For reasons I can't entirely explain, I love the CBS show Survivor. I'm somewhere between a fan and a super-fan. (Super-fans have knowledge that I can't begin to compete with, but I do watch every episode. And I read after-show interviews. And I occasionally text with some former contestants to discuss strategy. And, okay, I listen to some Survivor podcasts. Look, nobody's perfect.) This week was the season finale, and it was awesome.
Survivor is less of a reality show and more of a fully immersive game show. The contestants go to an island for several weeks, and vote each other out one at a time. Over time (44 seasons over 22 years), the game has become more complex, with incredible strategic play evolving. I highly recommend it. Nobody is paying me to say this.
Survivor Has Its Share of Medical Content
As an emergency physician, I'm always interested in any medical situations that arise on the show. There have been an awful lot of "medical evacuations" over the years. The first one was really tough to watch. A player burned his hands on the camp's fire when he dozed off and fell into the pit. Over time though, some of the medical evacuations have gotten softer, shall we say. In addition, the amount of on-site medical treatment that is permitted has gradually increased, it seems. (Treatments that can be given on the island are allowed, at the discretion of the medical unit.)
There's a large gamut. Players have been pulled for skin infections that didn't look that bad to me. Others have been pulled because they got dehydrated and didn't perk up quickly enough. (I thought these evacuations were unnecessary, given that they could run IV fluids and use cooling devices. They just got impatient, in my view.)
But look, I'm not there, so it's hard for me to judge the medical team's decision-making process. Still, it often seems to me like the teams err on the overly cautious side. It's too bad when that happens because once a player leaves the island for medical reasons, they can't come back.
Sometimes, I can see that they had tough calls to make. This season, a player was removed from the game after a concussion during a grueling physical competition for immunity from the first vote-off. After initially being cleared to remain on the island, the player clearly got a lot worse a few hours later. This meant he needed a CT scan of his brain to rule out internal bleeding. Pulling him made sense. (That player is getting to play again next season, we have recently learned, which is not always the case).
Here's a list of medical evacuations from Survivor. Some of these I agreed with and some I did not. I'm hoping to interview the medical team at some point just to get a sense of what they can and can't do on the island these days. Again, I'm not there, so I always temper my judgement!
Survivor May Be an Untapped Resource for Understanding Weight Control
There's another big health-related topic I've long thought about, which I'd love to discuss here. There's something every Survivor player who lasts more than a few days in the game has in common. They lose weight. Lots of it. There's just not enough food on the island. The players are often starving. By the end of the show, the remaining players look a lot smaller. I've never seen a better piece of evidence that calories-in versus calories-out is the thing that determines weight loss in the short-term. (It's probably true in the long-run too, but how people maintain that balance becomes more crucial later on.)
I'd love to know exactly how much weight each player lost during the game and also how long it took them to gain it back. Maybe some never did, but I imagine most did gain it all back eventually, though, due to biological phenomena like "set points" -- which are weights that our bodies sort of "gravitate towards." The set point theory states that over time, even if you decrease your caloric intake consistently, your body's metabolism slows down to adjust to that. Eventually, the same number of daily calories that it took to have lost a bunch of weight 5 years ago could actually now be enough to cause weight gain. As one obesity (bariatric) surgeon I worked with once said to me, "The question is not why are some people obese; the question is, why isn't everyone?"
Game theorists have studied Survivor. I'd love obesity and endocrine specialists to do the same. To do it right, researchers would need access to the data (which I imagine the medical team keeps; and we've seen some post-game "weigh-ins" at various points in Survivor history) and the players would have to be willing to participate. But that island seems like a potentially valuable laboratory to learn about metabolism -- that is, how people survive both in and outside the game.
Jeremy Faust, MD, is editor-in-chief of MedPage Today, and an emergency medicine physician at Brigham and Women's Hospital. He is author of the Substack column Inside Medicine, where this post originally appeared.