Changing how the world thinks about nursing

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They dare to be do-able

February 13, 2007 -- Tonight's episode of Fox's "House" included something rare: the brief appearance of a nurse character (Wendy) who, though hardly interesting, was a bit more than just a mute servant. Of course, Wendy only enters the plot because she is the current girlfriend of House's underling physician Foreman, not because she has anything to contribute to important health care. That care, as always, is provided entirely by the physician characters. Foreman breaks up with Wendy by telling her he'll make "a few calls" and get her into an elite hospital-based nurse practitioner program in a distant city. This will likely suggest to most viewers that the most prestigious NP preparation is non-degree training in which entry can be had at the whim of physicians, rather than graduate degree programs at major universities with real admissions requirements. The rest of the episode, Matthew V. Lewis's "Insensitive," includes suggestions that nurses are sniping handmaidens or anonymous sexual diversions. And the episode invites its 26 million U.S. viewers to chuckle at that irreverent genius House's suggestion that if a physician friend would just stop annoying him, they could be "ranking nurses in order of do-ability."

The episode starts with a standard encounter between House and an unsuspecting civilian who struggles to cope with the central character's razor-sharp wit. In this case, the victim is Wendy. House appears in the hospital's ED, where Wendy is apparently working.

House:   "Where's Foreman?"

Wendy:   "He's down here, somewhere."

House:   "Somewhere. Very helpful."

Wendy:   "Do you have any idea when he's getting out tonight?"

House:   "Some time."

Wendy:   "I realize you can't predict. I just thought you might be able to estimate. It's Valentine's Day. I've planned a surprise getaway."

House:   "Getaway." (There is a pause as Wendy expects him to continue.) "Getaway." (Now she's unsure what he means.) "Get. Away."

Finally understanding House's insult, which is especially impressive coming from a grownup, Wendy turns away in hurt and/or disgust. House finds Foreman providing care to a young woman whose mother is going into surgery following a car accident.

House:   "Foreman! Your girlfriend wants to know if you're available for Valentine's. Act surprised. What're you doing down here?"

Foreman:   "There's a snowstorm. ER's short-staffed. We're all supposed to be down here--you're supposed to be down here. You're an ass. Act surprised."

(See Quicktime clip 1 in broadband or dialup.)

Ooh--pushback.   After a few seconds of assessment, the Sherlock Holmesian House diagnoses Foreman's patient with the rare condition CIPA (congenital insensitivity to pain with anhidrosis). House orders lots of tests. The woman denies the condition, and Foreman doubts that House could be correct about such an obscure diagnosis with so little data (Foreman seems to have forgotten what's happened in the past 59 episodes of the show).

Later, as House and Foreman are walking down the hospital hallway, House returns to the subject of his African-American employee's girlfriend.

House:   "Nurse Shorty, your biz-nitch. How long you gonna waste her time?"

Foreman is displeased and evasive. House is convinced Foreman is destined to be alone.

House : "Date or no date, [inaudible]. Because you're the ultimate Darwinian. You fight for everything. Anybody else would just slow you down."

Foreman: "I'm still with her, aren't I?"

House : "Yeah. I can only imagine it's because she hasn't given you an excuse to break up. And you don't have the guts to recognize your own reality."

(See Quicktime clip 2 in broadband or dialup.)

Actually, we don't recall Darwin suggesting that individuals are best adapted who are too busy working to mate. If anything, being too busy practicing medicine suggests that Foreman's helping other genes to survive at the expense of his own, which is not all that Darwinian. But of course, House's brilliance is beyond the reach of even the smartest other physicians, and Foreman has no answer.

Needless to say, House is right about Foreman. In a late-night scene with fellow physician Cameron in the lab, Foreman gives her a kind of mixed compliment which is clearly meant to apply to himself as well: "People who avoid commitment are people who know what a big thing it is." Foreman's endgame with Wendy comes the next morning in what seems to be a locker room, after the House team has been up all night working to fully diagnose and thus save the CIPA patient. (See Quicktime clip 3 in broadband or dialup.)

Wendy:   "You haven't gone home."

Foreman : "Sorry I screwed up Valentine's Day."

Wendy:   "I'm dating a doctor. I'd be an idiot to expect anything else."

Foreman: "I did get you a gift." (He hands her some folder.) "MGH. Best teaching hospital in Boston. You want to be a nurse practitioner, that's as good as it gets. [I'll] make a few calls, and you're in if you want in."

Wendy:   "This is why you've been helping me get my surgical hours for accreditation."

Foreman:   "I...thought you'd wanna--"

Wendy (angry at herself):   "Stupid. You've got 10 feet of personal space around you. I step forward, you step back."

Foreman:   "I've shared a lot of things with you."

Wendy:   "Which is why you're breaking up with me. You can't stand to be close."

Foreman:   "Wendy--you think I'll stay with you because you're angry with me?"

Wendy:   "I'm upset--because I care. Only you'd expect an argument to be rational. You, and that ass boss of yours."

(See Quicktime clip 4 in broadband or dialup.)

This could have been worse, but it's no cause for celebration either. Wendy isn't so much a real character as a slightly annoying plot device to advance the larger theme that Foreman is kind of like House, and that he's growing increasingly uncomfortable with this "reality." Wendy even sells her own comments short; she's not just angry, but also correctly analyzing Foreman, which is in fact very rational.

As it happens, Massachusetts General is one of the nation's great hospitals. And the MGH Institute of Health Professions certainly is a respected place to obtain a masters degree or doctorate and become an NP, though it is not commonly ranked among the leaders in NP preparation--that distinction goes to programs at major universities, just as is the case with medicine. At least the scene suggests that NP training is substantial enough to merit the attention of a place like MGH, and that some programs are better than others.

However, with all due respect to the MGH Institute, Foreman's words will likely suggest to the vast majority of the show's viewers (who know nothing about NP training) that NPs are RNs with some undefined amount of additional on the job training at a hospital. This is driven home by an egregious inaccuracy--the idea that Foreman could get Wendy into the program with a few phone calls, as a physician with presumably impeccable credentials, or maybe simply as a physician. This is a slur against MGH and all NP programs, because it suggests that they aren't real graduate programs with rigorous admissions standards like the GRE, transcripts, and so on, but fiefdoms that physicians control at their whim--like what we see on "House," essentially. The bit about surgical hours suggests that Foreman would also control the shifts Wendy was working as an OR nurse. Of course, OR nurse staffing is determined by OR nurse managers.  

The remainder of the episode is business as usual: the main characters, all physicians, do everything that matters, saving lives through clinical interventions almost incidentally as they work to solve the overall puzzle. Their rapid-fire diagnostic discussions are meant to convey their formidable intellects to viewers who may have no idea what they're talking about. On the rare occasions that nurses appear, they tend to be mute and purely assistive; at times, only their arms appear onscreen. This makes perfect sense in a looking glass hospital in which, as chief of medicine Cuddy actually says to House at one point, "diagnoses happen at the end of cases." That remark neatly summarizes the show's whole vision of care. Once the brilliant House and his team solve the case--find the correct diagnosis--using only data that they personally collect, everything that happens afterwards tends to be ministerial and almost automatic. In short, physician diagnosis = cure and all related treatment. There's little need for skilled nursing in this environment. (See Quicktime clip 5 in broadband or dialup.)

A few specific anti-nurse elements of the episode do deserve mention. One brief plot strand presents nurses as a source of sexual diversion, something in which, it must be said, the show rarely indulges. At one point, House's physician friend Wilson asks House if he knows that "the new nurse from cardiology is sleeping with that weird lawyer from the board... The nurse used to be a man." Wilson is annoyed because they can't talk about that. Instead, he must act as House's conscience, since Cameron has told him that House wants to do a procedure on the CIPA patient that seems to be more about House's research and/or personal interests, i.e. finding a way to relieve House's own chronic pain. House agrees that the "tranny nurse" is way more interesting, and then observes:  

I think if you'd stopped talking to Cameron, right now we could be ranking nurses in order of do-ability.

(See Quicktime clip 6 in broadband or dialup.)

Yes, yes, the show isn't saying this is the right way to think--it's just a joke by that irreverent, politically incorrect House guy. That attractive guy who saves lives with his peerless intellect, who sleeps with hot women, who has varied talents, who skewers the bogus and the pretentious, who says things that many viewers actually think, and wish they could get away with saying, as House does. This episode also features House saying things that are arguably racist and anti-Semitic, but in a knowing, ironic way, like he's just tweaking those silly martinets who might take offense at his little words. We know he's not really racist or anti-Semitic, because of what happens in the rest of the show. Do we know the same about his feelings about nursing, that he would never really endorse the naughty nurse stereotype? Do diagnoses happen at the end of cases?

The episode also includes a couple interactions with Cameron that bring out its handmaiden vision of nursing. In one, Cameron is in the CIPA patient's room, providing solo bedside care and monitoring her condition, as physicians on "House" generally do. The patient starts seizing. Cameron presses a button, saying "call a code," then seems to note the patient's high temperature. She yells out the door, "need ice packs and cooling blankets!" A nurse arrives, and Cameron says, "Got saline in there?" The nurse actually starts to argue: "She's not flushed, she's not sweaty, you must be--"" Cameron cuts her off: "She has a temperature of 105." That silly nurse, thinking she had anything to contribute! She needs to listen to the physicians who provide all significant bedside care--they know the patient's status. And they stabilize the CIPA patient. (See Quicktime clip 7 in broadband or dialup.)

Of course it's OK for nurse characters to be wrong about things like this. And we suppose the nurse character did actually display some knowledge and patient advocacy impulse. The problem is that we've never really seen nurses be right or helpful in a clinical context on this show. Instead, even when they have a minor interaction about care with the dominant physicians, they are almost always sniping ninnies with inferior knowledge who don't see the big picture, or bureaucrats who are afraid to take responsibility. And they tend to need physicians to tell them when a patient starts to crash.

Later, Cameron opts out of a quest to learn what metabolic conditions might be causing the CIPA patient's latest unexplained symptoms. Instead, Cameron wants to take the patient to see her mother between her mother's surgeries. House is incredulous:

Get a nurse to take the kid. There are more than 60 different metabolic conditions that could account for what she's got, there's only 3 of you guys. (See Quicktime clip 8 in broadband or dialup.)

We suppose this could be defended as simply an argument that Cameron is best used doing what she's been trained for, pursuing the most immediate threat to the patient's life. But another way it's likely to be received is that Cameron is crazy, or at least soft, for thinking that it would be a priority to do some silly unskilled nurse work when she could be going after the diagnostic holy grail. Of course, the show doesn't necessarily think that the psychosocial care real nurses provide is always a waste of time; House's team spends a lot of time doing it. It's good enough for physicians when it's being presented as compelling and important. It's just for nurses when it's being dismissed as low priority helper work.

In the end, House realizes that the cause of the patient's critical unexplained symptoms is a long tapeworm, which he heroically pulls out of her, to general astonishment. She hasn't felt the worm because of her CIPA. And with that correct diagnosis, the case is basically closed. House wins again.

And the nurses? Why, they're elementary, my dear Watson. Elementary.

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