-they expected their mom to survive. However, they did not treat Mrs. Jin as an independent person with the right to know the truth and to take full control over her life. Instead, she was deprived of her right "not to be brave enough" or to make "cowardly" decisions. The Jin brothers only cared about "want[ing their] mom to survive a few more years." Mrs. Jin was treated like a puppet whose role was to show how much the Jin brothers cared about their mom.
Taking for granted that family members play a crucial role in making medical decisions, patients who were "lone wolfs" were considered abnormal. One short story on this topic was highly representative. An old man went to the nurses' station to pick up his X-ray examination results. Noticing that the man was by himself, the nurse asked, "Where's your family?" She could not believe that a patient would pick up X-ray results by himself. People had normalized the fact that family members were deeply involved in the intervention process, so much so that a patient showing up by himself had become an unusual phenomenon.

A critical reflection
What were doctors' attitudes toward the above phenomenon? Doctors understood that these practices were against conventional bioethics and medical professionalism (Charter on Medical Professionalism, 2002). However, they had to adapt their behaviors to the local culture, even though they did not, deep down, like these practices. Jiang, one of the main figures in The Doctors, was angry with the Jin brothers' behavior, and she said, "I will not play an act with them." Her colleague Yan, Chair of the Medical Council, comforted her: "Of course, you're right, but our hospital would get into big trouble if you broke the 'hidden rules'." These conversations indicated that doctors did not agree with patients' families' attempts to prohibit patients from making their own decisions, but, facing pressure from various social forces (e.g., court decisions were usually in favor of patients' families (Liebman, 2013), they had to acquiesce to the practices that were deeply rooted in the cultural context.
Rather than simply presenting this phenomenon to the audience, these shows included a few stories in which the patient was unhappy with their family members' involvement in their medical care. In Emergency Room, Guan, the director of the ER, asked a patient to complete a nuclear magnetic resonance (NMR) test, and the patient agreed immediately. However, the patient's son did not agree. He asked Guan many less than relevant questions: "Why can't you make a diagnosis without an NMR? How much money do you make by having one patient have an NMR?" The patient could not bear it and yelled at his son: "You shut up! I want to have an NMR right away." The story was an apparent criticism of, or at least a skepticism about, the taken-for-granted phenomenon of deferring to family members for medical decisions.
Other shows used humor to problematize this issue. Huo, a character on Angel Heart, had a new patient and began asking questions. One of the patient's relatives answered most of the questions, leading Huo to believe that she was the patient. Not until the end of the conversation did Huo realized who the real patient was. Similarly, Surgeons had a story in which Mr. Gao was sent to the ER, and his friends and family members tried explaining his condition to the doctors. They spoke over each other so much that Mr. Gao had to stop them by shouting: "Be quiet! I want to talk to the doctor. I'm the patient." Overall, these stories suggested that the scriptwriters of medical dramas were aware of the problem of the intensive involvement of patients' family members, and they were trying to encourage viewers to question the phenomenon using different rhetorical approaches.
RQ2. Which type of physician-patient relationship did Chinese medical dramas present?
RQ2a. Which group, doctors or patients, had more power in communication?
Communication behaviors in Chinese media dramas were found to be two-fold. Doctor-patient communication during medical interventions was paternalistic (Eckler et al., 2009;Emanuel & Emanuel, 1992), but it shifted to a consumerist model (Eckler et al., 2009) when the interventions ended. This phenomenon has a few implications. First, the Confucian ethical injunction to respect and obey authorities (Tu, 1996) prohibited patients from realizing their due rights. Second, patients' trust in doctors was fragile: they were fearful of the authority of doctors rather than trusting of them, so their trust immediately turned into distrust when miscommunication occurred. Finally, many factors have made doctors the vulnerable party in medical disputes.

A paternalistic model
Doctor-patient conversations about medical issues followed a typical paternalistic model, in which doctors had almost full control over the conversations. Patients who trusted doctors would accept their suggestions without question, and patients' rhetoric indicated that they voluntarily placed themselves in the weaker position. Patients who did not trust doctors would reject doctors' suggestions, but their rejections were presented in a highly emotional and sometimes irrational manner. Patients' resistance did not indicate that they were attempting to play an active role in decision-making; instead, their reactions were more indicative of their rebellion against treating doctors as authorities. A doctor described the typical way patients challenge doctors as being "just like a three-year-old kid revolting against his/her parents." The comparison perfectly encapsulates the features of patients' reactions: they wanted to say no, but they subconsciously viewed doctors as authoritative figures who could not be challenged. This deeply-rooted notion caused patients who wanted to disagree with their doctors to react in an irrational manner. Nevertheless, in both cases, the doctor-patient communication was still paternalistic in nature.
Patients used a wide variety of rhetorical strategies to demonstrate their trust in doctors, and many of them treated doctors as authority figures who could address all kinds of problems. Such dialogues appeared in almost all of the episodes analyzed. For example, when asked whether to have a surgery with a low likelihood of success, Mei, a patient on The Doctors, said: "I give my life to you." In another episode, when asked "Do you give us permission to perform a thoracotomy?" the patient's family members answered unanimously, "We don't have viewpoints. Do whatever you think is necessary." A patient on Angel Heart explained why he fully trusted his doctors: "I'm a patient, you are doctors. I don't know more about my illness than you doctors." Due to its ER setting, conversations on Emergency Room were even shorter and more concise. Common questions asked by family members included: "Is there any likelihood that he/she can be saved?", "Could you please tell me what's wrong with him/her?", and "Please save him/her!" One patient who was saved, Wu, thanked all the doctors, saying: "You saved my life, and I will let everyone I know how doctors great are." Similarly, a patient and his family said excitedly, "You are the 'God doctor' (shen yi)" after the completion of a surgery. The term "God doctor" also was used occasionally on Angel Heart and Inspire the Life.
Due to the high level of trust, patients (and sometimes their family members) discouraged each other from questioning doctors' decisions. On Inspiring the Life, while a patient's husband expressed his intentions to ask the doctors why an NMR was necessary, the patient said unhappily: "Why do you have so many questions? What's the point of asking these questions?" Overall, patients who implicitly trusted doctors placed themselves in a weaker position in the doctor-patient relationship. Although a high level of trust in doctors was desirable and following doctors' orders often resulted in positive outcomes, treating doctors as "Gods" suggested that patients were not aware of their rights to be autonomous. The knowledge gap between doctors and patients made patients voluntarily accept a submissive position in the doctor-patient relationship. As seen in the conversation on Inspiring the Life, the patient and her husband may not have been able to fully understand the complicated mechanisms of the medical procedure even if they had asked the doctors more question. In terms of knowledge gain, asking more questions could be pointless, as the patient indicated. However, it was fully reasonable for the patient to learn more about the intervention she would experience in the near future. Unfortunately, influenced by the deeply-rooted paternalistic notion in doctor-patient interactions, most patients were not aware of the active roles they could play before, during, and after interventions.
The paternalistic relationship and patients' expectations of a paternalistic relationship with doctors did not always generate win-win outcomes. Not all patients would take their doctors' advice without hesitation. Even though many patients disagreed with doctors in terms of treatment, they did not manage to convert the relationship into a mutual (Eckler et al., 2009), interpretative, or deliberative (Emanuel & Emanuel, 1992) one. Instead, they would engage in irrational and dramatic behaviors to reject doctors' suggestions.
A short conversation on Emergency Room reflects this trend. Having a difficult time convincing her patients, a junior attending physician named Wang blurted out: "I'm the doctor, [so] you have to listen to me." The patient kept rejecting Wang's suggestion, saying: "I've paid you, [so] you have to listen to me." In this case, the patient tried seeking more autonomy, but apparently "I've paid you" was not considered to be a legitimate reason to challenge the doctor.
More patients would reject doctors' advice in a passive-aggressive manner. For example, on Surgeons, after being told that doctors could not perform two different operations for his father at the same time, a man cried out and repeated: "No, I don't think so. I request you to complete two at the same time." Doctors tried their best to explain to him that this was impossible, but the man insisted, leaving no space for negotiation. Eventually he was taken away by a senior director. A patient on The Doctors simply said, "[My body] is none of your business" to reject a doctor's recommendation for surgery. Patients like this appeared in almost all the medical dramas examined.
Theoretically speaking, patients did not have to accept all the suggestions of their doctors because they had the legal right to control their bodies and health, but, unfortunately, patients did not appear to be aware of their own rights. Failing to justify their attempts to decline doctors' suggestions, patients gave highly sensational and even dramatic responses. Most of these responses were disrespectful in nature to the doctors. In this way, patients managed to convert their legitimate rights into unreasonable demands, making themselves the "bad guys" who caused conflicts with doctors.
Overall, very few patients expressed their own viewpoints and negotiated with doctors. They either completely accepted the suggestion or rejected it in an irrational manner. Accordingly, few rational and meaningful negotiations occurred when patients disagreed with doctors; rather, patients resisted "like a three-year-old kid revolting against his/her parents," in the words of a bystander doctor. Both doctors' and patients' behaviors enhanced the paternalistic relationships during medical decision-making and intervention.

A Consumerist Model
The power relationship between doctors and patients (including patients' family members) was completely reversed when they were involved in conversations that did not directly target medical treatment, such as those addressing medical disputes. In these cases, patients had more power in directing the flow of conversations, while doctors became the vulnerable group. Even when threatened by patients, doctors could only patiently offer explanations. This phenomenon can be explained by two factors. The paternalistic relationship during intervention was fragile and relied solely on patients' trust in doctors' medical expertise. Once they were not discussing medical issues, doctors were no longer viewed as authorities, and patients did not consider them worthy of respect. Second, courts often found in favor of patients and their families in lawsuits, placing doctors in a weaker position in disputes.
All the medical dramas had at least one story like the following: patients' families harassed and even threated doctors, disturbing orderly medical services, because they were dissatisfied with the outcome of medical treatment, in most cases, the death of a patient. In all these cases, the doctors in question were not found to be at fault in causing the patients' deaths, making their relatives' requests unreasonable and their behaviors unlawful. However, doctors did not appear to have the power to effectively stop these behaviors, so they tried their best to comfort the relatives and "calm the issues down." The story of Yao's family extended across more than five episodes on The Doctors. Immediately after Yao's death, the Yaos gathered together at the ward and demanded that Liu, the nurse in charge, kneel and apologize. When Liu refused, other family members locked the door and kept attacking Liu. Eventually, another doctor kicked the door open and helped Liu. Although attacking the hospital staff was obviously a crime, doctors still attempted to be patient and communicate with the Yaos. Wu and Yan invited the family to a meeting room and explained why they failed to save Mrs. Yao, but the Yaos rudely refused to accept the explanation. They kept saying the following: "The patient was good when she arrived, how could she die within so short a period of time?", "You have to be responsible for a patient's death at your hospital", and "It's your fault. You killed my mom." Facing these ungrounded accusations, Yan, director of the Medical Council at the hospital, still asked the family to leave in a polite manner: "You're interrupting the normal work of a hospital, other patients cannot be treated. Let's talk in a different place." The Yaos also requested millions in compensation from the hospital to "make up for [their] fault." After many disputes featured on multiple episodes, the hospital committee decided to give the Yao family 200,000 yuan as a "humanitarian subsidy (ren dao bu chang)" in order to settle the case even though the hospital was not found guilty of wrong doing.
An almost identical story appeared on Emergency Room. Family members of a deceased patient blocked the door of the ER to request 200,000 yuan as compensation. Guan almost begged the family to let them enter the ward: "We feel sorry for the patient's death, too. But there're so many people waiting to be cured. Could you please let us in?" The family refused, so doctors and other patients could do nothing other than wait outside of the ER. Eventually they managed to enter the ER because a patient with a critical condition arrived. Su, a senior doctor, angrily yelled at the family and rushed past them into the ER. But the story was not over yet. Not receiving enough money, the family placed the woman's dead body in the doctor's office. Since the office was taken over, all the doctors at the ER department moved to a different office. Guan, as the director of the ER, reminded his staff multiple times to "stay safe", but he was not able to remove the "time bombs" that might impose threats. The show did not explicitly describe how the hospital management resolved the issue, but two nurses whispering after the family left implied the possible outcome: "They are willing to leave? I wonder how much money they got this time?" Other medical dramas also depicted similar stories between vulnerable doctors and rude, greedy families.
The medical dramas subtly implied the inherent causes of doctors being so vulnerable during disputes. Doctors, like Guan, did not dare to explicitly warn family members that "what [they're] doing is unlawful"; they could only try persuading them mildly (e.g., "your mom won't look good"). Overall, patients' family harassed doctors because the activities were low risk, but had the potential to generate large "profits." On The Doctors, doctors called the police when the Yaos attacked Liu, but the police refused to interfere: "We have policies, we can't help." Doctors on Emergency Room also asked the police to help them make the family leave, but the police said that since they did not physically hurt the doctors or destroy things, the police could not help.
Mrs. Yao's son mentioned in a conversation, "If we do not keep harassing the hospital, they won't take care of the problem." To some extent, he was right: they got a large amount of money from the hospital, even though the hospital was not at fault. Without continuous harassment, hospitals would never give compensation to the family members of deceased patients who died of illness rather than malpractice. Medical dramas used these dialogues to indicate that hospital administrators indirectly endorsed unlawful behaviors.

Discussion
RQ1 asked to what extent patients' family members were involved in medical decision-making processes. Textual analysis results suggested that family members were so deeply involved in the process that they were considered to be equally important, and sometimes more important than patients, during the process of medical decision-making. RQ2 and RQ2a were about the features of doctor-patient communication. The medical dramas presented two types of doctor-patient relationships: a typical paternalistic one in which doctors had almost complete control over conversations that were relevant to medical treatments and a consumeristic one during the resolution of medical disputes in which doctors were placed in a weak and even vulnerable position. The shift between these two extremes exemplified the inconsistency between conventional medical practices and the indigenous Confucian tradition, as well as the severe consequences of the state's failure to address medical disputes using laws and regulations.

Doctor-patient relationships in Chinese medical dramas
Chinese producers adopted the genre of medical dramas from Western countries, especially the United States. This study identified two prominent differences between Chinese medical dramas and their Western counterparts. First, Chinese medical dramas extended the definition of "patients", as patients' relatives were intensively involved in medical decision-making. Second, instead of depicting unusual and highly dramatic situations, such as diagnosing rare diseases and making extremely difficult ethical decisions, Chinese medical dramas placed more emphasis on people's unusual reactions to ordinary situations. The distinctions between Chinese medical dramas and American medical dramas were primarily caused by the Confucian cultural tradition.
The extended definition of patients was one of the major characteristics of Chinese medical dramas. In most of the popular medical dramas examined by previous research (e.g., Gauthier, 1999;Jason et al., 2013), doctor-patient communication only referred to the conversations between doctors and patients. In Chinese medical dramas, however, family members were so intensively involved in medical decision-making that a large percentage of conversations occurred between family members and doctors. The trend suggested that medical dramas treated family members as important as, and occasionally more important than, patients. This kind of practice was against medical professionalism (Charter on Medical Professionalism, 2002), but it could be explained by the family-centered Confucian culture (Bell, 2010): individuals were identified as members of families first, and family interests were more important than individual rights (Tu, 1996). Medical decision-making was thus considered a decision that would affect the family rather than the patient, so it was not surprising that family members played a dominant role during the process. This kind of depictions were rarely found in Western medical dramas. In essence, the theme demonstrated an incompatibility between conventional medical ethics and local traditions.
Another prominent difference between Chinese medical dramas and their Western counterparts was embedded in specific storylines. American medical dramas often featured unusual and difficult ethical decision-making situations. In House M.D. and Grey's Anatomy, for example, most dramatic storylines were triggered by controversial bioethical issues such as organ transplantation, questionable departure from standard practice, and death and dying (Czarny et al., 2010). These shows emphasized "ordinary people's reactions to unusual situations". Chinese medical dramas, however, intended to depict "people's unusual reactions to ordinary situations". A few common issues, such as negotiating medical cost, signing consent forms, and dissatisfactory with treatment outcomes, were mentioned by all the medical dramas. These problems were so common that almost every viewer might encounter them in his/her daily life. The "drama" in Chinese medical dramas came from different people's dramatic reactions to these ordinary situations. For example, when patients were notified the risks associated with a surgery, medical dramas thoroughly depicted a wide variety of reactions: some patients signed the consent form without hesitation, some patients were so scared that they cried, parents of a child spent several days arguing whether to sign the form, a couple almost fought with each other because they could not agree whether to take the risk, and so on. The phenomenon can partially be explained by the Confucian cultural tradition that emphasizes the arrangement of relationships between people (Tu, 1996). In the context of medical decision-making, "the arrangement of relationships between people" was exemplified as different people's reactions to identical situations. People's identities and relationships with patients determined the rightness or wrongness of their decision-making: a decision might be considered normal and ethical if it was made by a patient's spouse, but it would be considered unethical if the patient's children made the same decision. In this way, Chinese medical dramas explored a set of important issues emphasized by Confucianism: how would/should a husband/wife, or a son/daughter, behave during the medical decision-making process.

Framing the problems in doctors-patient relationships
Framing theory suggests that media frames define problems, diagnose causes, make moral judgments, and suggest remedies (Entman, 1993). Regarding doctor-patient relationships, medical dramas defined and exemplified problems, elaborated the causes of these problems, and made moral judgments, but they did not suggest remedies.
The medical dramas first "defined" problems in doctor-patient communication using vivid individual stories and then disseminated the stories to large audiences. Existing literature shows that doctors had been unsatisfied, even angry, with the fact that public safety departments and the court did little to help them handle threats from patients' families (e.g., Chen, 2016). A considerable number of them, particularly celebrity physicians who have some influence on social media, have tried various means of calling public attention to the issue and to provoke change (Chen, 2018). However, their influence was highly limited because they could only reach a small number of the population, most of whom resided in the urban areas of China and had a high level of health and media literacy (Chen, 2016). Televised medical dramas managed to reach a much wider and more diverse population, breaking the silence on these problems. In particular, the interpersonal conflicts revealed the challenges doctors and patients were facing during and after medical interventions. These stories demonstrated two types of doctor-patient relationships, a paternalistic one and a consumerist one, both were deviant from a mutual doctorpatient relationship where both parties exercised equal control (Eckler et al., 2009).
Medical dramas then "diagnosed" the causes of these issues. The cause of doctors becoming the vulnerable group during the dispute resolution process was rooted in the legal system. Legal experts argued that "the formal legal system [in China] operates in the shadow of protest and violence" (Liebman, 2013, p.181). Caught between legal requirements and state stability concerns, courts have tried their best to mollify the plaintiffs-expanding the liability of hospitals and allowing them to pay more than the laws required. From a political science perspective, favoring plaintiffs in medical dispute resolution with a disregard for laws and regulations was an approach typically used by governments in populist authoritarian regimes (Tang, 2016). Liebman concluded that this kind of practice had "created a cycle of protest, responsiveness, and disregard of legal rules and procedure" (p.253), indirectly encouraging patients to seek monetary compensations by threatening hospitals.
Even though medical dramas did not explicitly state these causes, the statement "if we did not keep harassing the hospital, they won't take care of the problem" from the family member of a deceased patient illustrated the vicious cycle identified by Liebman (2013). Numerous highly dramatic stories showed that the official dispute resolution system was almost useless in resolving the conflicts between doctors and patients. Instead, to stop patients' family members from disturbing the orderly medical services, doctors were asked to make compromises to the best of their abilities. All these depictions subtly blamed the problematic legal system for fostering unhealthy doctor-patient relationships.
Moral judgments were made by these shows, too. The medical dramas did not endorse the practices that violated medical professionalism. Most of the patients who initiated hostile dialogues dressed in an indecent manner and acted rudely. Meanwhile, doctors managed to keep calm and be patient in most circumstances. The sharp contrast between the two implied a moral judgment on the disputes. Likewise, the shows sometimes used humor to mock those patients who were unnecessarily and overly involved in the medical decision-making processes. Doctors also expressed criticism of the phenomenon in various situations.
The medical dramas, however, did not suggest "remedies" to these issues, which could be for two reasons. First, the causes of doctor-patient conflicts were rooted in the complicated sociopolitical system, and the solution to these conflicts was far beyond what an entertainment program could address. As was previously described, doctors' vulnerable position in conversations about medical disputes resulted from the state's attempt to maintain social stability through "nationalizing private litigation" (Liebman, 2013, p.250). The practice was an outcome of a populist authoritarian regime, in which a hyper-responsive government attempted to address the grievance of the public by ignoring legal procedures (Tang, 2016). The problem was much more complicated than a simple miscommunication between individual doctors and patients; it was the result of the state's approach to social stability at the cost of breaking laws. Hence, popular television programs were not able to suggest appropriately complex solutions.
The study has a few limitations. The first limitation is that the content analysis could only approximate media content, but it did not predict its impact on viewers. Research surveying viewers will be needed to determine the extent to which watching medical dramas shapes viewers' perceptions of various medical issues. The second limitation is that the textual analysis only identified the common themes in the most popular medical dramas. The results were interpretative in nature, and it did not predict the extent to which the findings were generalizable. Future research could further extend the scope of the current project: scholars may take a quantitative approach to systematically analyze the dialogues between doctors and patients, conduct case studies of miscommunication incidents using rhetorical approaches, or compare the content of medical dramas produced in different countries.

Conclusion
The study examined depictions of patients and doctor-patient communication in Chinese medical dramas. Two major findings were revealed by the textual analysis. First, medical dramas extended the definition of "patient" to include family members, an outcome of the impact of Confucian ethics. Second, doctor-patient communication was found to be two-fold: conversations during interventions were typically paternalistic, while conversations about non-medical issues exhibited consumeristic features. Doctors' unshakable dominance during interventions resulted from patients' lack of awareness of their rights as independent individuals, while doctors' vulnerable position in medical disputes resulted from systemic deficits in the current legal system. Both trends challenged the typical doctor-patient relationships described by previous literature (e.g., Eckler et al., 2009;Emanuel & Emanuel, 1992;Jason et al., 2013). Regarding the differences between Chinese and Western medical dramas, this project found that instead of introducing ordinary people's reactions to rare or extreme situations, Chinese medical dramas placed more emphasis on people's unusual reactions to ordinary situations.
The results of the textual analysis suggested that medical dramas presented an extended group of patients: both the person who needed intervention and his/her family members were of equal importance to doctors, and medical decisions were not made until they reached a consensus. Patients' family members were found to be deeply involved in the medical decision-making process and doctor-patient communication, being the first to be informed of the patient's condition and the primary figures making decisions. These practices were inconsistent with the maintenance of a fiduciary doctor-patient relationship in conventional medical practices, which could only be explained by the Confucian ethical values that prioritized a person's identity of being a family member over being an independent individual.
The study also revealed a two-fold doctor-patient communication model in Chinese medical dramas. Neither the paternalistic nor the consumerist relationships were relationships of mutual trust. Instead, the paternalistic relationship primarily resulted from patients' habitual respect for authorities, which was an outcome of the impact of Confucian ethics. The trend was evidenced by the fact that rather than negotiating in a reasonable manner, patients were more likely to act irrationally and even dramatically when they attempted to reject doctors' suggestions. These behaviors suggested that patients were not aware of their legal rights to negotiate as independent individuals. The consumeristic relationship, in which doctors were too vulnerable to fight against patients' unlawful behaviors, resulted from a hyper-responsive government (Tang, 2016) that prioritized social stability over law enforcement (Liebman, 2013). Doctors and hospitals were not treated fairly by the court; thus, they had to make many kinds of compromises.
Like typical entertainment media, medical dramas defined and presented inherent problems in doctorpatient communication, elaborated the causes of most of these problems, and made moral judgments about these issues using vivid individual stories, but they did not attempt to offer solutions to the problems. Failing to offer remedies did not weaken the power of the medical dramas: these shows broke the silence and placed the controversies in a public discourse, inspiring and encouraging viewers across the nation to think about, talk about, and reflect critically on problematic but taken-for-granted phenomena.

Funding
The author received no direct funding for this research.