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"ER": the nurse as physicians' Girl Friday

November 20, 2003 -- Tonight's episode of NBC's "ER" entitled "Freefall," credited to supervising producer and physician Joe Sachs, included more divisive, damaging comparisons of nurses and physicians. Guess which group looked smarter, stronger and more important, and which looked more sensitive, empathetic and common sense-oriented.

In the first scene, nurse/medical student Abby Lockhart was shown running a practice cocaine overdose code on a dummy, with chief of ED medicine Romano in his usual role as the teacher from hell. Lockhart was unable to recall key physiological effects of the patient's condition, or the full appropriate treatment, and she botched the code, resulting in the "patient"'s death. As part of his brutal schtick, Romano pointed to Lockhart's nursing experience, which meant that she could "handle 90% of the patients" but "might kill the other 10%." Yes, Romano abuses everyone, and the show finally put him out of his misery by killing him in this episode. But no one contradicted him, and there was no suggestion that he was pushing anything but a harsh, nasty version of the truth. The code result confirmed it.

The idea that nurses are essentially people who've hung around long enough to pick up some medical knowledge--just enough to be dangerous--is a subtle but devastating example of anti-nurse bias. This is because it will resonate with the millions of people who mistakenly believe that nursing is a subset of medicine. In fact, there is a significant overlap between nursing and medical practice, and experienced nurses do absorb a lot of medicine. But suggesting that nurses' expertise depends on their medical skills is like saying that baseball pitchers' expertise depends on their hitting skills. Nursing is an autonomous scientific profession with a knowledge base and practice sphere that are distinct from medicine. Nursing is not about giving medical treatment in the easy cases, it is about giving nursing care in all cases, a very different thing. Of course, nurses cannot practice medicine without completing medical school, but neither could physicians practice nursing without completing nursing school. We would be as justified in saying that someone with "medical experience" might be able to "handle," in some rudimentary way, the nursing for a majority of cases, but at the risk of killing a significant minority. But that would be highly questionable and needlessly divisive, since we recognize that neither profession is a junior version of the other.

At another point, Lockhart has the temerity to question a surgeon's plan for an HIV-patient who has had a miscarriage, a plan that seems likely to include a hysterectomy. Lockhart mentions another option that would preserve the patient's ability to have kids, but the surgeon is not interested, apparently because she doesn't think kids would be a good idea for the patient. The surgeon haughtily tells Lockhart that she is not in the habit of justifying her surgical plans to nurses. Does Lockhart inform her that in fact, experienced nurses regularly question physician plans that they believe are not in patients' best interests, and that as a result, plans are often changed and lives are often saved? Does she suggest that the surgeon focus on the real issue, rather than resorting to personal attacks to cover her inability to justify her own plan? Ha ha. Welcome to "ER," my friend. Lockhart, as usual unwilling or unable to defend nursing, instead notes that she is now a medical student, the implication being that now her views are worthy of respect. As a result, the surgeon does consider her opinion, and explores the option in the actual surgery. To us, this is a big unintended joke, since we doubt that even most surgeons would automatically pay more attention to a medical student than an experienced nurse. But few of the show's tens of millions of viewers know that, and they are likely to conclude that lowly nurses would never dare to question an almighty surgeon.

The show continues to show Lockhart struggling with the intellectual and judgment requirements of being a medical student. The extent to which her problems implicate nursing is debatable. But the frequent negative references to her status as a nurse, juxtaposed with unfavorable comparisons to the cerebral medical student Neela's knowledge, seem to suggest that Lockhart is struggling because nurses really aren't that strong with all the book larnin' stuff. Lockhart is also shown giving the HIV-positive patient too much assurance that her miscarriage can be treated with a simple D & C procedures, as if Lockhart is used to incomplete knowledge, sloppy thinking and reckless statements, but physicians must meet a higher standard. The show is eager to assure us that Lockhart has practical experience, horse sense, and some initiative. She manages to successfully intubate a patient when no attending is available, and she is more able than the inexperienced Neela to handle the high stress multi-tasking that follows a bad helicopter crash. That's nurses: efficient and capable assistants to physicians, they are the Girl Fridays of health care.

There is one moment of dark, doubtless unintended humor. Now that Lockhart is a medical student, she finally gets to defibrillate, a task which nurses do in virtually every case at real Level One trauma centers. This is an apt symbol of the show's whole approach to nursing. We can hear the producers now: "Of course we're willing to let the nurse characters illustrate some of the real life nursing role. All they have to do is become physicians!"

Take Action!

See the Nov. 20, 2003 letter we sent "ER"

Bullet points for this episode that might be addressed in a letter:

  • Nursing is not a sub-specialty of medicine, but a distinct profession with its own knowledge base and scope of practice.
  • Nurses are autonomous professionals who care for patients based on their training and experience, not physician helpers whose expertise depends on how much medicine they absorb on the job.
  • Nurses regularly question physician care plans when they believe those plans are not in patients' best interests, and good physicians listen.



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