November 16, 2004 -- Tonight's series premiere of Fox's "House," written by David Shore, takes a firm stand against one thing: lying. Specifically, the lies patients tell physicians, but also the lies of physicians themselves. In fact, "everybody lies." Only one physician tells it like it is: the brilliant, caustic Gregory House (Hugh Laurie), a master diagnostician who tries to avoid patients, even as he guides his diverse "CSI"-like team of "genius doctors" toward the elusive truths of life-threatening mystery diseases at a Princeton hospital. Unfortunately, the show's key premise is itself a damaging lie: that a team composed entirely of physicians would rove the hospital providing all significant care to desperately ill patients, as the few nurses and other professionals stand silently in the background or simply disappear. In fact, in a kind of extreme irony, the mystery disease that nearly eludes all the genius physicians and kills the first episode's main patient (tapeworm) could have been discovered by a skilled nurse's standard evaluation of the patient's stool--yes, the bedpan. With six out of six major characters as physicians, this may be the most physician-centric new TV show of the last decade. There is talent, wit and intelligent (if reactionary) life in "House," but the show's early promise only underlines the disservice it does to nursing.
House, whose bitter demeanor is linked to the lingering effects of a prior illness that still causes him pain and requires the use of a cane, is an infectious disease specialist who heads up the hospital's "Department of Diagnostic Medicine." We aren't aware that such departments typically exist in U.S. hospitals, but to the extent they may in Canada or elsewhere, they appear to be laboratories that examine bodily fluids and tissue samples. But House's team includes a neurologist, immunologist, oncologist and intensivist--in short, it is an all star team of young hotshots who solve cases that no one else can. (What was that about lying again?) Obviously, one key model here--as in NBC's new "Medical Investigation"--is "CSI," with mysterious disease as the stand-in for wily criminals, though "House" owes a debt to detective fiction as well. These new shows are a kind of "Health Scene Investigation," and it is easy to see why nurses are even more marginalized than they are under the "ER" model, which is far more focused on interactions between care providers and patients. Here, the main theme is the interactions among the physician detectives as they work out the diagnostic puzzle through debate and analysis of physical evidence.
Of course, even the primacy of medicine in diagnosis is overstated, and "House" takes it way beyond reason. Comprehensive nursing assessments are often critical to patient survival--and to physicians' own medical diagnoses. For instance, the main focus of the first episode is a kindergarten teacher with unexplained seizures and neurological problems. This patient is ultimately diagnosed with a tapeworm infection in her brain (neurocysticercosis). Though this disease is unusual in the developed world, thus the novelty to the makers of "House," in fact over 50 million people worldwide have it. Some neurocysticercosis patients pass tape worm segments into their stool, and an observant nurse may note this obvious symptom of the disease as part of his standard nursing assessment. In some other cases, tape worm eggs are present in the stool, which is collected by nurses for a laboratory analysis. The physician-centric media often ridicules the "bedpan" aspects of nursing, but in both of the above situations, nurses would have played key roles in identifying or helping to identify this deadly infection.
It is ironic that this largely nurse-free episode unwittingly shows the potential for disaster when nursing is ignored. We assume it would never have occurred to the creators of "House" to have a nurse weigh in on this patient's condition, or that nursing might be the key to her survival. No nurse is ever part of the House team's discussion of the condition or care of the teacher. And no nurse is shown doing anything of significance for her or any other patient.
But we wouldn't want to suggest that the episode completely ignores nursing, because what it does show is also revealing. We did spot one nursing mention, and three fleeting appearances of characters who seemed to be nurses. At the beginning of the episode, the patient has a seizure in front of her class, managing to scrawl "call the nurse" on the white board before collapsing. That's nice, but the scene cuts there. Whatever the school nurse did is of no interest to the producers. In the first nurse appearance, a faceless hospital nurse regulates an IV pump before leaving a patient's room so an important physician can interact with the patient. In the second, a nurse silently complies with the great Dr. House's request that she leave the patient's room; obviously, they have something important to discuss and nursing could not be relevant. And in the last, a nurse actually delivers a line, telling Dr. House that a patient is here to see him (those nurses are critical to care after all! they help people get to Dr. House!). This was one of the clinic patients House had very reluctantly agreed to see, back for more of the sugar pills House had craftily given him for his self-diagnosed fibromyalgia, which the show clearly suggests is a fictional disorder.
The clinic scenes give the show a chance to vent its reactionary ire at certain modern health and social trends, as House wittily mocks the role of the Internet in informing patients, the reluctance of parents to pump their kids full of whatever drugs physicians happen to prescribe, and so on. Without necessarily defending the failures of some people to be ideal patients, this perspective would seem to be another barrier to the show recognizing the contributions of nursing. Nursing does have a more holistic, patient-centered approach to care (so touchy-feely!). And it is focused on educating patients, rather than just telling them what to do, and dismissing them if they question it or show weakness in compliance. What House really misses is the old world--not in terms of racial or gender equality, because the show is clearly with the prevailing Hollywood program on that--but the world where patients and other care givers were so cowed by the almighty physician that they would do whatever he asked, without question and without regard to whether it made any sense. Knowledge is power, and nothing is worse than a rabble awakened by it. And in fact, the success of "CSI" and its descendants may owe something to a post-9/11 desire to see things in simpler, more traditional terms, as we gain comfort from the skilled elite using high tech tools to avert shadowy threats, even if that may require a little more power concentrated in fewer hands. This traditionalist agenda is ironic given that "House" has been marketed and received as a radical presentation of a gruff physician who doesn't seem to like or even care about his patients or colleagues, a kind of anti-Marcus Welby. Actually, just suggesting that such physicians are rare seems like an outdated and uninformed notion to us, but evidently it has been widely accepted. In any case, even the first episode makes clear that House is really an interestingly wounded man who does care in his way. He just has trouble showing it, or suffering fools. Such has always been the lot of genius.
While the nurses are doing whatever trivial things they do, the physicians provide all meaningful care, doing jobs that real physicians would clearly never do. In this respect, the show is very much in the Marcus Welby tradition, and that of "CSI," which typically shows CSI's doing the jobs of several different real life criminal justice professionals. Even by Hollywood standards, "House" is impressive in this regard. The physician characters in the first episode have virtually all patient interactions. Nurses have none. And in one short, priceless scene, two of the young physicians are shown doing the jobs of at least three other professionals. These two physicians have accompanied the main patient to an MRI scan. If anyone were to do this, it would of course be a nurse, though because the patient is not critical that might not have been deemed necessary. Then the two physicians actually take over the conduct of the MRI scan from the MRI technician, who simply disappears. When the patient goes into anaphylactic shock and subsequent cardiac arrest, the two physicians pull her out and begin to resuscitate her by themselves. Of course, in real life, a code would have been called, and that would have meant the quick arrival of a team of nurses, physicians, and a respiratory therapist.
Yes, yes, we can hear the response of Hollywood now: "We must be allowed some dramatic license, and we really can't fit all those different real-life characters into an effective scene (or show). We have to work with the major characters we have, and those just happen to all be physicians." The problem is that we become a little suspicious of "dramatic license" when, just by coincidence, it virtually always seems to result in the inaccurate portrayal of one type of health care professionals as the brilliant, exciting providers of all meaningful health care, and in the inaccurate portrayal of other types of health professionals as peripheral subordinates, to the extent they are portrayed at all--even though real nurses provide at least as much interesting, dramatic care as physicians. Thus, it just so happens that NBC's "ER" has nine major physician characters and one nurse, that "Scrubs" has five major physician characters and one nurse, that "Medical Investigation" has three major physician characters and no nurses. What would we think if all Hollywood portrayals of men showed them to be smart and strong, and all portrayals of women showed them to be slow and weak? What would we think if a tossed coin always came up heads?
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