Medical Errors in Hospitals.

Show: FRESH AIR
Date: FEBRUARY 24, 2000
Time: 12:00
Tran: 022401np.217
Type: FEATURE
Head: Interview With Dr. Mark Chassin
Sect: Medical
Time: 12:06

This is a rush transcript. This copy may not
be in its final form and may be updated.

TERRY GROSS, HOST: This is FRESH AIR. I'm Terry Gross.

Our fears about being hospitalized were reinforced by a recent study which found that 44,000 to 98,000 hospital patients die each year as a result of medical errors. That's more than the number of deaths caused by highway accidents, breast cancer, or AIDS.

The study comes from the Institute of Medicine, an affiliate of the National Academy of Sciences. President Clinton responded to this report earlier this week by calling for mandatory reporting of serious medical errors and the creation of a national center for patient safety.

My guest, Dr. Mark Chassin, is one of the authors of the Institute of Medicine report. Dr. Chassin is a professor at the Mount Sinai School of Medicine and senior vice president for clinical quality at the Mount Sinai-New York University Medical Center.

He's former commissioner of the New York State Department of Health, and he practiced emergency medicine for 12 years.

I asked him about the type of medical errors he and his colleagues found.

DR. MARK CHASSIN, INSTITUTE OF MEDICINE: I think it's fair to say that we don't know as much as we would like to, but what research there is available suggests that medication errors are particularly common, errors that lead to preventable infections in hospitalized patients are very common, errors that lead to preventable falls, for example, in hospitalized patients are also fairly common. And some of those turn out to be medication errors.

But those are some of the kinds of errors that are very common.

GROSS: Now, I know someone who actually had a knee replacement done on the wrong knee, much to his horror, and I think most people have some kind of horror story like this that happened to a friend or relative or, God forbid, to them.

How does something like that happen? Do you feel like you understand that any more now?

CHASSIN: Well, I -- you know, I think we really don't understand it as well as we should. Operating on the wrong side of a patient with a particular problem on usually a leg or an arm, but sometimes, as we've seen all too frequently, in the brain as well, is not as uncommon as one would hope. And there turn out to be, at least in the cases that have been reviewed extensively, a large number of problems.

And they result from the lack of having a systematic way of making sure that every patient every time has the right operation done. So for example if one case of the wrong side of the brain being operated on, an X-ray was reversed in the operating room, and the lesion appeared to be on the wrong side, because nobody noticed that the X-ray was put up backwards.

Patients frequently now mark their limb that is to be operated on with an indelible Magic Marker, away from the operative site, but where it can be visible to those in the operating room. There are a number of systematic ways that we could be putting in place to prevent these, and that's really a big part of the problem.

GROSS: You're saying that patients have to take it upon themselves to mark the right limb with indelible Magic Marker?

CHASSIN: Well, some hospitals have put a system in place where the surgeon visits the patient the night before or the morning of or prior to the patient's being sedated and so out of it they can't talk, and discuss the operation, and then together, or the patient by themselves, actually marks the limb that is to be operated on to increase the likelihood that the right limb does get the surgery.

GROSS: Now, you say a very typical problem that the Institute of Medicine report found is medication errors, people given the wrong medication, or I imagine the wrong dose of the correct medication. What are some of the typical causes of those medication errors?

CHASSIN: This is an area about which we do know some, although the studies are from a limited number of hospitals. And it seems to be pretty clear that the sicker the patient, the more interventions the patient is undergoing, the more likely errors are to occur. And that frequently happens in intensive care units, in patients that are elderly with many chronic illnesses receiving many drugs.

One of the most common reasons for error is that many drugs need to have their doses adjusted depending on how well your kidneys are functioning, how well your liver is functioning, how large or small a person you are. And those calculations are difficult and time-consuming. And if they're not checked very carefully using automated reminder kinds of systems and checking systems, humans are prone to make mistakes when they do those calculations.

GROSS: Now, I imagine that the need for this has grown because there are so many new medicines, and I think so many people are taking more medicines at one time than people used to be prescribed.

CHASSIN: Well, that's exactly right, and that -- you put your finger on a very important ingredient in this set of problems that I think is relatively underappreciated. Twenty or 25 years ago, we really had much less effective treatment to offer patients than we do today.

I tried to get an estimate of how big an issue this was, and one of -- what I looked at was the number of articles in the research literature that are published from experimental randomized trials. That's a kind of research design that really gives us the best information about what works and what doesn't work.

And over the last 30 years, there's some 86,000 articles published from randomized trials, but 30 years ago they were published at a rate of about 100 per year and spread over all of medicine and surgery and obstetrics so you could pretty well learn all of them that were relevant to your practice.

But now they're being published at a rate of 10,000 per year. The last five years, there were more published than in the previous 25 combined. So we're faced, as physicians and as other providers, practitioners of health care, with an avalanche of really good information about what works and what doesn't work.

But we're functioning under the old paradigm of how physicians and other practitioners are expected to behave, which is to have all the information that they need to make decisions in their heads at the time they need to make those decisions.

GROSS: Where should they have the information now, on a computer?

CHASSIN: Well, computerized systems and other kinds of decision support systems are extremely valuable. Computers are a part of the answer, but I don't think they're the whole answer.

GROSS: Is there something else you'd recommend in addition to computers for helping doctors keep up with the new information coming up -- coming out, and therefore being able to recommend just the right thing for a patient?

CHASSIN: Well, I think there are a large number of implications of this phenomenon of rapidly increasing information. Good health care today requires a team approach that includes in a hospital setting a pharmacist, a social worker, a nurse, frequently a respiratory therapist. We don't train physicians, we don't educate them to be part of teams, to rely on other team members for key parts of the delivery of health care.

And we don't train them to expect that they will need other sources of information to make decisions when they're taking care of patients. We train physicians in the expectation they'll make perfect decisions every time, and that is just increasingly not possible.

GROSS: When it comes to medication errors, what percentage of the errors do you think are caused by doctor incompetence, doctor sloppiness, and how much of it is more a problem with the system, that doctors need to have better systems?

CHASSIN: Yes, you raise a very good point. I think that with respect to medication errors, they are so common, preventable injuries due to medications occur at a rate at a hospital about the size of mine, 800-, 900-bed hospital, of about 10 per week. Ten patients per week are injured due to medication errors. That is, those injuries are entirely preventable.

And this is not rocket science, you know, we're talking about patients with a known allergy to penicillin receiving penicillin, a patient receiving 10 times the dose of an antibiotic when that antibiotic hurts kidney function.

So these are entirely preventable injuries. And the vast majority of those, especially the ones that occur in hospitals, are, I believe, at least from the literature that we've been able to look at, the vast majority of medication errors are probably system related. That is, there are so many different components, steps along the way, from the time a physician thinks of the right medication to order until the patient actually receives it, that the opportunity for mistakes just gets multiplied many, many times.

Now, those kinds of errors require system approaches, that is, we need to construct systems that instead of anticipating that physicians will be perfect decision-makers, expect that normal human error will creep in and build those systems to anticipate error and compensate for it before it does harm.

There are also, however, as your question indicates, some physicians, some nurses, some other practitioners who are so egregiously bad and make so many mistakes so often, that they need to be dealt with differently and in a disciplinary fashion, educationally, hopefully if they can be improved, but if they can't be and if they continue to make mistakes and do harm, they need to be disciplined by the licensing process.

GROSS: Doctors are famous for illegible handwriting. When I was a kid, I used to think, well, though -- even though no one I know could possibly decipher what this prescription says, a pharmacist will genetically be able (laughs) to have the skills required to read this handwriting, because they're a pharmacist. I no longer believe that, that they have special skills in reading handwriting. Is this a problem too, when you're getting a prescription filled?

CHASSIN: Yes, I think that that belief is probably in the same category as the tooth fairy. And what's really quite remarkable is that more errors don't occur because of bad handwriting. What usually happens is there is a dialogue between the pharmacist and the physician's office, or the physician's office actually calls in the prescription, so the nurse in the office knows exactly what the medication is supposed to be and calls it in.

There are many checks and balances in these systems that prevent a lot of these errors from occurring. Nevertheless, errors still do occur because of bad handwriting, and we need to take even more steps and computerized entry, order entry, typing in of prescription orders is a good way to combat the handwriting problem.

GROSS: My guest is Dr. Mark Chassin, co-author of the Institute of Medicine report that found 48,000 to 98,000 hospital patients die each year as a result of medical errors. We'll talk more after a break.

This is FRESH AIR.

(BREAK)

GROSS: My guest is Dr. Mark Chassin. He's co-author of the Institute of Medicine report that estimated that medical errors kill between 48,000 and 98,000 people in the U.S. each year. And this is the report that led President Clinton to urge states to require mandatory reporting of medical errors.

One of the problems that you mentioned -- one of the problems your report found was a lot of infections that patients get while they stay in a hospital. And I think this is something that a lot of people who are about to enter a hospital live in fear of, that the problem they're entering with will be fixed, but yet they'll emerge with a new infection that will cause a lot of problems. And this is often a staph infection that's very difficult to treat.

Did you find that these infections are often caused by problems in hospitals that don't have to exist, problems that could be addressed?

CHASSIN: There are absolutely preventable causes of hospital infections. Probably the most easily instituted, but most difficult to maintain, is simple hand-washing. Hand washing between patient contacts, both before and after patient contact, is one of the most important ways of preventing the spread of hospital organisms.

But you're quite right that hospitals, from an infectious disease standpoint, are very dangerous places. They are the places where the most powerful antibiotics are used and where resistant organisms congregate because the most vulnerable hosts or patients are there. And we have produced, along with a very powerful armamentarium of antibiotics, a tremendously resistant universe of germs, in large part because of our overuse of antibiotics. I'll come back to that.

I said 24 million Americans got antibiotics for colds and other viral infections in 1992. That's about a half a billion wasted doses of antibiotics, and that's the single most important preventable cause, over the long run, of these very resistant organisms.

So having said those two things, the other kinds of problems that result in preventable infections are the misuse of antibiotics, errors in the use of antibiotics in hospitals. For example, we know that if you're very careful about giving antibiotics prophylactically in some surgical procedures, you can reduce the incidence of infections after the operation.

But you have to give the prophylactic antibiotics only at the time surgery begins and stop them very soon after surgery ends. That's the maximal protection. But what we find when we look -- what we find is that lots of times, the antibiotic continues long after the surgery's over and the patient gets an infection with a resistant organism.

But talking to the physician about precautions for infection, making sure that everybody has -- is alert to that possibility is also a very good idea if you're going into the hospital.

GROSS: You mention that patients often fall while they're in hospitals, and that's something that your study found could be avoided, that the falling is often a function of a medical mistake that could be avoided. Examples?

CHASSIN: The most common preventable reason for falls goes back to medications, and it's the particular combination of a tranquilizer or a sedating medication in an elderly patient, that both inside the hospital and outside the hospital is one of the most important preventable reasons for falls.

And again, it's a very wise idea for patients who have elderly relatives or elderly spouses or other loved ones to be sure, if they're in the position of advising their elderly relative about medications or working with their physicians, that the number of medications that elderly people are on is really kept to the absolute minimum, particularly those with -- that have sedating side effects or that have the side effect of reducing blood pressure when you stand up. That's another common circumstance when elderly people fall.

GROSS: President Clinton has made a series of recommendations in response to the Institute of Medicine report on medical errors, the report that you co-authored. His main recommendation is that states require mandatory reporting of medical errors. This is very controversial in the medical profession. A lot of doctors fear that this is going to drive medical errors underground, that doctors or hospitals won't want this information to be public, so they just won't mention that it happened, they'll try to cover it up.

What are your thoughts on this recommendation of mandatory reporting of medical errors?

CHASSIN: I wouldn't say that was the main recommendation of President Clinton's package. It certainly wasn't the main recommendation of the Institute of Medicine report. It certainly is the one that has sparked the most debate and controversy.

GROSS: Are you concerned that mandatory reporting of medical errors might drive medical errors underground because doctors live in fear of medical malpractice, live in fear of losing their credentials?

CHASSIN: That's a part of the problem. But when I was the state health commissioner in New York, for example -- New York is -- has one of the oldest programs of mandatory reporting -- there were far more important problems than that. We've had mandatory reporting for over a decade in New York State. And the basic problem is that it's extremely difficult to get the definitions of the kinds of mistakes and outcomes that you want reported to be objective enough that everybody reports with the same frequency, the same thoroughness.

And if you don't have a massive police force of auditors going around checking behind the reports -- which is really totally infeasible, given the magnitude of this problem -- there's no way of getting all of the data from all of the, in this case, hospitals or nursing homes.

And the second part of the problem is, I don't know of any state, and again, New York has the most experience here, that has successfully completed the other side of the loop. There's no point in having reporting if the entity that receives the reports cannot efficiently and in a timely way analyze those reports, find out what there is to be learned from them, and report back to the hospitals or the nursing homes or whoever is reporting the data on errors.

And to my knowledge and my experience, that part of the loop has not been successfully closed in a way that we could replicate anywhere in the country.

GROSS: Is there such a thing in the medical profession as an honest mistake, or somebody makes a mistake that has serious consequences, but it's a mistake where they shouldn't be severely punished, because under the circumstances, it was a regrettable but an honest mistake?

CHASSIN: I'm not sure that "honest" is the best characterization...

GROSS: Right.

CHASSIN: ... because the problem really is not so much honest or dishonest, but mistakes that result because human beings are fallible. Every human being in every line of work makes mistakes. What we have not done a very good job of in health care is learning from other sectors of society and industry, where failure is also a life-and-death matter -- air travel is the best example, I think -- because what they have found is that reducing mistakes doesn't happen by punishing the individuals who make them or by expecting them to be perfect and to always make the right decisions.

Those industries have reduced errors, serious errors, to very, very low levels by creating systems, backup systems, training systems, checklists -- the preflight safety checklist that pilots go through before every flight, every time -- that anticipate the kinds of mistakes that human beings are prone to make, and expects that they will occur, and then puts compensatory mechanisms in place so that they don't do harm.

That's what we need to put much more effort into in health care, in addition to, as I indicated earlier, ferreting out the physicians and other providers who are just so egregiously bad in their performance that they pose a danger in and of themselves and no system will be able to prevent those errors.

GROSS: Dr. Chassin, thank you very much for talking with us.

CHASSIN: It was my pleasure.

GROSS: Dr. Mark Chassin co-authored the Institute of Medicine report on medical errors.

I'm Terry Gross, and this is FRESH AIR.

(BREAK)

GROSS: Coming up, trying to keep a show fresh after 165 episodes and 9,000 pages of scripts. We talk with Christopher Lloyd, executive producer of "Frasier." A new book collects 15 "Frasier" scripts.

(BREAK)

TO PURCHASE AN AUDIOTAPE OF THIS PIECE, PLEASE CALL 877-21FRESH
Dateline: Terry Gross, Philadelphia, PA
Guest: Dr. Mark Chassin
High: Dr. Mark Chassin is the co-author of a report on medical mistakes in our nation's hospitals. This week, in response to that report, President Clinton ordered that all U.S. hospitals take measures to reduce their errors. The report, issued by the Institute of Medicine late last year, shook up patients and practioners alike. It estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors. The study was based on two studies in three states: New York, Utah, and Colorado. The mistakes include drug mix-ups, surgical errors and misdiagnoses. The report also blamed hospital systems over individuals, and recommended that a center for patient safety be established within the Department of Health and Human Services. Chassin is a member of the Institute of Medicine. He's also professor and chairman of the Department of Health Policy at the Mount Sinai School of Medicine and Is former Commissioner of the New York State Department of Health.
Spec: Health and Medicine; Diseases; Government; Accidents; Death

Please note, this is not the final feed of record
Copy: Content and programming copyright 2000 WHYY, Inc. All rights reserved. Transcribed by FDCH, Inc. under license from WHYY, Inc. Formatting copyright 2000 FDCH, Inc. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to WHYY, Inc. This transcript may not be reproduced in whole or in part without prior written permission.
End-Story: Interview With Dr. Mark Chassin

Show: FRESH AIR
Date: FEBRUARY 24, 2000
Time: 12:00
Tran: 022402NP.217
Type: FEATURE
Head: Interview With Christopher Lloyd
Sect: Entertainment
Time: 12:30

This is a rush transcript. This copy may not
be in its final form and may be updated.

TERRY GROSS, HOST: This is FRESH AIR. I'm Terry Gross.

"Frasier" is one of the funniest and most honored TV programs of our time. It won an unprecedented five consecutive Emmys for outstanding comedy series. Kelsey Grammer stars as Frasier Crane, a neurotic and pretentious psychiatrist who hosts a radio call-in show. Even more neurotic and pretentious is Frasier's younger brother, Niles, played by David Hyde Pierce. John Mahoney co-stars as their father, Martin, who lives with Frasier.

Fifteen "Frasier" scripts are collected in a new book. The introduction is by my guest, Christopher Lloyd, the show's executive producer. He's been with "Frasier" since the first episode.

Let's start with a scene from last week's show. Frasier's producer is on vacation. Her substitute is an African-American woman. After Frasier encourages her to occasionally say a few words on the air, she ends up giving her own homespun advice on love and marriage to his callers. Frasier thinks she's not only taking over his show, she's giving bad advice. But he's afraid to say anything to her.

He comes home and explains his problem to his father and brother. They think he's afraid to confront her because she's black, and he's worried he'll sound like a racist.

Here's Niles.

(BEGIN AUDIO CLIP, "FRASIER")

DAVID HYDE PIERCE, ACTOR: For heaven's sake, Frasier, why don't you just talk to her?

KELSEY GRAMMER, ACTOR: Well, it's a delicate situation, Niles. For God's sakes, I mean, it's not all that easy. I mean, she is new to the field, she's sensitive, and she's eager to please.

JOHN MAHONEY, ACTOR: She's black.

GRAMMER: Dad, please!

MAHONEY: Well, you know damn well that's what this whole thing's about. I don't know what the big deal is. If she's talking too much, just tell her to shut her big bazoo.

GRAMMER: Oh, really? And how do you suggest I accomplish that without sounding like a complete bigot?

PIERCE: Well, perhaps a little diplomacy is in order.

GRAMMER: Oh, are you saying I should just choose my words more carefully? Is that it?

PIERCE: Yes, exactly.

GRAMMER: Oh, fine. Fine. All right, Niles, just exactly how would that go? Why don't you play me, and I'll be Mary?

PIERCE: All right. Mary -- Frasier -- I've been meaning to speak to you. You know, people listen to the show for my expertise.

GRAMMER: So my opinion's not worth anything?

PIERCE: Well, I'm the one with the medical degree. All right, now, I want you to contribute, but only up to a point.

GRAMMER: So you want me to stay in my place, Massuh.

PIERCE: She's not going to say "Massuh."

GRAMMER: What, am I getting too uppity for you? You sherry-swillin', opera-lovin', Armani-wearin' elitist? You have no idea how difficult it is for a black woman in a white man's world.

PIERCE: Frasier...

GRAMMER: I don't think so!

Look at me. This is ridiculous. I have walked myself straight into a minefield.

(END VIDEO CLIP)

GROSS: Christopher Lloyd, was this a difficult subject to take on? Dealing with race is so loaded.

CHRISTOPHER LLOYD, EXECUTIVE PRODUCER, "FRASIER": It was, in fact, just sort of dealing with any politically oriented stories, we've stayed away from, for the most part, in seven years. For whatever reason, it seems to sort of divide people or get people kind of agitated. And so we have really not done any issue shows per se.

But this is one that we were kind of intrigued by just because these guys are so rarefied and so white. And I think a lot of people probably thought that this was in response to the kind of call for greater diversity on television, which it wasn't, although it kind of played into that a little bit, in the sense that it is such a touchy subject, and Frasier is sort of the perfect person to be made especially touchy by it.

So we spent a long time, you know, wondering, is this really funny, or is this just kind of a -- uncomfortable, is it going to make viewers uncomfortable? But I think we walked the line pretty well with it, because it was true, it was a white guy saying, I have this African-American woman working for me. I don't like what she's doing, and I do not know how to tell her that without sounding like a bigot. And he struggled with that, and I think people laughed at it because it was a very real-seeming situation.

GROSS: Can I take you back to the very beginning...

LLOYD: Sure.

GROSS: ... of "Frasier"? What was the very basic conception of the main characters, the father, Frasier, Niles?

LLOYD: I think the original idea was, all right, we have to find a way to make Frasier a little bit more human. All right, well, what about...

GROSS: Compared to his character on "Cheers."

LLOYD: Exactly. So let's explore his relationship with his father. Well, all right, we want some contrast here. So they decided, all right, more of a blue-collar father. Let's give him a brother too, somebody he can talk to. Well, the obvious way would be to make the brother blue-collar also, so that there's conflict there. And Frasier's really the odd man out.

What if we go the other way and make the brother a psychiatrist too? In some ways there was an echo of Lilith there, I think, two psychiatrists sort of nattering on in their way. So they tried that, and it worked tremendously well, in large part thanks to the casting of David Hyde Pierce, who's a great actor.

After that, I mean, I think the story was that Frasier was looking for freedom in his life. He'd been kind of encumbered in his job and in his marriage in Boston, wanted to try something really new, started out in a new career, got himself this wonderful apartment, felt complete freedom. And the story of the pilot was to gradually take away that freedom, first with the father moving in, then the father bringing his chair, then the father bringing his dog, and then the father bringing his physical therapist. So those characters sort of fell into place.

GROSS: I'd like to find out a little bit about the writing process on "Frasier." Are there different -- are there some writers who specialize in creating the story, and other writers who specialize in creating the funny lines within the story, you know, some writers who are specialists at character development and plot, and others on jokes?

LLOYD: Yes...

GROSS: Not jokes per se, I mean, not -- you know, but funny lines, repartee?

LLOYD: No, jokes per se. There are certainly writers that we've had on staff who are brilliantly funny but don't have as good a sense of story structure, story-telling ability, as some other people. There are other people we've had on staff who, if you met them in a coffee shop and talked to them for half an hour, you would never in your life imagine that they made a living as a comedy writer, because they're not particularly funny to talk to, but just have a great sense of how to structure a story.

So on a writing staff, you like to have a mix of those people with those different strengths.

GROSS: Now, as the executive producer, do you often have to referee, like if a writer comes to you and says, you know, My idea was to do blah-blah-blah, and, you know, the majority of the writers don't like that, they want to -- they want this plot twist instead, and I don't think it works, so, you know, you be the judge?

LLOYD: That's a large part of my job is sort of -- yes, I guess refereeing those disagreements. It's sort of understood in television writing, sitcom writing in particular, that you can't maintain a proprietary interest in your script. It's -- it becomes the property of the staff once you turn it in. And there are people that don't like that. But frankly, I think it makes the scripts better.

We all, every one of us, have our names on scripts that are much better than they would have been if they had -- if we had simply performed, produced, the scripts as we wrote them.

GROSS: My guest is Christopher Lloyd, executive producer of "Frasier." And there's a new book called "The Frasier Scripts."

I want to play a clip from the "Frasier" Valentine's Day episode. And this was the story of Frasier and his father going to the opera, and at the opera they strike up a conversation with a woman Frasier's age who's at the opera with her mother. And Frasier wants to date the woman who's his age, but the problem is, the older woman wants to date Frasier's father, and Frasier's father isn't interested. But Frasier has warned his father not to do anything that would alienate the mother, because it would ruin Frasier's chances with the daughter.

So here's Frasier's father and the older woman who's interested in him conversing at the opera.

(BEGIN AUDIO CLIP, "FRASIER")

ACTRESS: Lovely production, isn't it? I adore Verdi.

MAHONEY: Oh, he's my favorite.

ACTRESS: Though the woman singing Gilda's a bit off.

MAHONEY: She's not Renata Tebaldi.

ACTRESS: You know, if you like Verdi so much, I happen to have a spare ticket to "Aida" next week.

MAHONEY: Whoa, that sounds great. But if it's a week from tonight, I'm busy, I'm sorry.

ACTRESS: Actually it's next Thursday.

MAHONEY: Oh, Thursday. You know, there's this thing at my wine club.

ACTRESS: Oh, that's all right, Martin. We just met. I shouldn't have asked.

MAHONEY: No, no, no, Helen, it's got nothing to do with you. It's me. I'm afraid I've given you the wrong impression of myself. You see, the truth is, I'm...

ACTRESS: Gay.

MAHONEY: Right, gay.

ACTRESS: I thought you might be. How many straight men remember Renata Tebaldi?

MAHONEY: Not many.

ACTRESS: Well, I'm sorry if I was too forward. It's just that sometimes it's so hard to meet nice men.

MAHONEY: Tell me!

(END AUDIO CLIP)

GROSS: Now, this is a very funny episode. Was this a kind of sensitive issue to deal with at all?

LLOYD: Yes and no. It's not entirely virgin territory for us. We did a show in the second season, for example, that also explored a similar theme, called "The Matchmaker," which had to do with Frasier thinking -- well, Frasier, on a date sort of with his -- the station manager, who is gay, it's (inaudible)...

GROSS: Well, he doesn't think it's a date. Let me explain what's happening. Frasier invites his boss over to dinner with the hopes of matching him up with Daphne, the live-in physical therapist. Frasier doesn't realize his boss is really gay, and his boss has interpreted the invitation as a kind of intimate overture, you know, like a date, you know, and he's expecting an intimate dinner with Frasier. And comedy ensues. It's a very funny episode.

LLOYD: Thank you. And written by the same gentleman who wrote the one that you're talking about, the opera show. His name is Joe Keenan (ph). He's a fabulous writer.

GROSS: What makes it particularly funny on "Frasier" too is that Frasier and his brother, Niles, are written almost like the stereotype of gay characters, you know, they love opera, fine wine, home decorating, refined language, they're kind of snobbish. You know, I mean, that's like the stereotype of a certain type of middle-class professional gay character. So when people mistake them for -- one of them for being gay, it kind of just, like, fits in with the stereotype.

LLOYD: There was an article in a British newspaper a couple of weeks ago that described Frasier and Niles as "heterosexual sissies." I think that comes pretty close to describing what we're after. And I have to say, I think we all kind of resist the stereotype, the idea that just because these guys like the finer things in life, the clothes and the wine, and are cultured, that that necessarily -- well, that that suggests that they're gay. And sort of by extension, people have said "Frasier" seems to be written with a gay sensibility.

Well, I'm not sure exactly what that means, and we've always had gay writers on the staff. But we've always had straight writers on staff too. And just because we like kind of more of a verbal orientation -- you know, we use big words and the characters are witty, I'm not sure how that got translated into a gay sensibility, exactly, but...

GROSS: I'm wondering if it's almost easier to write these kind of traits for straight men, because then you can't be accused of creating a stereotypical gay character.

LLOYD: I guess that's possible. I hadn't thought of it that way. I mean, Niles -- neither one of them is gay, neither one of the characters is. And there's -- you know, Niles is in love with his wife, in the first four or five seasons of the show, and at the same time nursing a crush on Daphne. I mean, that, I think, sets him apart from a homosexual character right there. Frasier is constantly on the prowl for women. So I think it's a little unfair to say that they're gay in everything but, you know, the admission of it.

GROSS: Which is what some people say...

LLOYD: Not that I'm accusing you of...

GROSS: ... right? A lot of people say that, yes.

LLOYD: Which is what a lot of people say, yes.

GROSS: My guest is Christopher Lloyd, executive producer of "Frasier." We'll talk more after a break.

This is FRESH AIR.

(BREAK)

GROSS: My guest is Christopher Lloyd, executive producer of the sitcom "Frasier." He wrote the introduction to a new book collecting 15 "Frasier" scripts.

I think sometimes when a sitcom's been on for a long time, it gets broader and sillier as the writers seem to have exhausted some of the ideas that they started off with. And perhaps the best example of that was "Seinfeld," which started off as this, you know, very kind of realistic show about trivial talk, you know, the whole thing about "Seinfeld" being about nothing. And then it just become more and more preposterous toward the end, more and more like a sitcom.

I'm wondering if that's an impulse that you've seen happen a lot and something that you have tried to resist.

LLOYD: Well, I think everyone tries to resist it. It's hard. You know, this week we're shooting our 165th episode. That's 9,000 pages of "Frasier" scripts. And so there aren't too many subjects that Frasier and Niles haven't talked about while sipping their lattes at the cafe.

You have to really challenge yourself to not repeat things that you've done before, because people are very quick to say, Wow, the show's getting stale, they've done that before. It's -- it is harder every year. And part of the things -- one of the things that you do is take the characters into new territories, obviously, new relationships or new dynamics.

We got Frasier fired last year, and people hated that. But it gave us sort of an arc and a whole new thing to explore with Frasier. But it -- at least we weren't repeating ourselves.

GROSS: What's your best way of measuring what people do think, what your viewers do think?

LLOYD: That's a very good question. We have 20 million viewers -- well, probably more than that. And you probably end up listening to 15. You know, you listen to your wife, or you, you know, maybe check in on the Internet, the chat group, which has, you know, the same four people weighing in, or, you know, you sort of listen to the (inaudible) and say, God, you know, that was a really good show, I got a lot of calls on that.

And it's such a tiny sampling, and yet somehow you get a sense of what shows they really liked and which ones they didn't.

GROSS: There was an episode in which there's a new doctor who's joined the radio station, you know, doing a phone-in advice show. And one of the things he prides himself on is that he -- you know, he sings, he loves to sing. Unfortunately, he sings really badly. And to get even with him, Frasier and Niles suggest that he sing at a party. And the song that he sings, quite badly, although he doesn't realize how badly he sings, is, "Isn't It Romantic," which is -- it's a great song, and it's not a very well-known song. I thought it was interesting and kind of brave to sing a song that most people probably wouldn't know.

And that strikes me as kind of typical of the program. A lot of the jokes and a lot of the situations, they're just very smart, and a lot of shows, I think, would worry, Oh, is this going over the listeners' heads?

How much do you have to worry about that?

LLOYD: We worry about it less and less. Early on, we would write a joke that used a real, you know, $10 vocabulary word, or an obscure reference, and we'd say, Gosh, aren't we clever and smart and wonderful, and we've amused ourselves with this, but the audience is never going to get this. We should really dumb this down. And really Kelsey Grammer was one of the big champions of not doing that, and saying, The audience is smarter than anyone gives them credit for being, don't dumb this audience -- don't dumb the material down, don't write down to the audience. Keep that joke in, they will get it.

And a joke that we refer to as a 10 percent joke, meaning we thought 10 percent of the audience would get it, would end up getting a big laugh. Sixty percent of the audience would understand it. So we were, I think, a little bit, maybe, ashamed of that, but also encouraged by it, and started writing those sorts of references and jokes more confidently.

Just as a footnote, I appreciate your giving us credit for using -- having the courage to use "Isn't It Romantic," but the reality of it is, it's owned by Paramount. We didn't have to pay anything to use the song.

(LAUGHTER)

GROSS: Oh, well!

LLOYD: But I accept the compliment (inaudible).

GROSS: Oh, yes, I thought it was so much more interesting than going with, say, "I Got Rhythm," or, you know...

LLOYD: We have -- we've had our share...

GROSS: ... it's wonderful.

LLOYD: ... of strange references and musical pieces, but that was not one of them.

GROSS: I'm wondering if you guys have to keep up with psychiatry. Let me -- at the risk of ruining these lines, let me read something that Frasier says in one of the episodes. This is the "Room Service" episode, one of the episodes included in the book "The Frasier Scripts." And this is the episode in which Niles, Frasier's brother, ends up sleeping with Frasier's ex-wife, Lilith. And, you know, Frasier finds out about it and is obviously really angry at both Lilith and Niles. And Lilith is trying to, like, explain and rationalize what happened.

And Frasier says, "Very impressive, Lilith, but I happen to be a psychiatrist too. Let me tell you what really transpired. This is a passive-aggressive manifestation of the deep resentments that you both have toward me. You were punishing me for my notoriety, my successful adjustment after our marriage. It is this shared bond that brought you two to your palace of sweet revenge."

Do you actually try to read recent psychic...

LLOYD: You can say what's on your mind. Do we all go see psychiatrists? Absolutely. All of us are deeply troubled.

GROSS: Oh, even a better question than the one I was going to ask.

(LAUGHTER)

GROSS: Do you? I hadn't thought of that.

LLOYD: Do I personally? I have been known to, as have, I think, a lot of people on our staff. You know, I could tell you it's purely for research purposes. It isn't. But I think we all have a sort of a passing either interest in or dependency on -- yes, psychology, psychiatry. Enough to fake it in a script, at any rate, to throw around your passive-aggressive stuff, mumbo-jumbo, your -- you know, your unconscious/conscious distinction, stuff like that.

GROSS: Do you try to read psychiatric books so you can throw out -- throw around more of the professional language?

LLOYD: It tends to be more like, well, we've found a place where we need a reference to something. We had a piece in a story two years ago where Niles -- Frasier's been named Seattle Man of the Year, and meanwhile Niles has gotten his name as a footnote in a tiny psychiatric journal. And he comes in very proud of this, and Frasier doesn't quite know how to tell him that he's completely trumped Niles' achievement by being named Seattle Man of the Year.

So we had to come up with a funny name for something that Niles could have written something about, so then we dipped into some kind of journal and came up with "trichotillomania," which -- I don't think we even knew what it was until we heard from the Trichotillomania Institute, who commended us on, you know, advancing their cause. And trichotillomania, for those trichotillomaniacs out there, is obsessive hair-twisting.

GROSS: (laughs) OK.

My guest is Christopher Lloyd, executive producer of "Frasier." We'll talk more after a break.

(BREAK)

GROSS: My guest is Christopher Lloyd, executive producer of the sitcom "Frasier." He wrote the introduction to a new book collecting 15 "Frasier" scripts.

What are you doing now that's giving you a problem? What's a problem you have to solve with "Frasier" right now?

LLOYD: A big...

GROSS: Either...

LLOYD: Go ahead.

GROSS: Yes, a problem either with a script or with the writers, with the network, with the audience, any kind of problem.

LLOYD: With the network, the only problem we have is that they keep giving away our stories. We spend a lot of time kind of carefully crafting our stories so that surprising things happen at particular points along the way. And the network is in the habit of running promos all week beforehand that give away those surprises. So when you finally come to watch the show, you're watching the first 15 minutes waiting for that huge surprising thing to happen.

I remember a show that we did last year which had to do with Frasier dating a woman who has brought over her mother, her mother is Jewish, she asks him to pretend to be Jewish just so that the mother doesn't get her nose out of joint. She's on her way out of town in an hour, could he just do that? Frasier says sure. Niles, for various other reasons, is appearing in a Christmas pageant and has to be dressed as Jesus. And he comes in, you know, obviously at an inopportune moment for Niles to enter dressed as Jesus as Frasier's trying to pretend to be Jewish.

Well, all week -- I mean, it was a huge surprise the night that we filmed it. The audience went berserk when Niles entered that way. And the network chose to use that as their promo, which means that the home audience is not going to have the same reaction when they see that moment, because they've seen it all week. That drives me crazy.

On the creative side, really the biggest problem we're dealing with is what to do with Niles and Daphne. Niles is involved with a woman now, Daphne is engaged, but Daphne just a few weeks ago on the show discovered that Niles has had this crush on her for a long time, and I think she's starting to recognize some reciprocal feelings herself.

It's very exciting, it's a -- it's kind of a violation of a primary principle in television that if you have great sexual tension between characters and the audience really wants to see them get together, you probably shouldn't bring them together, because you blow the whole thing.

And yet we've gotten so much mileage out of almost bringing them together for seven years, we're starting to say, Gosh, should we actually do it? We don't know, it's -- there's a lot riding on how we conclude that story, and we're not exactly sure how we're going to do it yet.

GROSS: So you really don't know whether they're come together or not.

LLOYD: Well, I might just be saying that.

GROSS: (laughs) Why is sexual tension such a good audience booster? I -- even like on -- in the "Moonlighting" era, Cybill Shepherd and Bruce Willis, there was always something between them on the show, but they'd never really -- you know, they'd never really become a couple.

LLOYD: Well, I think in all good story telling you need a rooting interest. We constantly ask ourselves when we're figuring out stories, What is the -- what is Frasier after here? What is the audience getting behind Frasier or whoever we're writing the story about, what do we want the audience to be rooting for? And love is a great thing for people to root for. They like to root for it, love or sex.

I mean, I think in the case of Niles-Daphne, it's really love, it's a -- seeing those two get together. The problem is, once they're together, love gets kind of boring. Rooting for it to happen once is one thing. It's sort of like an unresolved chord in music. There's an instinct you have, you want to hear it, hear the chord resolved. But once you've heard it, you're ready to move on to something else.

GROSS: One last question. I'll start with a statement, that I always assumed, well, the reason why the actor Christopher Lloyd doesn't get that many roles now is because he's directing -- he's the executive producer of "Frasier." But it turns out you're a different Christopher Lloyd than the actor Christopher Lloyd. I'm sure everybody makes that mistake. Has that caused any mayhem in your life?

LLOYD: (laughs) It hasn't caused any mayhem. I was -- I get letters constantly, you know. It's actually dwindled a little bit. But for a while there, it was a letter a week from people. You know, one woman wrote to me saying, you know, You were my favorite actor for all these years, and now you're producing my favorite television show. I've cleared it with my husband. If you'd like to come down to South Carolina, I'll make you some Creole duck and maybe have some light petting on the couch. I mean, all kinds of crazy things like that.

But I did meet him a couple of years ago, and I told him that I have some mail for him, and he told me he has some mail for me. And I haven't gotten his mail yet, nor has he gotten his from me, but it was funny to hear that he's got some of the same misunderstanding.

GROSS: Well, Christopher Lloyd, thank you very much for talking with us.

LLOYD: It's been my pleasure. Thank you.

GROSS: Christopher Lloyd is the executive producer of "Frasier." He wrote the introduction to a new book collecting 15 "Frasier" scripts.

FRESH AIR's executive producer is Danny Miller. Our interviews and reviews are produced by Naomi Person, Amy Salit, Phyllis Myers, Monique Nazareth, and Joan Toohey Wesman, with Ann Marie Baldonado and Patty Leswing, research assistance from Brendan Noonam. Roberta Shorrock directs the show.

I'm Terry Gross.

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Dateline: Terry Gross, Philadelphia, PA
Guest:
High: Christopher Lloyd is the executive producer of the TV show "Frasier", The show made its debut In 1993 and since then has won many awards, including the Peabody. The new book, "The Frasier Scripts" collects 15 of the staff's favorite shows.
Spec: Entertainment; "Frasier"; Christopher Lloyd; Television and Radio

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End-Story: Interview With Christopher Lloyd
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