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The Swan, M.D.

May 13, 2004 -- Looks like our little Abby has finally made something of herself. On tonight's season finale of NBC's "ER," executive producer Dee Johnson's "Drive," nurse Abby Lockhart learns that she has passed her medical boards, finally achieving what she and the show itself have longed for. It was a fitting end to a season in which the show exhaustively chronicled the medical school experiences and future plans of Lockhart and colleague Neela Rasgotra, while ignoring (as it has for 10 seasons) the professional development of nurses, with recent plotlines involving lone major nurse character Sam Taggart centering almost entirely on her personal life.

On the plus side, the episode makes an obvious effort to blunt potential criticism with a scene in which Lockhart, while working a nursing shift pending receipt of her board results, reels off a jargon-heavy medical care plan for a patient. Physician Jing-Mei Chen tells Lockhart: "I thought you were a nurse today." Minor nurse character Chunie says that "Abby's a nurse every day, that's why she'll kick ass as a doc." This is mostly commendable, for a couple reasons. First, obviously, it suggests that nursing experience is relevant and helpful in medicine. Of course, based on recent episodes, it appears that the show feels this nursing advantage centers on Lockhart's initiative, pragmatism and people skills; her intellectual qualities have been in question, thus the need to take the boards twice--even though a few seasons ago, she was second in her medical school class. Less obviously, the statement that Lockhart will always be a nurse is (though the show may not realize it) a rare compliment to nursing, as it suggests that nurses are like other serious professionals who do not stop being members of their profession merely because they no longer practice. For instance, a physician who becomes a health care administrator is unlikely to be referred to as a "former physician." Yet references to "former nurses" are common, as if the profession was a part-time job at a fast food restaurant.

However, Chunie's comment is not enough to counter the show's overall view of Lockhart's nurse-to-physician transition. It is clear that Lockhart is moving up. No one has seriously suggested that she might miss nursing, perhaps because of the reduced patient contact in medicine (oh we forgot--that's just in real life), or that this will be a loss to nursing or all the patients she would have been able to help as a nurse. No one has suggested that Lockhart's career change is unfortunate given the critical global nursing shortage, which the show has steadfastly ignored for years. No one would think to question whether she could do more good as a physician or a nurse. Of course all of these concerns must bow before what is right for a specific individual, but the show's failure to even have a character suggest any of it as a dramatic vehicle speaks volumes.

So does the show's habitual failure to counter the virulent anti-nurse comments it enjoys inserting in the mouths of authoritative physician characters. Here, after Taggart asks Lockhart if she can cover a nursing shift for her, attending Kerry Weaver snaps "find another nurse. [We] can't have one of our interns changing bedpans during their residency." As usual, the nurses have no real reaction to this, beyond Lockhart's quiet later suggestion to Taggart that she will consider it. Yes, Weaver is not a nice person. But she has been highly sympathetic in recent episodes, as she fights to get her son back from her deceased lover's homophobic family. And in any case, the show's failure to offer any rebuttal sends the same message as similar comments by the late Robert Romano--the attending's comments may be harsh, but they are the unvarnished truth. Most viewers will likely have the impression that, at best, nursing involves physical tasks that are simply too degrading for physicians to perform. The master class does not collect the garbage. At worst, bedpans are a convenient shorthand because they are the essence of nursing--you can dress it up with some fancy language (e.g. the technical dialogue the show occasionally bestows on nurses) but at heart, it's still menial work. Of course, changing bedpans actually involves a series of nursing assessments that could have major implications for patient outcomes, but that is not something that ER's writers or physician advisors are likely to know.

Near the end of the episode, a cranky, dying math teacher--to whom Lockhart has given vital comfort by bringing former students to show him that he really has made a difference--asks her if she will be back tomorrow as his nurse. Lockhart notes evenly that she will not--but that she will be back, and he should ask for "Dr. Lockhart." It is hard not to share at least some of the understated elation actress Maura Tierney brings to this moment. We only wish the show could conceive of a world in which someone would display that kind of feeling about becoming a nurse. We only wish that in the show's eleventh season, which is already being created, the producers would devote even a small percentage of the attention they have lavished on physicians' professional development to that of nurses. We dream of an "ER" in which major characters confront the challenges of the last year of nursing school, in which they worry over their nursing boards and whether they will measure up as nurses, in which they learn from senior nurses and slowly work their way forward, in which we see all the drama of their turbulent first year of practice, as we no doubt will for Lockhart and other interns. We dream of a show that even knows nurses experience professional development. And of course, we dream of a show that sees nurses as the critical ED professionals they are, rather than as subordinates and romantic interests for the physicians who really matter. In short, we dream of an "ER" that is actually about the ER, rather than simply about ER physicians.

As Morrissey once wrote, "kind people, do not shelter this dream. Make it real." Please let the producers of the massively influential "ER" know that you expect the show to start meeting its responsibilities to nursing and public health--just as it has gladly accepted responsibility and credit for highlighting important medical and social issues. With some 20 million people still watching each week in the U.S. alone, it's never too late to make a difference.

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