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The Power and the Glory

February 3, 2005 -- Tonight's episode of NBC's "ER," physician Lisa Zwerling's "Middleman," offered its 18 million viewers a compelling, nuanced endorsement of physician dominance in hospital care, showing why "ER" is simply without peer in fostering disinformation and disrespect as to other highly skilled caregivers. The episode follows the tragic results when a social worker fails to prevail upon an impatient ED resident, whose authority supposedly "trumps" hers, to allow her to finish assessing an abused child. It reinforces the idea that physicians do and should direct all hospital care by showing what can happen when their awesome power is abused. But it does not question that power. Instead, an authoritative attending physician and even the social worker herself underline the supposed hierarchy's value.

We do have something good to say. This episode, like several others this season, occasionally shows a nurse character presenting a care option to a physician with the sense of, "of course this is what we should do, please sign off on it." Here, for instance, minor nurse character Haleh Adams confirms with physician Abby Lockhart that they will need a second 12-lead EKG. Even leaving aside care that is the unique province of nursing, modern medicine could not work if nurses waited for physicians to tell them to do everything that the physicians would ultimately want done. These interactions on "ER," while so fleeting that they will likely slip past many viewers, do show experienced nurses as proactive and knowledgeable. They are a vast improvement over the standard television interaction between physicians and nurses, which involves stern commands from omniscient physicians and mute compliance by deferential nurses, if nurses appear at all (see, e.g., "House"). "ER" itself still has far more of that than what happened with Adams, but we give credit where credit is due.

For most of the episode, it isn't due. In one scene, a physician calls major nurse character Sam Taggart in to help with a critical patient. When Taggart arrives, she asks the physicians: "[W]hat do you want me to do?" This wrongly implies that nursing consists of following physician instruction, that nurses are there to assist physicians in their important work, but have none of their own. But when real nurses confront a critical patient, they assess the patient themselves and set a priority list, factoring in both nurse- and physician-identified needs. They conduct a range of nursing assessments and plan the care they will deliver pursuant to their own professional duties--before they are free to help physicians with other work. Nurses set priorities based on patient need, not physician need.

In the abused child plotline, the set-up is that social worker Wendall is miffed because she has been called to the ED for consults that she feels amount to physicians wanting her to baby-sit difficult patients. The potentially abused child is an exception, and Wendall makes efforts to learn more about why he got certain injuries. But the fearful child provides an innocent explanation that seems to be enough for resident Pratt. Pratt is also having a bad day--starting with having his lover dismiss him as too immature--and he is impatient to discharge the patient and move on. Wendall puts up some resistance, but Pratt tells her that he doesn't actually need her approval, and the patient's mother says she will lose her job if they don't go. Wendall ultimately gives up in frustration, clearly affected by the lack of respect that she feels has colored all her ED interactions that day. Later the child returns on death's door with new injuries. It turns out all his wounds have been inflicted by sixth grade bullies who are after his clothes. As he lies past hope in a trauma room, surrounded by a code team of four physicians, Taggart and two wallpaper nurses, a stunned Wendall tells the family that they may wish to go inside because "sometimes it helps to see how hard the doctors are working." The child's parents enter, and attending physician Carter gently forces Pratt to stop the code. Carter courageously breaks the bad news to the parents, and Taggart turns to shut off the monitor. Taggart continues to face the monitor, leaving the parents to console themselves, although a real nurse would likely be at their side.

Wendall is devastated. She knows she has not done her job, and she refuses to be consoled by boyfriend Carter; he is too sensitive to say anything stupid. Pratt is also deeply affected, and he laments to the wise, authoritative attending Kovac: "I pulled rank on [Wendall]. Attending trumps resident, resident trumps intern. We all trump the social worker. It's a great system." Kovac responds gently: "Most of the time it works."

Pratt, actually emboldened by this reminder of the full scope of his responsibility, ends the episode by calmly confronting his ex-lover in front of several female friends at a crowded restaurant, letting her know that he's all grown up, thanks, and wishing her the best as he departs. Zwerling resists the urge to have the ex-lover say "You had me at hello," as in "Jerry McGuire," but we get the idea.

Obviously the episode is critical of Pratt's abuse of his power, but it does not really question whether physicians should or do have that power. On the contrary, everything points in the other direction, starting with Kovac's masterful affirmation of the system. We need this system, he's saying; only physicians have the judgment, knowledge and other qualities needed to make these calls. Ultimately, we are and must be responsible for every aspect of health care. Only we, as Carter showed, can confront death in a mother's eyes. Even the distraught Wendall cannot bring herself to question it; instead, she cries and turns inward, faulting herself for not doing her job, much as a short-staffed nurse might blame herself because she was not able to save a patient. In response, Carter, another font of physician wisdom and authority, confirms Wendall's view with a quiet embrace. Wendall does not rant and rave to Pratt, Carter, Kovac or anyone else about how physician dominance must end, or how she has a master's degree--as social workers do--and knows about 100 times more about situations like this than some physician does. She does not, needless to say, point out that social work is an autonomous profession and medicine does not "trump" or "outrank" it, however much more power physicians may have. She does not even seem to blame Pratt. Instead, with her comment to the patient's family about how hard the "doctors" are working, she effectively endorses the very physician-centric view that may have just killed her patient. How stereotypically "female" of her. Of course, if physicians "outrank" master's-prepared social workers, we don't have to wonder where nurses stand.

We do commend the show for including a plotline about how physician aggression and complementary surrenders by less powerful colleagues can kill patients. This is a significant issue in modern health care. But the problem, again, is that the show can't see that physicians do not direct and control other autonomous professions like social work and nursing, nor should they. Physicians do not know what these other professionals know, and they do not have the special care focus that these other professionals have. Though Taggart plays virtually no role in the conflicts over the child's care, except to try to keep her head down, in real life a nurse would or at least should be involved at every step, advocating for him and not allowing him to be discharged without all appropriate care. Nurses coordinate care from physicians, social workers and others. Modern health care is a team effort.

But this episode presents physicians as something like a class of divinely chosen lords (the resident Pratt may be a "middleman," but the attendings are clearly closer to Heaven). The benevolent lord/physician is one who rules firmly but wisely, listening carefully to advisers and peasants before making decisions. The bad lord/physician is one who does not listen, who makes arbitrary or harsh decisions, perhaps because he or she is tired or distracted, or simply because he or she can. But in any case, whatever power the lord/physician's subjects may have is a matter of the lord's grace, not the rights--and certainly not the equal status--of the subjects.

Of course, there is sometimes real debate in the House of Lords. Pratt sounds like he is questioning the system at the end, but Kovac firmly sets him straight. However, there is someone who really has the juice to stand up to a full-blown Lord: another Lord. Thus, in this episode, Kovac himself ultimately prevails in a conflict with the chief of surgery as to whether a different patient may have a certain complication. He does so despite the doubts of his resident Pratt and his girlfriend Taggart. Taggart thinks this dispute is really about physician testosterone, and that Kovac feels threatened by the surgeon--even though Kovac already has "the girl" (her). Yes, this is a criticism of physician aggression, but Kovac is never less than calm and mature in presenting his views, and the episode ultimately shows his concerns to be well-taken. Taggart would appear to be more focused on keeping her man on an even keel than on protecting her patient, just as Wendall was too busy feeling disrespected to protect the abused child.

Thank God that one class of health care professionals has what it takes to be patient advocates.

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