The St. Elsewhere Dream Universe Theory, Explained

Medical dramas have been a fixture of TV for nearly as long as TV has existed. One stalwart of the 1980s was St. Elsewhere, which ran on NBC from 1982 to 1988. The show followed several experienced doctors and medical professionals as they trained up-and-coming interns in a struggling Boston hospital. The show earned praise for its realism and was a hit in the younger audience demographic.

The show featured a sprawling main cast that included names such as Ed Begley Jr., Howie Mandel, William Daniels, Mark Harmon, Bruce Greenwood, Alfre Woodard, and Denzel Washington, among dozens of others. St. Elsewhere was instrumental in popularizing the modern medical drama. But what if none of it ever happened? Well, if a scene in the series finale is to be believed, the entire show was essentially one six-year-long dream sequence. But what does this mean? And how much truth is there to the “St. Elsewhere was all a dream” theory? Let’s look at what we know.

How Did the St. Elsewhere Dream Theory Start?

St. Elsewhere followed the staff of the rundown Boston-based St. Eligius hospital. Ed Flanders, Norman Lloyd, and William Daniels were the leading cast members throughout all six seasons, portraying the experienced doctors mentoring incoming classes. The show also launched the career of Denzel Washington, who appeared as Dr. Phillip Chandler in all six seasons. While it was not his on-screen debut, St. Elsewhere was the venerable Washington’s first major gig. Despite its popularity, the show was never a ratings juggernaut. Its highest yearly ranking (#47th overall) came in the sixth and final season. Perhaps it could have enjoyed a longer life (a la ER or Grey’s Anatomy) if it had been able to rate higher.

The finale, appropriately titled “The Last One,” featured significant life-changing moments for several characters. It’s remembered more today for the character of Tommy Westphall, the autistic son of Ed Flanders’ character Dr. Donald Westphall. In the final scene, an exterior shot of snow falling outside the hospital cuts to Tommy in an apartment building. His father, Donald, enters, though he is now a construction worker rather than a doctor. Norman Lloyd, who played Donald’s recently deceased colleague Dr. Auschlander, is now Tommy’s grandfather and Donald’s father. As the two talk, Tommy shakes a snow globe while the camera zooms in to reveal a miniature replica of St. Eligius Hospital. The final few lines of dialogue heavily imply the entire series was in Tommy’s imagination.

Grandfather: “[Tommy’s] been sitting there ever since you left this morning, just like he does every day. World of his own.”

Father: “I don’t understand this autism thing, Pop. Here’s my son, I talk to him, I don’t even know if he can hear me. He sits there, all day long, in his own world, staring at that toy. What’s he thinking about?”

How True Is the St. Elsewhere Dream Theory?

The common interpretation of this scene is that the entire series existed within Tommy’s mind and that he imagined his father and grandfather as doctors at that hospital within the snow globe. However, it’s deliberately meant to be ambiguous to open up room for debate. While it doesn’t appear that any cast members have ever directly addressed the theory (likely to keep the mystery alive), others have offered their own explanations.

One theory says the hospital could be both a dream and a real-life location. Just because Tommy dreamt about the hospital doesn’t mean it does not exist, as dreaming of real-life events or places wouldn’t be uncommon. Even if he made up his father and grandfather’s careers, the other characters on the show could still work at St. Eligius. Other ideas point to the exact opposite of the theory being true, with the snow globe incident being the dream sequence and Dr. Westphall only imagined as a construction worker.

In any case, it’s heavily implied the show was a work of fiction within the mind of a fictional character, so what does that mean about the nature of reality? It was likely just a fun gag to keep people guessing after their favorite show had wrapped. But what if it’s not limited to St. Elsewhere?

The Extended Universe of the St. Elsewhere Dream Theory

Let’s assume the dream theory is true, and the show exists just within Tommy Westphall’s mind. How many other series could be affected? The character of Warren Coolidge, the hospital’s orderly played by Byron Stewart, was carried over from CBS’s earlier drama The White Shadow. However, a later episode noted The White Shadow as a fictional TV show in St. Elsewhere‘s world.

In the second season of Cheers, Rhea Perlman’s Carla Tortelli gives birth at St. Eligius. Later, a group of doctors visits the Cheers bar for a drink in St. Elsewhere‘s third season finale. This loops in Cheers, and by extension, its spin-offs, Frasier and The Tortellis, to the dream universe. Cheers crossed over with Wings, and taking things even further, Cheers has technically crossed over with The Simpsons. The Simpsons shares a world with Futurama, Family Guy, and American Dad! thanks to additional crossovers.

Alfre Woodard’s character of Dr. Roxanne Turner later appears in the sixth season of Homicide: Life on the Street, where things get really messy. A key player in all this is the character of John Munch, played by the late great Richard Belzer. Munch began on Homicide before being transferred to Law & Order: Special Victims Unit. Law & Order shares a universe with NBC’s Chicago and CBS’s FBI franchises. John Munch also made guest appearances on The X-Files, The Wire, and even Arrested Development. But it doesn’t stop there.

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Showtime’s City on a Hill features an establishing shot of St. Eligius to go with its early 1990s Boston setting, while HBO’s Oz mentions that a member of the prison’s medical staff was fired by St. Eligius. William Daniels’s Dr. Mark Craig discusses serving in Korea with B.J. Hunnicutt from M*A*S*H*. Elliott Carlin, played by Jack Riley on The Bob Newhart Show, showed up for treatment in the hospital’s psych ward. Carlin later returned in the follow-up series Newhart (which itself featured an iconic dream revelation in the finale) and mentioned his time at St. Eligius. So, was Newhart‘s dream just one element of St. Elsewhere‘s dream? A dream within a dream?

Several other series can be connected indirectly. Numerous characters from different shows were regularly paged over the hospital’s intercom system as an inside joke, far too many to list here. Of course, whether the theory is really “true” will always be up for debate, as there can be numerous interpretations for the end of St. Elsewhere. We’ll likely never have a definitive explanation of whether it was all a dream. It can’t be proved that the characters and their respective shows only exist in Westphall’s mind. However, in a 2003 article published by the BBC, Tom Fontana, a writer for St. Elsewhere, who would go on to create Oz and several other shows, said, “Someone did the math once… and something like 90 percent of all [American] television took place in Tommy Westphall’s mind. God love him.” St. Elsewhere is available to stream on Hulu and rent on iTunes and Prime Video.