Admiring their credentials
January 12, 2011 -- Tonight's series premiere of ABC's new Shonda Rhimes drama Off the Map introduced the standard complement of seven smart, attractive physician characters saving lives, as the hot senior ones train the hot junior ones. Set at a clinic "somewhere in South America" that seems to be staffed mainly by U.S. physicians, the show does display a little more awareness of global public health issues than Rhimes' other surgeon-centric products. And it occasionally includes pointed criticism of the cultural insensitivity and narrow vision of health care displayed by a couple newly arrived physicians. But clinic boss Ben Keeton (right) was also supposedly the youngest chief of surgery ever at UCLA before starting the clinic, and one of the new physicians gushes that he's "one of the greatest humanitarians of our time." Whatever nuggets the show may include about U.S. arrogance and caring for the poor, the main theme still seems to be U.S. physicians saving native people and tourists, especially in trauma settings. We're not quite sure how to take the premiere's title, "Saved By the Great White Hope." Maybe the show is being ironic, but the show does reflect the basic Rhimes world view that physicians are demi-gods. Every clinical scene features physicians alone providing all skilled care, including lots of care that nurses do in real life. There are no significant nurse characters, and in the premiere, we saw only two notable references to nursing, both damaging, and both involving recently arrived U.S. physician Mina Minard. In one scene, Minard demands epinephrine for a clinic patient who is having an asthma attack, and a local nurse in patterned scrubs fetches and hands it over. Minard grabs the drug, saves the patient, and receives all the credit. In the other scene, Minard complains to a fellow U.S. physician that the other physician is lucky to have a seriously ill patient to care for, because Minard just "handed out Band-Aids today…like a school nurse!" Minard starts to learn that the clinic's less exotic care has value, and she will likely grow in other ways. But we doubt anyone will question the assumption that nurses are low-skilled lackeys who play no important role in health care, whether at elite hospitals or remote clinics--whose foreign health professionals are, incidentally, more likely to be nurses than physicians, as is the case with Médecins Sans Frontières. The series premiere was written by series creator Jenna Bans.
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|Ben Keeton, Derek Shepherd|
|Otis Cole, Ryan Clark|
|Lily Brenner, Meredith Grey|
|Tommy Fuller, Mark Sloane, Alex Karev|
|Mina Minard, Cristina Yang|
|Zee Alvarez, Tuck Brody|
Let's briefly consider the characters who've gone Off the Map. According to the ABC web site, Ben Keeton is "the courageous and charismatic founder of La Clinica Cruz del Sur," the clinic where all the characters practice. "When he's not changing lives, he's dealing with a dark and mysterious past…" For fans of other Rhimes products, this is the Derek Shepherd character.
Otis Cole is the tough, blunt former Navy physician who seems to function as Keeton's second-in-command.
Ryan Clark "is a fearless, uninhibited, and deeply spiritual doctor. Fluent in Spanish and many other languages, she moved with her missionary parents all over the world when she was young."
New arrival Lily Brenner "is half Emergency Medicine Resident and half Girl Scout, which is the perfect combination for La Clinica Cruz del Sur." She seems to have a romantic future with Keeton, and generally seems to be the show's central, Meredith Grey character.
Another recent arrival is Tommy Fuller, "a highly skilled plastic surgeon, despite the fact that he partied his way through college." He also seems to be an insensitive, somewhat shallow party animal and babe chaser with a troubled past--kind of a mix of Mark Sloane and Alex Karev.
The last of the recent arrivals is Mina Minard, "an ambitious infectious disease resident who's come to the jungle hoping to discover the next Ebola virus," but who struggles not to be a heartless jerk--she seems to be the Cristina Yang figure.
The show actually has two apparent local characters, though they get the least attention. Zee Alvarez is a physician who seems to manage the day-to-day clinic operations, at one point in the premiere complaining about how overloaded she is managing 40 patients with no apparent help. "Her blunt attitude and short temper sometimes makes her curt with the new, American doctors," says the ABC site, and she is "the resident expert on herbal medicine"; the show at times refers to the Amazon as the world's greatest pharmacy. It was not clear until recently that Zee would be a physician. We wonder if the creators originally thought that she might be a nurse in the mode of Miami Medical's Tuck Brody, a feisty logistics expert who made the trains run on time for his brilliant trauma surgeon masters. But maybe that would have seemed insulting to the locals in Off the Map; their only health worker character had to have more skill and authority. And maybe the show needed someone it considered a peer of the physicians to be another serious romantic player, a role no nurse has ever played on a Shonda Rhimes show, despite the occasional dalliance of Grey's characters with nurses. At the moment, Alvarez seems to be hooking up with Otis Cole. The only other local character is Charlie, the precocious 13-year-old clinic translator "who loves giving the new doctors a hard time," but also apparently wants to become one.
The first scene of the premiere introduces the gorgeous scenery that surrounds the clinic (the show is filmed in Hawaii). As the veteran clinic physicians await the arrival of the three new ones, Keeton and Cole leap off a cliff into the raging sea to rescue an injured tourist who is thrashing around in the water, conveniently right next to the cliff. This sets the tone of physicians who save lives not just with traditional, developed world health expertise, but by being courageous and pragmatic men (or women) of action. Another scene finds five physicians removing a living stingray that is partly embedded in the leg of a patient for whom there is no anesthesia, despite the proximity of the world's greatest pharmacy. And another scene introduces the workplace flirtation between godly physicians that is rarely absent for long from Grey's. As Brenner and Minard ogle a shirtless Keeton, Brenner jokes, "You realize we're objectifying one of the greatest humanitarians of our time?" Minard responds that they are "just admiring his credentials."
Other scenes focus on the development of the three recent arrivals, all of whom are running from some type of failure or personal trauma. Emergency physician Brenner plainly has a natural aptitude and enthusiasm for the work--the premiere finds her cutting loose an older tourist whose arm has become caught in a recreational wire system suspended high above the jungle. But it's going to be harder for the other two. Both Fuller and Minard are insensitive, ignorant of the Spanish language, and seemingly ill-equipped for life at a clinic in the jungle. Fuller struggles to embrace the holistic ways of the clinic physicians, who must adapt their care and their assumptions to the beliefs and traditions of the local people if they are to be effective.
For her part, Minard seems obsessed with rare and deadly diseases, rather than what she sees as the more humdrum work of the clinic. And this is the source of the two nurse references. In the first, Brenner tells Minard about the older tourist Brenner saved. This means Brenner has "won" the first day contest among the newbies, confirming that the show will have some of the puerile competitiveness among junior physicians that is a central theme of Grey's. Minard laments:
At least you have a patient to check on -- I handed out Band-Aids today…like a school nurse!
Perhaps needless to say, her voice is dripping with contempt. But later, Minard will learn that the clinic's work is not quite so mundane. An older woman Minard earlier dismissed as having merely a mild virus is still in the clinic's waiting area, having trouble breathing. She evidently has undiagnosed asthma. The woman collapses, and stops breathing. Minard commands an apparent local nurse in patterned scrubs to get epinephrine. The nurse has enough English to understand the request and she runs to comply. Minard alone does chest compressions. The nurse returns and hands Minard the epi, noting in Spanish that it is the last epi they have. Minard, of course, has no Spanish, and she snaps, "I have no idea what you're saying, just give it to me!" She grabs the drug, injects the patient and saves her. The nurse character mutely holds the patient's hand and helps Minard sit her up once the drug works. Later, Minard gives the woman an inhaler, and the patient heaps gratitude (in the form of a living chicken) on Minard alone. The nurse is of no consequence.
These scenes establish the show's attitude toward nurses, who are evidently peripheral subordinates good only for fetching supplies and handing them over. In real life, it would have been the nurse who gave the epinephrine. Nurses prepare and give drugs; it's very unlikely that a physician would have given this drug. And it's pretty unlikely that a patient's asthma attack would be discovered by a physician walking through a clinic waiting area, rather than by the nurses who actually spend far more time in waiting areas, and monitoring patients generally. Nor is it likely that a nurse would have remained mute while caring for a patient in distress.
School nurses are highly skilled health professionals who do far more than hand out Band-Aids. Today, they provide holistic care to students and manage a diverse array of serious chronic illnesses--including asthma. And they have saved many lives through timely, skilled interventions. School nurses have been hit especially hard in the cost-cutting of the Great Recession, and many are now responsible for thousands of students. It's especially hard to justify funding for school nurses when decision-makers and the public remain convinced that they are flunkeys who just hand out Band-Aids. Yes, Minard is learning that the clinic's work has value, but not that acting as a nurse has value. It's just that the clinic work she is doing turns out to be worthy of a physician. School nurses must appeal to Hollywood writers looking for a convenient example of what physicians are reduced to when their skills are being utterly wasted. In the June 2009 premiere of USA Network's Royal Pains, the heroic lead physician character complained that after being blackballed by a New York hospital, he couldn't even get a job as a school nurse!
Otherwise, Off the Map alternates between ignoring the importance of nursing and pretending that physicians do the nursing. The premiere presents trauma and other clinical environments as nurse-free zones in which physicians alone provide all care, including many key tasks that nurses do in real life. This is especially striking in scenes in which a group of physicians operates on a patient with no other health workers in sight, but it's also notable that Fuller and Minard are learning to be more complete physicians by doing what is in reality nursing work in non-trauma settings. One plotline finds Fuller trying to get a local father to accept that his kids have tuberculosis and to allow them to take the necessary drugs. The father believes that the drugs, prescribed earlier by Cole for the man's wife, actually killed his wife. With prodding from Cole, Fuller eventually succeeds in winning the father's trust by revealing how he screwed up his own family relations. In addition to having Fuller provide psychosocial care that is generally the province of nursing, the plotline suggests that conventional TB treatment consists solely of taking drugs a few times; in reality, it requires relentless nursing work. And it is Brenner who provides round-the-clock monitoring and sensitive, sustained interpersonal care to the older tourist, who has come of the jungle because his wife recently died, 40 years after they visited the area together. Advocating for her patient, Brenner delays his evacuation long enough for him to scatter his wife's ashes in a lake with special meaning to the couple.
All this physician nursing, which is to some extent inevitable when every major character who is a health professional is a physician, is especially ironic because in real life, it is likely that foreign nurses would outnumber foreign physicians at a clinic such as La Clinica Cruz del Sur. Nurses are the most numerous health professionals who do overseas volunteer work for Médecins Sans Frontières--"Doctors Without Borders."
It is sad to see yet another new Hollywood show whose contemptuous attitude toward nursing is so much at odds with reality. Despite the relatively strong nurse-focused shows that premiered in 2009, including Nurse Jackie, the shows that dominate the prime time broadcast network schedules--and are popular around the world--continue to send the message that only physicians matter, and that nurses are their low-skilled helpers. These shows take two main approaches to nursing, both very damaging: (1) ignoring nurses, while physician characters do key tasks that nurses do in real life; and (2) occasionally mentioning or showing nurses, but only as vacuous lackeys. Off the Map, like Grey's and House, does both.
Please tell those responsible for Off the Map that nurses are skilled, autonomous professionals who play a central role in the care of patients, from elite hospitals to jungle clinics.
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Jenna Bans, Betsy Beers, Shonda Rhimes
Executive Producers, Off the Map
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Los Angeles, CA 90027
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Burbank, CA 91521
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