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What's the differential diagnosis for chronic handmaiden-itis with persistent physician nursing? Quick! The patient is dying!

May 24, 2005 -- The season's last two episodes of Fox's hit "House," culminating in tonight's finale (19.7 million viewers), continued the show's grossly inaccurate depiction of nurses as uneducated, peripheral subordinates and physicians as the brilliant providers of all meaningful health care. Both episodes mostly ignore nurses, showing physicians doing important work that nurses really do, notably monitoring patients, providing emotional support, giving medications, and doing defibrillation. But one short scene in the May 17 episode, show creator David Shore's "Three Stories" (17.7 million viewers), is a small masterpiece of anti-nurse distortions. It deserves close attention in an era in which the mass media plays a major role in driving the nursing shortage that threatens lives worldwide.

We won't go into all the occasions in these two episodes in which "House"'s brainy physician lead characters perform key care tasks, such as giving medications, that nurses would give in real life. But we can't resist describing the scene in the finale, Lawrence Kaplow & John Mankiewicz's "The Honeymoon," in which an inpatient discovers that he is paralyzed, and starts to freak out. The patient's wife, a lawyer, hears the commotion and rushes into his room. As she nears his bedside, the nurse who has been standing there mute and passive rushes out of the way, like a fly before a flyswatter. This is small but telling: the show is telling viewers that the nurse has nothing to contribute to the patient or his wife; she is there awaiting physician "orders". In real life, the nurse would be managing the patient's episode and providing emotional support, not running away.

However, that's nothing next to our favorite scene, from the May 17 episode. This episode cleverly tells how, years ago, crusty lead character Greg House lost partial use of his leg to muscle cell death after a clotted aneurysm led to an infarction. The antisocial diagnostic guru himself tells the story during a lecture he is forced to give a group of medical students. There, House presents three apparently hypothetical patients complaining of leg pain. Eventually we see in flashbacks that the patient is House himself. At one point, we see House alone in his ICU bed recovering from an operation to restore circulation in his leg, which is causing him great pain because of the cell death. House is supposedly learning from printouts from his monitor that his potassium level is too high. We see the monitor, and it clearly shows wide complex tachycardia. House impatiently calls for the "nurse"--twice--and when she approaches, he tells her to give him more calcium gluconate. The nurse responds that he has just gotten five ml. He insists. She says: "I'll talk to your doctor." House tells her that will take too long, as he has a wide complex tachycardia and he will go into cardiac arrest. Her response: "I could get in trouble." House, exasperated and about to lose consciousness, informs the nurse that he is not asking for a narcotic, and will soon pass out. He does, and attending physician Lisa Cuddy rushes in, asking the nurse what has happened. The nurse says that House has wide complex tachycardia. "Who diagnosed it?" Cuddy asks. House did, the nurse responds. The nurse hands Cuddy the defibrillation paddles, which she uses. The flashback scene cuts, and back in class, House informs the students that the "patient" was dead for over a minute.

And speaking of one minute, from the moment the House character first says the word "nurse" until the scene cuts, less than one minute of screen time elapses. During that short time, the show packs in an astonishing number of anti-nurse distortions. First, any ICU nurse would have immediately seen from the monitor that House had wide complex tachycardia. Thus, House's need to insist that he was having that problem and Cuddy's question as to who diagnosed the condition (meaning it could not have been the nurse) both wrongly denigrate the abilities and knowledge of highly skilled ICU nurses. The show is clearly telling over 17 million impressionable people that nurses lack the education and skill to read the monitors of which they are in fact the primary users. Equally inaccurate and damaging is the portrayal of the nurse as a servant without critical thinking skills or any real concern for her patient's wellbeing. A real ICU nurse, assuming she was not driven past the edge of burnout by the short-staffing shows like House help make possible, would have been all over this situation: reading the monitor, identifying the heart rhythm and taking measures to restore it to normal, telling House why she thought he needed more calcium gluconate, calling the code team, defibrillating and initiating CPR. Instead, this nurse reacted like an uneducated, bureaucratic servant concerned only with following protocols and playing CYA. Instead of assessing House's condition, she noted that he had just received some calcium. Instead of exploring whether more calcium might make sense based on symptoms she was capable of assessing, she passed the buck to the what the show thinks are the real professionals: "I'll talk to your doctor." Instead of taking action to address House's clearly deteriorating condition, if necessary bringing in other members of the team, she could think only of herself: "I could get in trouble." Even the viewer could see that House was falling apart, yet the nurse character seemed unable and/or unwilling to assess that or to do anything about it. House's remark about drug seeking will suggest to most viewers that nurses are unaware that calcium gluconate is not a narcotic. Without knowledge, skills, initiative, or apparently even the desire to help her patient, all the nurse can do is await the arrival of the almighty Cuddy, who is clearly in charge. This nurse has not heard the term "patient advocacy." Of course, once it is time to defibrillate, only the physician can do that, even though nurses almost always do the external defibrillation in real life. And as is virtually always the case in "House" and "Grey's Anatomy," this nurse never gets a name--a fundamental, universal mark of disrespect.

So as House might say, what's the diagnosis for these symptoms? What could account for depictions of nurses that are so damaging? We see at least three possibilities. In the spirit of House himself, we won't pull punches. First, there's ignorance. It may be that those responsible simply assume that physicians and nurses must operate this way, because that is what they've always heard from their society and its mass media, and no one they respect has ever told them anything different. However, given the obvious effort that goes into the medical aspects of the show, it's hard to believe this is the only explanation. Second, there's simple expedience. The producers may have some inkling that they are hugely overstating the physician role and hugely understating the nursing role, but assume that no one of importance cares. They--like the makers of "Grey's Anatomy"--have constructed a show to celebrate physicians, perhaps because they assume that in health care, only physicians matter much. And in order fully to promote the main characters on their show, it is necessary that those characters regularly do things that other professionals would do in real life, just as occurs on shows in other genres (e.g., the CSI shows). And nurses are convenient foils for the leads, saying and doing things that allow the main characters to shine, relieving them of menial tasks, and so on. The third possibility is that the makers of "House" simply hate nurses. Their actions are consistent with this, because their show regularly presents a peripheral handmaiden vision of nursing that is so inaccurate that it could scarcely get much worse. Why would Hollywood producers hate nurses? Perhaps the popular image of nurses symbolizes everything accomplished modern media professionals don't really respect and would never want to be. Perhaps someone has recently been a patient in a hospital in the grip of short-staffing.

So which of the three is it? Well, because this is real life, we can't tie it all up in a neat little answer by the end of the hour. But we would suggest that sometimes such different scenarios--like any "Three Stories"--all turn out to be parts of a hidden, unified truth.

Please send your comments to "House" at:

David Shore
Executive Producer
10201 W. Pico Blvd
Building 89, Room 230
Los Angeles, CA 90035

FAQ: Why isn't the Center doing a full-blown campaign to improve the portrayal of nursing on "House"?

Answer: At this time, we just don't have the human or financial resources to mount this campaign in addition to our many others. Our resources are severely limited. Please help us build the strength of the Center by becoming a member or renewing your membership today. Please urge your colleagues, friends, family and professional associations to become members as well. Thank you! We rely on our members for your support.

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