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What does that M.D. mean?

February 3, 2009 -- The two episodes of ABC's Scrubs aired tonight included plotlines that highlighted physician disrespect of nurses, and that even included references to forced overtime. In a major plotline in the first episode, lone major nurse character Carla Espinosa was caught between her close relations with the show's physician characters and her role as "head nurse," a representative of the hospital's downtrodden nursing staff. The show deserves credit for this effort. Sadly, the plotlines were largely undermined by the show's deeply flawed vision of nursing. Key problems were the usual incorrect indications that the nurses report to the chief of medicine, who even makes nursing schedules; that physicians should and do control patient care plans and have no need to justify them to nurses, even when the nurses present an apparently better option; that physician knowledge is far superior to that of nurses, when nurses actually know far more than physicians about many important aspects of patient care; and that the problem with physician abuse of nurses is mainly that it's not nice and creates bad workplace relations, when in fact it endangers patients and contributes to the nursing crisis. The first episode, Dave Tennant's "My New Role," drew about 4.9 million viewers; the second episode, Debra Fordham's "My Lawyer's in Love," drew about 4.7 million.

See relevant clips from "My New Role" at broadband or dialup speed.

See relevant clips from "My Lawyer's in Love" at broadband or dialup speed.

Carla is married to surgeon Turk, best friends with physician Elliott, and perhaps the only real friend of the hard core Perry Cox, the new chief of medicine. Over its eight years on the air, the show has at times presented Carla as some kind of nurse manager, though it's never been clear how far her authority extends. She appears only in clinical settings, never with an office. Here, there's no indication whether Carla manages a unit, as a real "head nurse" would. Occasionally, Carla has shown real technical skill, particularly in teaching new physicians. At other times, the show has stressed her clinical inferiority and subservience. Carla is the most normal and perhaps the most positive character on the show. On the other hand, she also functions in the traditional nursing role of straight man, so the physicians can confirm our sense that brilliance and oddness go hand in hand. Other nurses on the show are generally mute servants to the physician characters who dominate care. The physicians often do things nurses really do, especially psychosocial care, but also things like defibrillation and giving medications. Only Carla wears solid scrubs like the physicians. In the first episode aired tonight, all the other nurse characters are in patterned scrubs.

Early in the episode, we see Elliott speaking with the show's main character, physician JD. A nurse approaches.

Elliot:   Ooh, Barbara, can you please put Mrs. Newell on 150 mg of clindamycin?

Barbara:   Can't we use azithromycin instead? That way she only needs one dose instead of four, and I won't have to be running around all day.

Elliott:   Interesting.

JD (in voiceover):   Elliott didn't really think it was interesting, so they went to the person who settles all disputes between nurses and physicians.

That person is Carla, who addresses the two of them.

Carla:   OK, I'm glad you guys didn't let this escalate. Elliott, I bet you didn't know that on weekends, Barbara is a semi-professional kickboxer.

Elliott (looking somewhat concerned):   I did not.

Carla:   Still, doctors decide all prescription orders, and you [Barbara] know that.

They leave, but as Barbara walks away, she kicks a tile out of the ceiling (yes, the ceiling). Elliott is impressed with her martial arts skills, but the medication decision stands. Evidently, we can't have nurses questioning physician prescriptions even if they have good reasons, but it is OK for them to let off steam, or they might get a little too restless. The episode never tells us if there is any benefit to the drug Elliott favors, and we are not aware of any based on the information presented here. Although a few viewers might wonder if Elliott could defend her choice on the merits, it seems likely that most will conclude that she must have a good reason because, after all, she's a physician.

In fact, nurses are required to assess care plans and advocate for better ones when appropriate. The show soon refers to the forced overtime the nurses must work, which would be the result of short staffing, but the show never links that problem with Barbara's concern that she not be required to do four times more work than necessary in giving this medication. That wasted effort might matter if it meant that Barbara was unavailable to provide other vital care, or that Barbara would drive herself to the edge of burnout trying to provide good care without enough time--both likely results. And although Barbara does not specifically mention it, patients generally benefit from fewer doses, because they are exposed to fewer encounters with IV contaminants that have the potential to appear with every intrusion into the IV system.

We suppose the show should get some credit for setting Carla up as an arbiter, but it's not clear if this is because she has real authority, or because of her relationships with the physicians. In fact, you could argue that Carla is caught in the middle partly because the show creators have trouble with the idea that someone could be both a nurse and a manager, which has often been a struggle for Hollywood--how could someone who's automatically a subordinate be somehow not a subordinate?

Later, nurse Nelly confronts Carla about the forced overtime, a phrase the actors pronounce very clearly so that viewers can't miss it.  

Nelly:   Hey Carla, next time you hang with Dr. Cox, maybe instead of braiding each other's hair, you could talk to him about making some new hires so we don't have to work forced overtime.

Nelly leaves.

Elliott:   Why is Nelly giving you so much attitude?

Carla:   Even though I'm the head nurse, I mostly hang with doctors, I'm married to a doctor, my best friend is a doctor, I'm allowed to wear solid scrubs like a doctor...

(OK, Carla did not really say the last part about the scrubs.)

Elliott:   Who's your best friend?

Carla:   You are.

Elliott:   I know; I just wanted to hear you say it out loud!

Carla:   The point is, nurses sometimes think I'm on the wrong team.

Elliott:   How could they think that? You're like the most loyal person I know...

Carla:   Look, most nurses feel under appreciated, especially by doctors.

Elliott:   It's not that bad here, is it?

There is a typical Scrubs flashback to an interaction between a male physician and a female nurse in a hospital hallway.

Male physician:   You know what the M.D. at the end of this badge means?   It means I make the decisions. You got that, missy? [The nurse nods, and the physician leans forward and kisses her forehead.] I'll see you at home.

Carla:   And sometimes it's not even that subtle.

There is a flashback to surgeon Todd and a different nurse standing near a patient's bed. Todd often punctuates his comically obtuse remarks with a request that bystanders give him a situation-specific high five (like "physician-centric five!")

Todd:  My post-op patient is still going in and out of consciousness. (Turning to the nurse.) You know what I'd like to go in and out of?   (Holding up his hand and smiling.) Disrespecting nurses five!

The nurse walks away.

We salute the show for stressing that physician disrespect is a problem. These scenes are comic, but the show means us to understand that they are just extreme examples of a real issue. However, the show does not give us a reason to question whether it is actually correct that physicians do and should make all the care decisions. The show seems to be suggesting that physicians really do play that role; it's just not very nice of them to rub it in. But real nurses make many decisions on their own, and they also have input on physician decision-making. Nurses discuss care plans with physicians, including proposing better options when appropriate. Physician decision-making without nursing input endangers patients. Research shows that when nurses and physicians don't collaborate well, patient health suffers.

Later, Carla goes to see Perry Cox in his new chief of medicine office. Cox has posted lists outside his door stating when specific people may see him (always, sometimes, or never). Only Carla appears on the "always" list. The beleaguered Cox says he is glad to see a friendly face, because everyone else is asking for favors.

Carla:   Actually, speaking of favors, I've been noticing all the recent forced overtime. Maybe we could hire a few extra nurses?

Cox (sadly):   Of course that's what you want. Carla, I can't help you with the nurses, and I'm really sorry.

Obviously, the idea is that the nurses report to the chief of medicine, as Hollywood shows often tell their viewers. In reality, nurses are autonomous professionals who report to nurse managers, and and ultimately to a chief of nursing, or whatever nurse executive is left after the chief of nursing position has been eliminated in budget cuts. Physicians do not manage nurses. This misrepresentation matters because decision-makers and career seekers are far less likely to take nursing seriously--and allocate scarce resources to the profession--if they believe it is subordinate to medicine, and that nurses "make" no "decisions."

Later, Carla reports her visit with Cox to a group of nurses.

Carla:   So I asked Dr. Cox about hiring some extra nurses, and he said no.

Nelly:   Did you really ask him, or did you just compliment him on his new office?

The nurses walk away.

Elliott:   You know what, frick them!

Carla:   Frick them? I'm one of them.

Elliott:   Yeah, but they're acting like a bunch of frickheads. Sorry about all the f-bombs.

Carla:   I don't blame them for being frustrated at working here because a lot of the times I feel the same way. God, you are so clueless. ... All nurses want is to be treated with the same respect that you doctors get treated with every single day.

Elliott:   I do that.

Carla:   You do with me, but what about all the other nurses? Like Barbara this morning, were you as respectful as you could have been?

There is a flashback to Elliott and Barbara with their patient.

Elliott:   And ma'am, you should feel confident in the decision to give you clindamycin because it was made by someone who went to medical school, and not someone who turned to nursing after a failed career as a recording artist. [Turning to Barbara] And don't you dare kickbox me.

We flash forward to the Elliott-Carla discussion.

Elliott:   Maybe not totally respectful...

Once again, we get that Elliott was disrespectful, but it is not clear to the viewers that she is wrong that nurses lack the education to weigh in on technical care decisions. The nurse in this scene has no chance to respond to Elliott's ignorant comments. In fact, nurses have years of college-level education, and they know a great deal about how different medications will affect patients and the care environment, as we have explained. Should we conclude from Elliott's remarks that "medical school" teaches you how to stress that you attended it, but not how to defend your care plans when they are questioned?

Later, Elliott approaches four of the nurses in the cafeteria, including Barbara and Nelly.

Elliott:   Hey guys, how's it going over here?

They're seething.

Elliott (dragging a chair over to sit with them anyway):   Awesome. ... Barb, I really just wanted to come by and apologize for the way I treated you earlier.

Barbara:   I was planning on waiting for you in the parking lot tonight and kicking your teeth in.

Elliott:   Please don't.

Nelly:   Even if she tried, Carla would just swoop in and protect her doctor friend.

Elliott:   You guys aren't even really mad at Carla, you're just frustrated by the situation and you're takin' it out on her. ... The point is, Carla's a nurse first--even if it means yelling at her best friend. That's me--she said that out loud earlier, you can ask anyone. Anyway, you can either use her relationships with us doctors to start a dialogue to make things better, or ignore me, stay pissed, and you can all hold me down in the parking lot tonight while Barb here boot stomps my face. ... Takin' a...pretty long time to think about it. [Barbara fake lunges at her, and Elliott jumps.] Well, you got me there...I thought that was when it was all gonna go down.

Near the end of the episode, the nurses pass both Carla and Elliott as they leave for the night--and they say good night to both, using their first names.

Carla (surprised at the goodwill, addressing Elliott):   Did you do something good?

Elliott (giddy):   I totally did!

Well, not totally. Of course it's good that Elliott appears to realize that she has disrespected the nurses, and that it's wrong to do so. The show also gets points for having the nurses not address Elliott as "Dr. Reed," which Hollywood shows generally do, reinforcing the shows' regressive view of nurse-physician relations. In the last scene, the Scrubs nurses actually use "Elliott," just as most real hospital nurses would.

But this is still inadequate. Elliott is not admitting that the nurses might actually have something of value to contribute to her care plans, just that she was rude in enforcing physician authority. And her message about Carla is nothing to celebrate either. Nurses should not have to depend on their manager's personal relationships with physicians in order to have a "dialogue" and get the respect they deserve. That should be automatic, and if it is not, the first thing to change is physician attitudes, not nurse attitudes.

The night's second episode included a brief scene in which Carla confronts an overwhelmed Cox with a handful of conflicting "Nurses Schedules" that he has apparently created. He promises to fix them. Later, Cox encounters Carla and a large group of nurses who have showed up at the same time because he has failed to fix the schedules. Carla says this has also resulted in 17 nurses taking a patient for a biopsy! Carla tells Cox he would not be so stressed out if he let her do the schedules. JD observes that Cox has a need to control everything; even Carla describes the schedules as "bureaucratic" work that Cox could hand off. Finally, Cox realizes he really can't do everything as chief of medicine. Among other things, he allows Carla to start with what he calls his "first pass" of the schedules, make whatever changes she wants, and put them out. JD describes this as letting Cox's "close friend" "cross the t's and dot the i's." Cox's apparent delegation to Carla of the schedules for all the nurses seems to suggest that she is something like a nursing manager, but obviously no viewer would be impressed.

This plotline is absurd and harmful. Nurses, often nurse managers, make these schedules, and physicians have nothing to do with it. Nor could they, because making them is not a trivial "bureaucratic" task, but one that requires nursing knowledge: the knowledge to provide a proper nursing skill mix for safe care, in view of the particular nursing needs of the units in question. Also, at least in theory, these decisions would also involve assuring an adequate absolute number of nurses, as the prior episode suggested (though the show promptly forgot about the forced overtime/staffing issues it raised, and it has not mentioned them since). Once again, this may seem like a small issue, but it is just one part of huge framework of false messaging telling the public that nurses report to physicians, and that those who want autonomy should look elsewhere.

"M.D." may stand for several things, but making nursing decisions is not among them.

 

 

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