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Another day, another barrage of physician-centrism from the Old Gray Lady

October 5, 2004 -- Three articles published today in the New York Times health section illustrate some key aspects of the elite media's continuing reinforcement of the public view that physicians direct or provide all significant health care. In each of these pieces, nurses are barely mentioned, even though they surely played critical roles in each scenario described. Readers should not assume from our selection of today's Times articles that this is anything unusual; the same thing happens every day, in media organs all over the United States. This is merely a ready example.

Elite media like the Times tend to regard as "news" health care tasks and issues in which physicians play a relatively large role, and to ignore key aspects of care that are primarily the responsibility of nurses or other professionals. Of course, physicians themselves have a key role in the creation of influential media on health care, from prominent newspapers to popular Hollywood products, including actually writing much of it themselves. Nurses are comparatively uninvolved, partly because few have sought such a role, partly because the media has not generally asked them to play it. Nurses are not alone in being marginalized; other professionals and even certain types of physicians at times suffer the same fate. Surgeons and specialists are deified. Less glamorous types, like anesthesiologists, may be ignored. But nursing suffers far more universally and to a far greater extent from the prevailing bias.

Evidence? Let's go to the tape. "The Kidney Swap: Adventures in Saving Lives," by Denise Grady and Anahad O'Connor, highlights the growing practice of "paired exchanges." This occurs where two patients who need transplants but whose own families are not matches each receive a matching organ from a member of the other patient's family, thus satisfying all needs at once in a simultaneous four person operation. Predictably, the article gives the impression that only the surgeons matter, naming them, quoting them, discussing their exploits, and generally giving them credit for virtually everything that happens. When that is too much of a stretch, other personnel are referred to so generically that most readers will not even notice them. Thus, a "transplant coordinator" sees that two particular families are a match and brings them together. Obviously, such coordinators (who are often nurses) are not important enough to be named or quoted. In the text and accompanying photos, surgeons seem to be performing a surgery at a New York hospital all by themselves; no OR nurses are identified, or even mentioned. There are mentions of "assistants" and one "chatty colleague;" perhaps those are the nurses. The anesthesia professionals, whether physicians or advanced practice nurses, are also ignored. There is no significant discussion of the critical post-operative care in which nurses play a central role, care that can itself be an "adventure in saving lives," especially because of the compatibility issues involved in transplants. Indeed, the article notes that some time after the operation, the patients are recovering, apparently all by themselves; only the occasional interaction with a surgeon is worth mentioning. In the entire article, not one nurse is quoted or even named. The only place the word "nurse" even appears is at the end, when a kidney recipient finally meets her donor "by the nurses' station."

Laurie Tarkan's "How Doctors Help Children Tame the Beast in the Belly" certainly establishes its focus right up front in the headline, which implies that only physicians are involved in caring for school-age children who suffer from severe recurrent abdominal pain. Though the relationship of these children's conditions with school is a major theme of the piece, the only reference to a school nurse is near the beginning, where one patient notes that she would "go to the nurse every other day, and be sent home." That's it. School nursing in a nutshell: sending sick kids home. Of course, in reality, school nurses are highly skilled professionals caring for an increasingly complex series of serious health conditions despite severe budget pressures, to the point where some are essentially operating primary care clinics in the schools (See "School kids insist on staying alive;" Baltimore Sun article; School Nurse article in Salon.) We feel confident that the piece could have benefited from the views of school nurses as to the nature, extent and potential factors in such abdominal problems, which appear to include anxiety. Indeed, the article reports that many suffering students are not adequately treated, or never treated at all--is it possible that the health care professionals who are actually on the scene might have some valuable information about why that might be? Much of the piece also concerns pain management, including alternative therapies, areas in which many nurses are expert. But the article does not even name, much less reflect input from, a single nurse. Instead, the focus is on pediatric gastroenterologists, and to a lesser extent pediatricians who specialize in pain control; no pediatric nurse practitioner is consulted. Recent articles in physician journals are cited; articles in nursing journals are not.

The third article is a shorter "Cases" piece called "On a Matter of Life or Death, a Patient is Overruled," by Sandeep Jauhar, M.D. This is a first person account about a cardiac patient who refused intubation but would have died without it. The author, a CCU attending physician, describes his discussions with a cardiac fellow and a cardiologist about how to manage this patient's refusal, and the attending's own internal struggle with how he can get around the patient's misguided wishes (in fairness, he does recognize that the patient might have some right to refuse treatment, even if it's a "bad decision"). At the cardiac unit, "a crowd of doctors and nurses" are at the bedside as an anesthesiologist prepares to insert a breathing tube in the unconscious patient, which he or she does. When blood starts spraying, nurses have to "scramble for face shields and yellow gowns." Are the physicians too macho for such equipment? Or just not that close to the patient? In any case, protecting themselves from that blood is the only action nurses take in the entire piece. Jauhar refers to the patient's "unusually rocky" next two weeks, during which the "critical care unit staff settled in for a long period of observation." This is a screamer. While ICU nurses certainly do constantly assess their patients for any sign of trouble, they're doing a little bit more than just "settling in" and "observing." In fact, ICU nurses perform a variety of complex tasks to keep patients alive 24/7, such as titrating cardiac medications and adjusting ventilator settings based on slight changes in the patient's cardiac and respiratory condition that they have been "observing". Performing these tasks is a special challenge in today's short-staffed nursing environment; there is little or no "settling in. A week later, the patient's condition "ha[s] improved," evidently all on its own. A week after that, the author goes to see the patient. The physician realizes that he has "never really looked at [the patient] as a person." Naturally, the patient does not recognize him. Undeterred, the physician introduces himself, and notes that he "was one of the doctors who made the decision to put in the breathing tube," without which the patient "would have died." (Of course, the implication here is that physicians make such critical care decisions alone, but in fact, nurses' patient advocacy duties require that they be actively involved in resolving such ethical problems, and they are, every day.) The patient, hoarse after two weeks of intubation, says that he's been through a lot. "I know," says the physician, who has presumably been present for a few minutes of it. "But thank you," the patient says, and the piece ends, having fixed all credit where it is really due, rather than giving any to the highly skilled CCU nurses who have spent the last two weeks--336 hours--keeping the patient alive.

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