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Weird Scenes Inside the Gold Mine

January 29, 2006 -- Tonight's episode of ABC's hit "Grey's Anatomy" featured the conclusion of the nursing strike plotline begun last week. "Break on Through," written by Zoanne Clack, MD, seemed to be an effort to show nurses some respect, and we give the show credit for that. The episode did manage to convey that the nurses' complaints about short-staffing and forced overtime had merit, that nurse staffing had been sacrificed to short-sighted cost-cutting, and that the hospital needed the nurses in order to run efficiently. Ultimately, the hospital agreed to hire more nurses and the strike ended. Unfortunately, the episode wrongly presented the chief of surgery as managing all the nurses. More broadly, the episode continued the show's tradition of damaging misinformation and unrebutted anti-nurse slurs. Nurses were seen as focused on administration and care tasks that the episode's 18.5 million viewers are likely to find trivial, like changing bedpans, handing things to physicians, minor handholding, and tracking little patient quirks. Physicians were depicted as saving lives, and handling exciting work that nurses do in real life, including all key patient relations, all monitoring, all significant clinical interventions--and of course, managing the nurses. Indeed, since physician characters on the show do all the nursing that matters anyway, the strike made virtually no difference in the episode's clinical scenes.

Several of the show's intern stars arrive at the hospital to find rowdy, sign-waving nurses staffing a picket line outside the main entrance. This creates a crisis for earnest intern George, who feels he can't cross the picket line because he comes from a strong union family. Pretty intern Izzie Stevens reminds him that he "took an oath to heal." (We guess that oath precludes collective labor action, but those clock-punching nurses appear to be under no such obligations.) Nasty intern Cristina arrives and asks eagerly: "Has there been any blood yet? Have they brought in scab nurses?" Izzie says she thinks "the nurses know that we are on their side. Don't they?" Cristina notes, with no apparent irony: "Well, we're doctors." Then, loudly, she says: "We have sick patients inside!" Softly again, she observes, "We have surgeries."

Cristina braves the picket line, and those low-rent nurses throw food at her. Izzie is taken aback: "That is just wrong." She follows Cristina, also getting some edible input from the nurses. We see Nurse Olivia ("skanky syph nurse" to those of you just tuning in) shout: "Change your own bedpans, Stevens!" Izzie replies: "Enjoy your syphilis, Olivia." Meanwhile, the striking nurses are chanting "Fair Wages, Fair Hours," and holding signs that say things like "Overworked Understaffed," "Quality Care Is Not Free," and "Nurses Are Necessary." One even says "Overtime Kills," but we doubt more than a handful of eagle-eyed viewers caught it, and fewer still are likely to realize how true it is.

Soon after, we see the chief of surgery's assistant, Patricia, walking through a unit and speaking to some temp nurses. We get a shot of patient charts arrayed on a desk. The show has presented Patricia as someone who "used to" be a nurse before she moved up to be the chief's assistant. Suddenly, she has become the surgical nurse manager! We're kidding, the show has no nurse managers; Patricia is just handling the staffing crisis in her role as assistant to the chief. But she is lecturing the strike-breaking temporary nurses:

And I can't say this enough. Charts are organized by room number. I know you're temp nurses. But there's no excuse for sloppiness.

We get the message: nurses are mostly rudimentary paper pushers, and none too bright or adaptable. Patricia encounters super-cute attending surgeons Burke and Derek, who are looking baffled. Patricia tells them: "You know why I stopped being a nurse? Doctors. Doctors who don't know how to pitch in." This sounds good, but with no real vision of nursing, what does it mean? The physicians are supposed to organize the charts by room number? The chief shows up, and Burke informs him that they need "a compromise." Derek adds: "This place is going to hell. We need the real nurses back." The chief says they need "an additional 40 nurses to relieve the overtime that they're striking about. That's 2 million dollars a year we don't have." Derek jokes: "Have you checked under the couch? I always find spare change under the cushions." The chief is not amused.

Elsewhere, cute intern and central character Meredith is walking the seemingly deserted halls of the hospital. In one room, she spies a disoriented older patient, who seems to be having trouble breathing. Meredith calls for a nurse. When a young woman arrives, Meredith says: "Her pressure's falling; she stopped breathing." The young woman, whose name tag says "Angela" in big handwritten letters, says: "Woah. Is she dying?" Meredith asks if she is a nurse. Angela, looking flustered, manages: "Um, I'm, like, a nursing student." Meredith says she needs to intubate, then orders: "Get me a 7 1/2 tube, they're out in the hall." Angela gets the tray, but gives her the wrong tube. Meredith: "Not that one. The one that says 7-5." Meredith performs the intubation expertly and announces: "I'm in." Angela, no doubt overwhelmed with all the technical questions an active mind would produce after seeing this procedure, says: "Awesome."

Yes, Angela is just a student, but her obvious inability to react with any maturity, or even to read the number 7.5, mark her as a childish dolt. The show has never shown a medical student in this light. Intern Alex did freeze when confronted with a life-threatening surgical intervention in an earlier episode, but he did not start spouting inane kiddie talk. Even if the nursing student had reacted well, it would still be a perfect example of the show's vision of care: nurses hand things to commanding physicians, so the physicians can save lives.

Granted, Meredith's triumph here is something of a Pyrrhic victory. When she returns to this patient's room, Patricia and three older women are there, looking unhappy. A temp nurse found the chart on another floor (?), and it turns out the patient is a do-not-resuscitate (DNR); Meredith should not have intubated her. But they're not upset for long. The rest of the episode follows the three cute friends as they try to enforce the DNR. The patient's daughter finally arrives and agrees, Meredith extubates the patient then turns off the monitor, and the patient dies a long but beautiful death. All of this occurs with no nurse involvement.

Meanwhile, on the picket line, union guy George is making new friends. To be more precise, he is reconnecting with an old friend, nurse Olivia, who gave him syphilis. Olivia assures George that he can enter the hospital and they won't throw food at him. George explains that the reason he has not entered is that he's a union guy. Working up some steam, he starts walking toward the hospital carrying a sign that reads: "Proud to be a Nurse!" And the crowd of nurses goes wild.

Later, the three nurses who have had minor recurring roles on the show (Olivia, Tyler, and Debbie) seem to be working up the courage to ask picket line George something. Eventually they start giving him specific care instructions for some of the patients inside the hospital. Debbie tells him that one pediatric patient needs to have "the Alphabet Song or Wheels on the Bus" sung to calm her when she's having her dressing changed. Tyler notes that another patient "has a major panic attack if you don't check on her at least once an hour." George asks why they want him to cross the picket line. Olivia tells him it's because "they're our patients too." This is actually hilarious, as if nurses (who care for patients 24/7) would need to inform physicians (who might average a few minutes a day with a patient) that the patients are theirs "too." Of course, in the up-is-down universe of "Grey's Anatomy," the physicians do that 24/7 monitoring, so perhaps the comment is understandable. The nurses' care instructions show that they do care, despite their strike. But they also suggest that the nurses would not even give report to their replacements, and that physicians would be able to act as nurses with just a few inside tips about specific patients. And though the emotional support underlying these comments is important, the superficial way this is presented is unlikely to bring that home to viewers who know little of nursing.

Soon, George is inside the hospital, trying to make sure the things the nurses want done are done. So does he go to the temp nurses? Ha. It seems the physicians can handle the non-administrative nursing care in their spare moments. George informs the chief that one patient who is allergic to chocolate pulls the allergy sticker off her chart, and that another hoards diuretics under his mattress. George also works in a statement that mandatory overtime is bad, then goofily runs away. Later, he tells Meredith about a patient who lies about her ins and outs, gets discharged, but soon returns to the hospital. Then he chants at the passing Burke, "Fair Wages Fair Hours"--and immediately apologizes. At another point, George asks Izzie if she realizes "how rarely doctors say thank you and please to nurses[.] How few surgeons even know the names of..." He retreats, observing: "I shouldn't be seen talking to you."

We're supposed to find all this cute. But the overall effect is to trivialize nurses' work and workplace conditions. The care issues the lovable George talks about actually do matter, but it's hard to imagine most viewers realizing it. Pulling off stickers and hiding pills do not sound like serious concerns next to the Big Life and Death Drama in which the show constantly immerses the interns. The statement about "please" and "thank you" suggests that physicians could be more respectful. But we'd be more impressed if we had any reason to believe the physicians on this show were going to start modeling respectful behavior from now on with the few nurses who do appear. As for knowing names, forget the physicians--we doubt more than a handful of viewers know the names of any nurse on the show, with the possible exception of skanky syph nurse Olivia. In real life, disruptive physician behavior and abuse of nurses is a significant factor in poor patient care and nursing burnout worldwide. More broadly, patients are dying because nurses are short-staffed, and the shortage is a public health catastrophe. If a show cannot bring an adult perspective to such issues, it might be better to stick with supply closet sex and food fights.

Later, at the nearby bar where the interns habitually get wasted, some striking nurses are toasting George. Of course, being serfs, they still address him as "Dr. O'Malley." At the bar, intern Alex insults George by calling him "Nurse O'Malley." (This reminds us of the series premiere, in which Alex deeply offended Meredith by calling her a nurse.) This starts the bar on a bad course. A nurse shouts: "At least nurses aren't butchers!" Another nurse pours a drink on Cristina's lap at the bar. Cristina, who is distressed and has apparently been drinking for some time, threatens to "kill" her. The nurse tells Cristina to "bring it on." Cristina starts sputtering about "bedpans," and something about "soccer mom." The bartender tries to separate her and the nurse, noting that if they "beat each other up there'll be nobody to set your broken bones." Cristina snarls: "Oh, that would be my job." Then, as Meredith drags Cristina away, she adds something about being off to "save lives," the obvious implication being that nurses have nothing to do with that. This is not a fair fight: Cristina forcefully presents the view (which the show has often endorsed) that nurses are basically boring, bitter assistants who change bedpans. The nurses can think of no decent comeback, even an unfair one (the "butchers" comment is too inane to count). The nurses do not, for instance, accuse the physicians of being motivated mainly by ego or greed, failing to listen to patients or colleagues, contributing to the nursing crisis, pursuing a questionable care model, or supporting policies that reduce public access to good care.

Finally, we see the chief inform Patricia gravely that "we" need the nurses, and ask her where they can find the "spare change" to fund the extra positions. Patricia says she remembers "pushing through paperwork for a multimillion dollar surgery robot" recently. The chief protests that that "will bring in huge business." Patricia: "And could you and the robot handle that business without nurses?" This apparently wins the chief over, because we next see him outside the hospital shaking hands with the three nurses we know and congratulating them. Presumably he has scrapped the robot and done whatever else would be needed to reduce mandation and short-staffing. And they all lived happily ever after!

Well, not quite. Of course, it is sorta cool that viewers were offered a vision of a hospital choosing to fund adequate nurse staffing, rather than gee-whiz technology that will increase short-term profits. And we suppose we should be grateful that the show resists suggesting that the surgical robot could replace the nurses--something that real-life surgeons and the media actually have done. And however lightly and fleetingly, the show does present to viewers the issues of forced overtime and short-staffing. In a basic way, the episode suggests that nurses are necessary to the functioning of the hospital, despite what viewers would likely conclude from the vast majority of the show's clinical scenes, which tend to be nurse-free. And very thoughtful viewers may even get that a few of the care issues the episode associates with nursing do matter, such as patient emotional support, and tracking allergies and medication administration.

But let's not kid ourselves. What virtually all viewers will take from this episode is that nurses are marginally skilled assistants who hand physicians things, carry out physician "orders," do their dirty work, hold patients' hands, and do administrative paperwork. They work for physicians, we see, but the physicians are the ones who do everything of importance--especially, as Cristina stresses, saving lives.

The physicians even do all the key nursing. That's why the supposed absence of the striking nurses makes no real difference in the key clinical scenes. One major plotline follows attending Addison and intern Izzie's care for a teenager with a problem pregnancy, including lots of emotional support and what amounts to options counseling. Another plotline has interns Alex and Cristina, along with a resident, handling a newlywed's necrotizing fasciitis, before, during, and after her operation. And then there's Meredith's dying patient plotline, which features a lot of end-of-life care. Though in real life nurses would have played central roles in such situations, in these scenes no practicing nurse appears, not even a temp or a manager. And that's exactly how the show would have portrayed the scenes even without the strike.

Another highly damaging element of the episode is the clear message that the physicians manage the nurses, which means nursing is not an autonomous profession. Patricia's the closest thing we've ever seen on the show to a nurse manager. But she is clearly acting in her capacity as assistant to the chief, and she expressly says she is no longer a nurse. Of course we don't really expect a realistic vision of how this labor dispute would go down, with actual union and management negotiators, including nurse executives on the management side. But this depiction is unusually confused. It seems like all the hospital nurses are on strike, yet the chief of surgery (not even the chief of medicine and certainly not the CEO) is presented as the relevant management authority. A January 2002 episode of Lifetime's "Strong Medicine" also had a nursing strike, and in it union nurse Peter Riggs negotiated with a physician. But at least that physician had some kind of hospital-wide authority. "Grey's Anatomy" seems to think the nurses report to any senior physician.

Sure, "Grey's Anatomy" reaches tens of millions of viewers around the world, but does it really matter whether its portrayal of health care bears any resemblance to reality? Zoanne Clack, the physician who wrote this episode, thinks it does. The ABC site has the following statement from physician Clack on the subject:

Putting out accurate medical information is a task that we take very seriously. We realize we could be an important source of information for medical and public health issues and see it as our responsibility to make our medicine as accurate as possible. That said, there is a fine line between drama and reality. Drama is king, or maybe queen would be more accurate for our show. We research the medicine very intensely and have outside doctors that we consult but our main focus is the relationships of our main characters and the impact that the cases have on them. As a result, sometimes (but not often, I promise) medical details are sacrificed to highlight dramatic moments.

This is truthiness. Since its inception, the show has provoked sharp complaints from physicians and health advocates that it is not just silly and inaccurate in a few details, but inaccurate in major ways that could really damage public health. In September 2005, Slate published a piece by two Harvard physicians explaining some of the problems, including the dangerously wrong treatment of issues from organ donation to autopsies, and the suggestion that interns spend a lot of time in the hospital on sex and romance, which seems to irk female physicians especially. And then there's the nursing. The show's frequent, unanswered anti-nurse slurs, and its grossly inaccurate vision of clinical nursing and nursing autonomy, strongly reinforce the already poor public understanding of the profession, at the worst possible time.

Let us leave you with an anguished quote from smart, caring intern Izzie. She's a hero who has fought her way out of a hardscrabble background to the height of modern professional success, but who must now try to earn the respect of her physician peers, even though she's just too darned beautiful and she posed for a lingerie catalogue to finance med. school. These lines, spoken by Izzie in a prior episode, ran as part of the previews for this episode:

I grew up in a trailer park. Put myself through med. school by posing in underwear. I walk into the OR, and everyone hopes I'm the nurse.

Presumably Izzie is so beautiful and sexy people think she's stupid, so she better be the nurse (and not the surgeon) because nurses don't do anything important anyway. Or possibly men hope she's a nurse because she's so attractive, and if she is a nurse they'll have an easier time hooking up with her, since, as we've learned, nurses are skanks.

The failure of this ostensibly pro-nursing episode points up the show's desperate need to consult nurse experts on its scripts. The show consults physicians on scripts, and of course some are actually written by physicians. But we understand that the only nurse involved is an on-set advisor whose job is to make scenes look technically realistic, which we assume often means teaching the actors playing physicians how to credibly do things that nurses do in real life. We realize that when all 10 major characters are physicians, only so much can be done to create realistic hospital scenarios. But almost any change would be an improvement. The Center has offered to provide free script advice, or to direct the show to other nurses who could do so. But for some reason, we're still waiting for a positive response from show runner Shonda Rhimes. Come on, Ms. Rhimes, call us! 410-323-1100.

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