"A midwife in a world of doctors"

 
August 2010 -- In the last episodes of the third season of ABC's Private Practice, the show killed off its one nurse character, midwife Dell Parker. That was no great loss to nursing, but the plotline that played out in the May 6 and 13, 2010 episodes included attacks on the profession, most notably through Dell's elation at having just been admitted to medical school. That was a powerful reinforcement of the enduring Hollywood fantasy that the most able nurses achieve by going to medical school, when in fact they are perhaps 100 times more likely to attend graduate school in nursing. The wannabe-physician stereotype is one with which real advanced practice nurses and men in nursing must still contend. In an amusing twist, the key May 6 episode was written by physician Fred Einesman, a former advisor to NBC's ER, which also pushed the wannabe-physician theme. Private Practice did, rarely, include minor plotlines in which Dell actually showed some aptitude for patient care and some limited autonomy. For instance, although the March 25, 2010 episode was mostly about how amazing the show's physician characters are, Dell did get to deliver a baby by himself in the field. And because he successfully executed a risky maneuver to free the baby, who was stuck in the birth canal, physician Cooper credited Dell with saving two lives! But Dell's exit reminded us of what the show really thought of midwifery and nursing. Don't take our word for it. In the May 24-June 6 issue of TV Guide, show creator Shonda Rhimes explained that Dell was "a midwife in a world of doctors. Babies can only be delivered in so many episodes. Dell got lots of coffee, answered lots of phones." She lauded actor Chris Lowell by noting that "an actor of his caliber should be doing Shakespeare, not handing people charts." In other words, nurses and midwives don't do much of interest, which is why Dell spent so much time doing receptionist work, and why he eventually had to go. But at least he has now gone on to that great medical school in the sky!
 

Saving two lives, in the field, with no equipment

Oh my God!

I got in

Postmortem:  "Shonda Rhimes on Dell's Death"
 

Saving two lives, in the field, with no equipment

See the relevant video clips from this episode in Quicktime at broadband or dialup speed.

As usual on Private Practice, the vast majority of the March 25 episode, Kathy McCormick's "Pulling the Plug," is about the physicians who dominate. They are confident experts who provide the health care that matters, including key tasks that nurses do in real life. On the rare occasions when nurses appear, they are mute ciphers who are there to do things like, well, answer phones and hand people charts.

But in Dell's scenes in the episode, there is a modest tribute to him as a midwife, though not necessarily as a nurse, since the show stopped referring to him as a nurse some time ago. Early in the episode, at the prosperous LA clinic where most of the show takes place, Dell is complaining to physician Charlotte about the new apartment he shares with his daughter Betsy (whose mother is dead). Dell feels like he's treading water. Charlotte, who is a no-nonsense individual with her own problems, tells Dell to stop whining, grow up, and change what he doesn't like. 

One minor plotline in the episode is about Dell's care for the pregnant patient Robin. We see Dell visit her at home; apparently Addison Montgomery, the show's main character and star obstetrician, has put Robin on bed rest till she delivers. Robin asks why Dell is there instead of "Dr. Montgomery." Dell explains that Addison has someone sick at home. That someone is Lucas, the baby of Addison's boyfriend Pete. Robin was hoping that after eight months, Addison might let her get off the couch and deliver whenever the baby is ready. Dell says maybe, after he looks Robin over. She notes that Dell is young, and she asks how long he's been out of medical school.

Dell:  I'm not a doctor, I'm a midwife.

Robyn:  Is [Addison] really unavailable? Can we call her?

Dell smiles, humoring her. He calls Addison, who tells him to explain to Robin that he will check her cervix. If it is dilated, she can go to the hospital, but if not, they'll check again tomorrow. Dell says he knows all that, but the patient wanted to consult her. Robin yells toward the phone, asking if they can't just reschedule, offering "no offense" to Dell as an aside. He smiles again. But Addison, who has no children of her own, is struggling with comforting baby Lucas on her end of the phone. With Robin listening, Dell gives Addison expert advice about caring for the infant, telling her to hold him, talk, and smile till it works. He says that sometimes with a sick baby, it's not so much doing something as being something. Robin is impressed, and she tells Dell to check whatever he needs to check. Robin seems to think this makes Dell qualified to provide obstetric care, though it would not seem to require professional health expertise. It's advice that any experienced parent might give, and that's what Dell is, since he has spent a lot of time raising Betsy on his own. So what viewers will make of it is unclear.

Dell's failure to mention that he's a nurse may be a deliberate choice by the character, made under the not unreasonable theory that the patient would respect him even less if he told her that, however unfortunate that choice would be for the nursing profession. But his failure to do so may also reflect that the show--despite having a nurse character for three full seasons--does not understand that nurse midwives are still nurses, that their work is an extension of nursing, and not some totally separate side thing. Show creator Rhimes's TV Guide piece also never mentions that Dell is a nurse; perhaps viewers will think he's not practicing as a nurse anymore. The show made clear that Dell was a nurse with a nursing degree in its early years, but it never did get specific about the nature of his midwifery training, and it certainly never said that the training was a graduate nursing program. So this suggests that the show may envision the character as having gotten lay midwife training. However, that would be very unlikely for a real nurse, given the long and strong tradition of nurse midwifery, from Mary Breckinridge (right) onward.

In any case, in the next scene in the plotline, we see Dell telling Robin that it's not time to deliver, but that he will come back the next day to check on her. She complains that she can't even take care of her daughter. They bond about the difficulty of being single parents. Her daughter arrives, and she has a cough, so Dell says he'll try to bring a pediatrician the next day.

When Dell and pediatrician Cooper return to Robin's house, she is in labor. She explains that her water broke after she unwisely picked up her sick daughter. Robin is in pain and they attend to her. Dell tries to calm Robin, who is blaming herself, and he tells her to push. Dell says the baby is crowning, but it is stuck. Dell tries to shift the baby's position, but this causes Robin great pain. He explains that the baby's shoulder won't clear the birth canal. He also says that the paramedics will not arrive in time for her to deliver in a hospital. He tries to consult Addison by phone, but she is unavailable, wiped out by her own baby issues.

Dell takes Cooper aside, with the air of someone who is uncertain but has made up his mind. He asks the pediatrician to press down hard just below Robin's belly, and says that he, Dell, will free the shoulder. Cooper notes that that might break the baby's clavicle, and he and Robin object. Dell explains that it's a "real thing." Cooper asks if Dell has ever done it; Dell says he's seen it done. This seems to be enough for Cooper. Dell reassures Robin and tells her again to push. Finally the baby boy is delivered, painfully but successfully. Everyone is thrilled. Cooper reports that the baby's air function is good, noting that there may be a small crack in his clavicle, but babies heal fast. They give the baby to Robin and she thanks Dell, who seems a bit stunned.

Later, Cooper arrives back at the clinic with Dell, and he sees Charlotte.

Cooper (gesturing at Dell):  Guess what this guy just did? He saved two lives, in the field, with no equipment. No fair.

Charlotte (smiling at Dell):  No whining.

Dell:  No whining.

Charlotte:  Nice!

Dell is presented as saving the mother and the baby with actual health care skills, and he does so more or less on his own, getting no direction or significant help from physicians Cooper or Addison. Dell also displays some autonomy and some psychosocial skill in talking Robin through the delivery. He is not an articulate, commanding expert--let's not get carried away--but he does manage it. He gets credit, from the patient and the physicians. And he does all this in the context of the patient's skepticism about his skills. Granted, the portrayal of Dell here is somewhat like press accounts that highlight nursing skills when they are all that is available in an emergency situation, without physicians present. Unlike the Private Practice physicians, Dell is not being celebrated for what the show sees as his normal scope of practice. And we can't say that Dell really mounts any defense of his skills with the patient; she happens to witness him advising Addison and decides he's OK. Of course, a defense of his skills might have required the show to define them in some way, and the show creators appear to have only the fuzziest sense about what midwifery is, that it's about delivering babies. Still, viewers of the plotline are likely to at least register that midwives (if not necessarily nurse midwives) have some obstetric skill.
 

Oh my God!

See the relevant video clips in Quicktime in broadband and dialup.

Most of the May 6 episode "In the Name of Love," written by physician and former ER advisor Fred Einesman, pushes the standard Rhimes show theme:  Physicians, particularly surgeons, are the most expert, heroic professionals, though they do have heart-rending, adorable flaws. As usual Dell plays no significant role in any of the major plotlines.

Early in the episode, we see Dell at the clinic. Physician Violet asks why he's there on his day off. Dell says Maya, the pregnant teenaged daughter of clinic physicians Sam and Naomi, has a history exam the next day, so he's doing her ultrasound today. Violet says he is so sweet. As they speak, Dell is looking at the contents of an envelope he has apparently just received. He is grinning, and he seems elated.

Dell:  I just got some really good news.

But before he can say more, Violet distracts him by telling him that an uncooperative clinic patient they know has returned. Maya shows up, looking very pregnant, and Dell tells her that her mom Naomi is on the way. Later, as Dell gives Maya the ultrasound, he confides in her.

Dell:  Hey, you want to hear something pretty cool, something I haven't told anybody else? I got into UCLA Medical School.

Maya (practically shouting):  Oh my God! That's fantastic, congratulations.

Dell:  Yeah, I have no idea how I'd pay for it.

Naomi arrives and Dell holds his finger to his lips so Maya will not say anything. We guess his news is so fantastically potent that it has to be doled out in controlled doses, so he can savor the reflected elation each time, but not totally lose control.

Dell and Naomi briefly discuss the ultrasound. Apparently it is three weeks before the due date. Dell notes that "everything looks great, her heart is strong." Naomi, who has been estranged from her daughter because of this unplanned pregnancy, asks about her birth plan. Maya says she has it all worked out, "a totally natural birth, Dell's doing the delivery here, I do my squatting exercises, my relaxation techniques in the afternoon--that's so I won't need an epidural--my bag is packed, and [the baby's father] Dink made a mix tape for my birth day music. I am so ready." Maya says her mother not being around actually gave her a chance to grow.

Late in the episode, Dell arrives at Maya's house. She's in bed in pain, and she complains that he took too long in coming. He says he came as soon as she called, and asks where Dink and his mother are. They are unavailable, because they assumed Maya's due date was far enough away. But now she is having contractions. Dell says he'll take her to the birthing suite. She insists on the hospital. Dell reminds her gently of the birth plan. But she says "screw the plan":

Maya:  I'm not waiting here, I want to go to the hospital like a normal person where they have doctors and pain medicine, so get your keys and let's go now!

A few moments later Addison, at the hospital, gets a cell phone call from Dell. We see from her reactions that Maya wants Addison to deliver the baby--she has kicked Dell entirely off the case, apparently, for the sin of not being a physician. Addison gets some data about Maya's status from Dell, and urges him to drive safely. But as she awaits Dell's arrival, victims from a head-on car crash start to arrive at the hospital by helicopter. As the episode draws to a close, we see that one of the cars held Maya and Dell. Dell is ambulatory, but Maya is badly hurt.

Although Dell does display some basic knowledge in this plotline, it's most notable for two distinct and powerful attacks on nursing. And just as on many episodes of physician writer Einesman's old show ER, the attacks are subtle enough that few viewers will consciously realize that they are there. That just makes them more persuasive and damaging.

First, there is the idea that Dell would be so eager to attend medical school. This suggests that able nurses achieve by becoming physicians, when in fact they are perhaps 100 times more likely to attend graduate school in nursing. And it is even more unlikely, almost unthinkable, that a new nurse midwife like Dell, who we assume has just obtained a graduate nursing degree, would immediately choose to go to medical school--unless, of course, his midwifery training was not a graduate nursing degree, but lay midwife training, which is also extremely unlikely for someone who is already a nurse. Whatever set of misimpressions the show has here, the result is a very damaging distortion of the real nature of nursing, and nurse midwifery in particular. Nursing is not a subset of or a stepping stone to medicine, but a distinct health profession.

The second major problem with the plotline is the contempt it displays for Dell's skills and those of other obstetric nurses. When Maya begins to feel the pain of labor, she doesn't just change her birth plan to include a hospital delivery and pain medication. She makes a point of specifically rejecting Dell in favor of "doctors," and in particular the almighty Addison. Maya is not in any distress yet. It's true that she is doing this at least partly because she's a kid without much ability to endure adversity, but it still operates as a vicious insult to nursing, because in response, Dell can only look stunned and move to comply with her demands. He does not point out that nurse midwives also do deliveries in hospitals, with pain medication, and that research indicates their care is at least effective as that of physicians. Why? Could it be that the show itself does not know that? No one gives viewers a reason to think Maya is being irrational in rejecting Dell here. It's not clear if she will also bar the hospital RNs who actually do the majority of the skilled work in labor and delivery, except on TV. This is a striking final kiss-off to midwifery and to nursing, as if only the physicians at the hospital would make a difference in Maya's care.
 

I got in

See the relevant video clips in Quicktime in broadband and dialup.

The series finale on May 13, Debora Cahn's "The End of a Beautiful Friendship," is another tribute to the surgeons. As the episode starts, the physicians gather around Maya at the hospital. Dell, who does not seem to be badly hurt, tells them that another driver caused the crash by running a red light. Dell also tells Addison that Maya's contractions are two minutes apart, and her pain is "seven, maybe eight." An apparent nurse nearby tells Dell to allow himself to be examined--a rare line from a nurse other than Dell. Meanwhile, Maya seems to think she has already had an epidural. With a look, Dell confirms to Addison that she has not. Of course, this is bad news. Addison is now in elite hotshot mode, and she issues expert commands, directing Maya's care. 

As the physicians work on Maya, Dell is concerned, but not of much help. He seems to feel guilty, though the physicians appear to accept that the accident was not his fault. In the OR, Maya is touch and go. Dell, who has been allowed in despite his injuries, reports that her blood pressure is down to 80 over 30. Addison tells Dell to get the panicky Naomi out of the OR; Naomi tells Dell not to touch her. They learn that Maya has a complex neurological injury. So the show's new neurosurgeon, Amelia Shepherd, explains Maya's options to Addison and Naomi. Later, while everyone is waiting on the outcome in a waiting room, the physicians notice that Dell is unconscious and unresponsive. They determine that his heart rate is slowing down because of a bleed in his head caused by the car crash. They drill to relieve the pressure.

Later, we see Dell awake in a hospital bed with a bandage on his head. At first he seems OK, but then he reports a headache. Charlotte quickly determines that this is likely another bleed. The physicians recruit the esteemed Amelia to handle it after she finishes with Maya, but it seems clear that Dell's outlook is not great. So Charlotte promises Dell she'll get the "most attractive" of the hospital's nurses to shave his head! Because really--there's no better way to say goodbye to a dying nurse than to endorse the stereotypes that nurses are mostly about female sexuality and that physicians manage nurses, so they control which nurses provide which care. Anyway, Dell finally breaks his incredible news to Charlotte and Violet, who is also present.

Dell (holding back tears):  So I got into medical school...

Violet and Charlotte seem impressed, even thrilled.

Dell (voice quaking a little, happy and sad):  Yeah...UCLA...I got in.

Charlotte:  But wait, Dell--what about nursing? Are you sure you want to abandon a great profession that needs you--after you just finished the six years of university training?! Less than two months ago, you saved two lives, in the field, with no equipment! And surely you know that the care of advanced practice nurses like you is at least effective as that of physicians? You act like you have a serious head injury!

Just kidding! : ) We invented Charlotte's last speech there, which we don't expect to see on network television any time soon. No one on this show would ever suggest that Dell reconsider his decision because of the value of nursing. Evidently, his decision is not one that would involve anything but the cost analysis he mentions earlier. ER nurse character Abby Lockhart's decision to attend medical school was handled in a similar way; she was thrilled to leave nursing, and no one even suggested that she or the nursing profession would suffer a noticeable loss. At least in ER's final season, nurse Sam Taggart did begin a nurse-anesthetist program. And in 2006, Dell's TV predecessor, nurse-midwife Peter Riggs of Lifetime's Strong Medicine, did decline his physician girlfriend's urging to attend medical school. But we can't imagine any defense of nursing on today's most popular network shows, particularly on Rhimes' Grey's Anatomy (ABC) or on Fox's House, shows on which nursing is mostly a job for disagreeable serfs.

Dell waits for the operation, holding his daughter Betsy, saying goodbye. He urges her not to be scared, telling her that her mom dying and him getting hurt are bad, but if the worst happens, all the bad stuff will have already happened to her. We see the surgeon Amelia finishing with Maya, saving her life, and Addison saves the baby. Amelia operates on Dell, but can't save him. This scene plays out quickly, with no dialogue, just images and music, which is fitting, since Dell was never as important as any of the physicians--giving him an extended code scene might have meant cutting short some display of surgical brilliance from Amelia, Addison, or Sam. No nurses clutter any of the surgical scenes with noticeable words or actions; only the surgeons matter.

Dell was a good guy, and the physicians are sad about his death. But the fact that he was a positive character does little for nursing. The profession is not suffering because people have forgotten that nurses are nice. It is suffering because of the stereotypes the show has embraced.
 

Postmortem:  "Shonda Rhimes on Dell's Death"

In the May 24 - June 6 issue of TV Guide, the Private Practice creator published a special item headlined "Shonda Rhimes on Dell's Death," in which she "pays tribute to the character" who died in the finale. Rhimes writes that she and actor Chris Lowell had felt for a while that "his character didn't have enough to do." Rhimes continues:

Dell was a midwife in a world of doctors. Babies can only be delivered in so many episodes. Dell got lots of coffee, answered lots of phones. Now, Chris is an amazing actor, talented and giving; an actor of his caliber should be doing Shakespeare, not handing people charts. So we decided that we'd exit his character from the show. But we disagreed on how. I wanted him in med school, happy, with [his daughter] Betsy. Chris wanted to die: "I want to go in a devastating way." He's a mountain-top guy, he likes a challenge. So I took a deep breath and headed for the writers' room.

This is not just a concession of the show's conscious physician-centrism. It also confirms that the show continued to view Dell basically as a receptionist even as he moved from being a midwifery student with a nursing degree to a full-fledged midwife in the second season. Lowell certainly did not have enough to do, but that was not because midwives' work is dull or unimportant. It was because the show's producers have little idea what that work is. Addison is an OB-GYN, but we don't suppose we'll be hearing that her character has to be limited because babies can only be delivered in so many episodes. We guess Dell's last plotline is somewhat better than the attitude toward nurses that has been evident on Rhimes's Grey's Anatomy since 2005. We can't imagine any of the pathetic nurse characters who have appeared (briefly) on that show getting into medical school. But Dell's last plotline is still an obvious reinforcement of the wannabe-physician stereotype that plagues advanced practice nurses and men in nursing.

The makers of Private Practice might well be baffled at the idea that Dell's medical school plans or the other elements of his departure are an insult to nursing. When you live in a world of doctors, it's hard to see much else.
 

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