Myths and fairy tales
March 13, 2007 - Recent articles in smaller newspapers have offered good discussions of the damaging misportrayal of nursing on popular U.S. television shows like Fox's "House" and ABC's "Grey's Anatomy." On March 5, the Salem News (MA) ran Julie Kirkwood's very good "As seen on TV: Real-life health care workers say medical shows aren't telling the real story." The comprehensive piece focuses on nurses' arguments that such shows can distort the public's view of health care. And it aims to debunk some of the key "myths" the shows present. Today, The Patriot-News (Harrisburg, PA) ran reporter Pat Carroll's "Doctored reality: Nurses chart complaints of marginalization on TV." This helpful article focuses on the common Hollywood depiction of a "pack of doctors engaging in patient care with no nurses in sight." Both pieces get expert comment from local nurses, and both rely on extensive input from the Center and its executive director Sandy Summers. We thank all of those responsible for the articles.
Kirkwood's March 5 Salem News piece starts with some reaction from local nurses to shows like "Grey's Anatomy," which is "so far from reality it drives the nurses nuts, but they watch it anyway, just like the rest of America." The local nurses seemed especially exasperated about a recent "Grey's" plotline in which the lead character nearly drowns and is brought back to life after an hour and a half of resuscitation. (Actually, research has shown that Hollywood in general greatly exaggerates the likelihood of a successful code, which even some physicians evidently find creates damaging public misimpressions).
Kirkwood notes that she also invited local physicians to comment on the shows, "but got no takers." The piece quotes Andrew Holtz, author of The Medical Science of House, M.D. , as noting that many physicians don't watch TV and are clueless about shows like "House." Of course, many physicians actually provide input on these shows, others study their effects, and others provide comment to the media about them.
Nursing student Heather Moore says she has a problem with "Grey's'" failure to credit nurses and its suggestion that nurses are physician handmaidens: "'Grey's Anatomy' depicts residents as being at the bedside and they really don't give any credit to the nurses. ... They're kind of like yelling orders to the nurses, and the nurses are subservient." Moore says (correctly) that NBC's "ER" is a little better about this, with "some fairly independent nurse characters." Reporter Kirkwood notes:
In real life, nurses tend to be supervised by nurses, not doctors. And while doctors make the high-level decisions regarding a patient's care, nurses have a lot of independence and responsibility for treating the patient, as well.
This is basically helpful, if somewhat oversimplified. Hospital nurses are supervised by other nurses (they don't just "tend" to be), though some nurses are employed by physicians in outpatient settings; even then, the physicians do not "supervise" them in the sense that the physicians are fully qualified to assess the quality of nursing care. As for the statement about physicians making "high-level decisions," it's true that physicians do currently have power to make critical decisions about diagnosis and treatment, though important inroads have been made on that power in recent years by patients and other health professionals. But we would not agree that all "high-level" decisions fall within the physician role; many life-saving decisions are made by nurses, and we don't think it gets any more "high-level" than that.
The Salem News piece goes on to examine--in surprising detail--some common "myths" Hollywood shows perpetuate. It first makes the critical point that the shows' distortions are not necessarily where we might expect--in the technical "medical science" of the diagnoses--but in "the depiction of the health care system," i.e., the roles physicians, nurses, and others actually play within that system. This is exactly the point that most press pieces about the "medical accuracy" of these shows ignore.
One of the myths is: "Doctors do everything." The "reality: "Nurses are responsible for much of the care patients receive, and technologists and nurse aides do a lot of the work, too." Here the piece relies on extensive comment from the Center's Sandy Summers: "Physicians (on television) are constantly doing the work that nurses do in real life. ... The majority of people who work in hospitals are nurses, not physicians." The piece says that the Center is so "infuriated" by this that it has "dissected episodes of 'ER,' 'Scrubs,' 'Grey's Anatomy' and 'House' to point out all the nursing work that television portrays as doctors' work." Of course, the Center analyzes the shows in order to educate and encourage improvement.
The piece includes a commendable number of examples of the shows' physician nursing. Summers notes that nurses are the ones who typically use defibrillators to save patients' lives, that nurses are the ones who spend hours at the bedside getting to know the patients and investigating why they are ill, and that it's often the nurses--rather than the surgical interns, as shown on "Grey's"--who "fight higher-ranking doctors to get the right care." The piece also notes that TV physicians tend to run complex machines like intra-aortic balloon pumps and dialysis machines, but nurses are actually the experts. Summers: "Nurses are trained for a very long time to be able to use those safely and effectively. We'd never let a physician near one." Holtz notes that the physician characters also do the work of other professionals, such as lab techs, giving the impression that it's all about them, rather than the complex team effort that modern care really is. Holtz points out that physicians are just one of the 15-20 types of health professionals needed for the typical ICU patient. Summers notes that this tendency suggests that the show creators are "under the delusion that only the work of the physicians matters."
Another reported "myth" is: "Most patients fully recover after a medical emergency." Relying on Holtz, the piece notes that "it's much more common for a person to be left with a chronic and serious disability, even if his or her life was miraculously saved." Holtz stresses that shows like "House" wrongly suggest that people can be cured of anything with the right physician, when in fact most conditions are not so hard to diagnose, just hard to fix:
The mythology that there are some great shamans of medicine out there who can produce miracles I think is a potentially dangerous myth. It gives that overinflated sense of what medicine can do. ... When you do get sick, it's not much of a mystery. It's pretty obvious what's going on and there are great limitations on what medicine can do.
This is a great point, and not just because this type of distortion gives people false expectations about health care generally. It also suggests that what brilliant physicians do, particularly diagnosis, is all that matters. That contributes to the undervaluation of nurses and others who provide much of the critical care that comes before and after diagnosis--care that often makes the difference between life and death. On "House," getting the right diagnosis is generally the same as being cured; naturally, the show has no use for nurses, or really for anyone other than its crack diagnostic team.
The final "myth" the piece explores is that it doesn't matter if television shows are accurate because viewers know they're just "fiction." The reported "reality" is that the shows "do change public behavior." The piece cites studies showing that TV plots have increased awareness of issues like emergency contraception and cervical cancer, and research about how portrayals of organ donation may discourage potential donors. The organ donation issue is a huge one (though the piece does not say so) for "Grey's," which seems to go out of its way to spread inaccurate negative information about such donations, generating strong criticism from those in the relevant fields.
The piece relies on Summers for the idea that how the shows portray the roles of physicians and nurses has a similar effect on the public. When physicians are shown doing all the important work, real nurses don't get the respect and support they need. As an example, Summers points to recent stories on the potential bird flu pandemic that focus on whether there will be enough physicians:
We're not really going to need that many doctors in a flu pandemic. It's going to take about three seconds to diagnose somebody with the flu. It's going to take weeks to help them recover. We're not going to be ready because we don't have enough nurses.
Holtz again stresses the potential harm from the shows' portrayal of medicine as being more powerful than it really is, and from related myths, including that more treatment is always better:
I really think there is a deep power to some of these stories, and by reinforcing myths that people have about medicine and health care, the shows can interfere with how society deals with issues of health care that are facing us ... Even when people understand that it's fiction, I think it plays on a subconscious level to reinforce the beliefs about what health threats face us and what medicine is capable of doing to face those health threats."
The piece also quotes Summers on the difficulty of persuading TV producers to pay attention to nurses' concerns about the shows' distortions and their real world effects:
[Show creators think they] know very well that nurses don't do anything, and when you try to tell them that nursing work is very valuable... They just can't believe it. Even nurses' own family members don't believe them. These same family members watch TV and they know what's what. They see this on "ER" and "Grey's Anatomy." Only physicians matter.
Pat Carroll's article in today's Patriot-News begins with two "TV medical show fairy tales" that come into play each time the House character "hears a telltale beep and rushes from his office to grab the emergency heart-starter paddles." According to the piece, these are that hospitals have "diagnostic units" like those on "House" with 3-4 physicians, and that "a doctor would be first on the scene." Local nurse Steve Hammaker explains that nurses (not physicians) are with the patients 24/7, and they would be first to respond. We'd also note that it's typically nurses who actually do the defibrillation.
The piece shifts to an extended account of the Center's work to improve such TV portrayals, with quotes from Summers and the group's web site. The piece actually includes two-sentence excerpts from Center analyses of several of the major shows: "House" ("While the nurses are doing whatever trivial things they do, the physicians provide all meaningful care..."); "Grey's" ("an enormous amount of what [the physician characters] do would have been done by nurses in real life"); and "Scrubs" ("reflects the prevailing Hollywood vision of nurses as peripheral health workers with limited skills who report to physicians") The piece notes (correctly) that the Center finds "ER" to be the least problematic, citing 2005 episodes introducing nurse manager Eve Peyton as presenting, in the Center's words, "perhaps the most clinically expert nurse character to ever appear on a major prime time U.S. show." The piece reports that the Center argues these images hamper recruitment efforts, citing a JWT Communications study showing that youngsters got their main idea of nursing from TV. The piece reports that the youngsters believed nursing was "a technical activity -- like shop for girls -- and inappropriate as a career for private school students." (Actually, shop is for girls.) And the piece quotes Summers on the Center's efforts to help the TV shows improve:
We have been asking...to have nurses review the scripts, but Hollywood just refuses. [The show creators] think that physicians [who do advise the shows] are experts in nursing. People think that nurses are junior physicians, rather than autonomous professionals.
The piece ends with additional quotes from local nurses about the gap between Hollywood and real nursing. OR nurse Phyllis Hicks suggests that these images at least provide an opportunity for nurses to talk about what they really do. This is one reason the Center puts so much effort into the shows--tens of millions of people care about "House" and "Grey's." ICU nurse Tom Abruzzi agrees that "ER" probably does the best job, portraying nurses as "the most autonomous," whereas the others are "really doctor-driven." (Of course, "ER" too is almost completely physician-driven.) The piece says that the "major point of contention isn't doctors dissing nurses, or even a distorted view of what nurses do. It's the pack of doctors engaging in patient care with no nurses in sight." However, a big part of the problem is distorted views of what nurses do (e.g. the unskilled handmaiden), and the shows do sometimes portray physician abuse of nurses as acceptable or even admirable, such as in emergency situations. Hicks closes the piece with a good, concise summary of how central nurses actually are to hospital care:
Nurses are around 24/7. We live in the place. We are here all the time. Somebody has to be, and it's us. This is our house.
These two March stories differ from most of the pieces appearing since fall 2006 that explore the "medical accuracy" of Hollywood shows. Most of the pieces that form this trend, particularly those appearing in prominent press sources, rely mainly on physician comment about whether the shows correctly describe specific diagnoses and treatments. It's as if viewers are affected by what "House" says about cancer, but not by what the show says about nurses. Most of the pieces ignore the damaging messages the shows send about the roles of health professionals and about how things actually work in hospitals. But these two March pieces--like Carol Ann Campbell's influential New Jersey Star-Ledger piece of January 28--provide critical balance by recognizing that the depiction of nursing matters. So we thank all of those responsible for the March pieces, especially Julie Kirkwood for her extensive Salem News article.
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