Not a doctor, but...
April 29, 2009 -- ABC's Private Practice, whose season ends tomorrow, April 30, may be the only broadcast network show with a major nurse character to return next season. In the February 5 episode (Mike Ostrowski's "Acceptance," 13 million U.S. viewers), lone nurse character Dell Parker, who is studying to be a midwife, shows some tentative clinical aptitude and knowledge to go with his boyish eagerness. Under the close supervision of OB/GYN Addison Montgomery, Dell ably performs a vacuum-assisted delivery. Later he haltingly guides the baby's parents toward breastfeeding. Dell also performs an assured solo ultrasound of pregnant psychiatrist Violet Turner, calming her panic attack and eliciting her agreement to his own suggestion that, though he's "not a doctor," he will likely become a "pretty good midwife." The show still condescends to Dell, who is also the office manager/receptionist at the LA clinic where the show is set. In the March 26 episode (Craig Turk's "Do the Right Thing," 10.1 million U.S. viewers), Dell starts hooking up with young women by pretending to be a physician. This earns quietly amused derision from the elite physician characters. Of course, neither registered nurses nor physicians are qualified to do the job of the other group. But aspiring advanced practice nurses, who may be wrongly perceived as "wannabe" physicians, would be unlikely to reinforce that impression, which would suggest a lack of respect for nursing and themselves. Needless to say, Private Practice remains physician-centric, with its many physician characters often doing key care tasks that nurses generally do in real life. Still, on balance, the early 2009 episodes seem to represent a small step forward in the show's portrayal of nursing.
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In its second season, Private Practice has given Dell a moderately more robust role. He's somewhat less of a wide-eyed kid and closer to a junior peer of the physicians who dominate the clinic. The January 15, 2009 episode even had Dell report to Addison that he had examined some research regarding an innovative treatment they were considering for a very sick cystic fibrosis patient. She seemed to accept that as an additional bit of information in favor of proceeding, rather than mocking Dell, as she might have in the show's first season. Some episodes this season even feature Dell in his own office! But that office seems to be more to aid in his office manager work, he still seems to spend time hanging around the reception desk, and there remains little doubt that he is a health care neophyte. And of course, the show regularly features physician characters providing care that nurses actually would, from giving life-saving medications to the full range of psychosocial care and even end-of-life care.
An early scene in the February 5 episode finds Dell and Addison delivering a baby. The nervous Dad wonders why it is taking so long. Dell, positioned below Mom, reports that the baby is at a stage plus 2 (high up in the birth canal). Addison says the baby's heart rate is slowing during contractions and she will need an assisted delivery, which Addison assures the parents is very safe. But she and Dell both fail to describe the actual hazards associated with these procedures. Addison asks Dell to prepare the vacuum extractor. Dell quietly tells her that he has never done one. Addison says she will guide him through it. After Dell is ready, she instructs him to place the cup on the vertex, and she asks Mom to get ready to push the baby out. Mom screams. Addison reports that the baby is crowning, and instructs someone to take it out. Someone other than Dell--evidently an RN--seems to come and do that, though we see only her forearm at the edge of the screen. The nervous Dell reports that it's a "baby girl," as if a 5-year-old girl was also a possibility. Addison and Dell then walk away with the baby--perhaps leaving Mom to bleed out, though of course few viewers will get that. Dell immediately voices concerns.
Dell: The discoloration on her head?
Addison: It's a hematoma, it happens sometimes with a vacuum delivery.
Dell: Her Apgar is low.
Addison: Dell, don't worry. (Noting that the baby seems responsive). She's fine, you did great.
Later, Dell and Addison check on the baby. Dell remains concerned.
Dell: She isn't responding to the pacifier, and she's barely cried, and the bruise, it looks worse.
Addison: Well, her color's good, she's active, let's see those feet....she responds to stimulation.
Dell: Maybe you should order a CT or an MRI just to be sure.
Addison: Dell, this is all within the range of normal after an assisted delivery...this baby isn't sick.
On the whole, this is better than the show has generally portrayed Dell. He is playing an important role in the delivery, and he demonstrates some substantive knowledge, what with his mention of the baby's position before delivery and the Apgar score. On the other hand, he also seems surprised that a vacuum delivery could result in a hematoma--actually it's not clear he even knew what a hematoma was before Addison told him--which seems pretty unlikely for an RN attending a midwifery program.
When Dell visits Mom and her baby again, he still seems worried about the hematoma. Mom thanks Dell for caring for the baby so she can get some sleep. Dell asks if the baby has "nursed" yet (we suppose it would be too much to expect a male nurse character not to equate his professional name with breastfeeding). Mom says the baby has not, and wonders if something is wrong. Dell says no and does his best to seem like he means it. But he fails at this point to encourage breastfeeding.
Dell confides in psychiatrist Violet, another member of the practice. He says he thinks he did something wrong delivering the baby, that he placed the vacuum tube too low, used too much force. He is upset because he thinks the red mark might be bleeding in the brain, but Addison won't do a CT scan.
Violet: I think you want her to run a test to treat your anxiety, and not the baby. If Addison thinks the baby is healthy, then accept it, whatever you did worked.
To some extent, Dell does seem to accept it--because that's what good nurses do! They try not to question physician opinions, certainly not by asking the appropriate clinical questions about neonatal responsiveness and other vital signs. Of course an experienced OB/GYN like Addison would have more knowledge of the potential effects of a vacuum delivery than a student would. But Dell's persistent concern about the hematoma does not seem to be based on any clinical judgment that Addison is incorrect, but irrational anxiety. Yet he supposedly has a bachelor's degree in nursing. Dell also never questions whether Addison was too quick to turn to the potentially risky vacuum delivery intervention, as a real midwife might. One key aspect of midwifery is its focus on avoiding medical interventions, and seeking a natural birth to the extent possible. But Dell merely questions whether he performed the intervention skillfully enough.
Violet confides in Dell that she herself is pregnant, and asks him to do an ultrasound. She says the father could be either of two physicians who practice in the building, and Dell manages to offer a mildly amusing comment on this without offending her (he notes with a smile that it's cool that she's keeping it local). Dell points out the baby's heart on the monitor, something Violet herself has not been able to spot (his obstetric skills exceed those of a psychiatrist!). And he doesn't stop there.
Dell: Good cardiac activity, rate of 150, everything's good. The cramping's probably just from your uterus expanding, it's nothing to worry about.
Not only is this an appropriate display of clinical knowledge, but Dell proceeds to expertly calm Violet's panic attack about her pregnancy, using a breathing exercise.
Later, Violet and Dell are talking.
Violet: Looks like you're good at your job.
Dell: Well, I'm not a doctor, but yes, I know a thing or two about pregnant women.
Dell argues persuasively--despite Violet's skepticism--that her cramps are not about the baby, but anxiety and guilt over who the father is, and the fact that she has not told either candidate that she is pregnant. Dell suggests that that situation is not good for her or the baby. She does not deny it, but says she can't tell them yet (she later does). Here Dell is offering some useful psychosocial care, something that is generally the province of show physicians who tend to do everything important for patients. Another scene in the episode--far more typical--shows a group of the physician stars providing nurse-free bedside hospital care to Addison's brother, with physician Sam actually giving medication through IV tubing.
In the final scene about the vacuum-delivered baby, Dell enters to find Dad holding the crying baby. The new parents are distraught because they cannot calm her. Dad frets that she "just woke up screaming," and wonders: "What's wrong, did we do something?" Dell takes the baby and tentatively assesses her: "I think...she's hungry." He takes her to Mom's breast, where she latches on, and all seems well. The parents are elated.
Mom: Look at her.
Dad: She's perfect.
Dell: She is.
Of course, it would be more perfect if Dell had known enough to help them breastfeed within the first twenty minutes after birth, rather than many hours later. It appears that Dell has helped the couple learn a basic aspect of parenting, and an aspect of neonatal care that is far more consistent with the midwifery model than the vacuum delivery.
Later, we see Violet looking at ultrasound pictures that Dell has given her.
Dell: So you're going to keep the baby?
Dell: You know what? I think I'm gonna be a pretty good midwife.
Violet (smiling genuinely): Yeah...I think you are.
Actor Chris Lowell, who plays Dell, delivers the "pretty good midwife" line in a way that conveys determination (and wonder) rather than ego. We are meant to agree that he will be a good midwife, though the show has yet to give us much of a sense of whether that will mean anything more than being a nice and supportive but less qualified version of an OB/GYN. After all, he's "not a doctor, but..." Viewers have not seen or heard about the midwives who would actually take the lead in Dell's midwifery education, and the show has never given the sense that he is in a graduate program. He mostly helps the clinic physicians. And Dell has rarely conveyed any of the health care expertise that a real RN would have. He seems more like he is doing his first real health training now.
This lack of serious expertise is underlined in the March 26 episode. After Dell's ex-girlfriend takes their daughter from LA to a distant city to take advantage of a job opportunity--without even allowing him to say goodbye--Dell is crushed. He starts a downward spiral, partying and coming to work late. In one scene, clinic physicians Cooper and Pete see a goth chick texting and generally looking out of place. Pete asks if they can help her.
Goth chick: I'm waiting for Dr. Parker.
Pete and Cooper are speechless, suppressing their amusement.
Goth chick: Dell?
Pete and Cooper laugh.
Pete: Dr. Parker.
Cooper: Of course.
Goth chick: Do you think he'll be long?
Pete: I don't think so.
Cooper: No. He's just finishing up some very important ... medical ... stuff.
Goth chick: Cool.
The physicians are plainly amused by this, but it's also clear that it is inappropriate. Dell is pretending to be a physician in order to help facilitate hookups. And no, there is no chance the show intends or that any viewer will think his doctorate is in nursing, though tens of thousands of nurses do have those degrees, and the doctorate of nursing practice is set to become the standard degree for nurse practitioners in 2015.
In reality, it is very unlikely that a nurse midwifery student like Dell would embrace the very stereotype that advanced practice nurses struggle with--that they are wannabe physicians. Of course it would be wrong for Dell to cause others to believe he is a physician. Registered nurses do not have the training and skills of a physician. But neither do physicians have the training and skills of a registered nurse. Neither should pretend to be the other. That is why such titles (including "physician" and "nurse") are protected by statute in some jurisdictions.
Leaving those issues aside, Dell is not wrong here because nurses are inferior to physicians. He is wrong because pretending to be a physician wrongly suggests that nurses are inferior to physicians. It seems fair to say that viewers will understand little of this from the episode. They will just chuckle at that zany, troubled young nurse Dell, pretending to be a member of the medical elite.
Still, the February 5 episode does present Dell as someone with increasing health knowledge, skill, and even some autonomy in his care for the new family and for Violet. Any serious care on the show will doubtless require a physician, but the show appears to have set aside the overt contempt for midwifery that infected its early episodes. And that's pretty good.
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