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"I'm here to do your bidding, Dr. Thornton."

October 16, 2005 -- Tonight's episode of Lifetime's "Strong Medicine" included another apparent effort by writers Darin Goldberg and Shelley Meals to highlight the skills of lone major nurse character Peter Riggs. Peter is a nurse-midwife, though he acted as an ED nurse here. One subplot tonight explored power issues between Peter and resident Kayla Thornton, also his girlfriend, in the aftermath of their ED care for a teen who dies of hypertrophic cardiomyopathy (HCM). The episode does manage to show that Peter has significant knowledge and the initiative to act on it to save the lives of others who are at risk. But it also confirms that at the end of the day, physicians like Kayla are in charge. Elsewhere in the episode, nurses are portrayed, as usual, as marginally skilled physician subordinates who don't talk to patients or families, while physicians provide all important care.

In the episode, "Rhythm of the Heart," Peter and Kayla report for work at the ED together. Peter is apparently just working an extra shift. Smiling sweetly, Kayla tells him on the way in: "Just remember, in the ER I'm the boss. That means you do whatever I say." Peter (playing along) replies: "I'm here to do your bidding, Dr. Thornton." Kayla says she's going to like this, and she asks him to kiss her, which he gladly does.

We wonder if Lifetime would have found this so charming if it was a male physician and a female nurse. Given that the show's intense concern for women has never extended to female nurses, maybe we don't want to know the answer. This will not be the episode's final word on the subject of nurse-physician power relations. But the fact that it is suggesting these two would consider nurse subordination a joke suggests the producers are not aware of the serious abuses that have flowed from the power imbalance between the professions, nor that they have been a serious factor in the global nursing shortage.

Sixteen-year-old Eric Marsh is brought into the ED after collapsing at a cross country meet. Initially, as usual, physician Kayla gives orders and does all interactions with the patient and his parents, while the nurses are busy hands. But because it's Peter, and the writers are planning to explore power dynamics between him and Kayla, Peter has a more robust nursing role than we have ever seen in an ED scene on the show. He asks Kayla what she thinks, and she gives a few possibilities (not HCM). Peter calls vitals and asks the parents to wait outside. (We're still waiting for Hollywood to catch up with nursing initiatives to have families stay with patients in settings like this; when it does, we fear it will be presented solely as a physician idea). Then it's time for defibrillation, and though nurses generally do this in real life, the show holds true to Hollywood tradition by having Kayla do it, while Peter and another nurse charge the machine. Peter does compressions. But they cannot save Eric, and Kayla breaks this sad news to his family.

Later, Peter talks sensitively to Eric's father. Peter says he does not want to add to the father's grief, but that Eric's death may have been caused by HCM, which runs in families. Peter says the father should have his daughters tested, to be safe. After the father leaves, Peter tells Kayla what he did, noting that Eric fit the HCM profile perfectly, as he was a tall African-American athlete. Kayla admits HCM is possible, but says only the autopsy will supply a definitive diagnosis. Peter: "I didn't mean to step on your toes, Kayla, I just wanted to help the family avoid more tragedies." Kayla: "This family is going through hell. They are entitled to time to absorb the loss of their son without being terrified with concern for their other children...As soon as the autopsy results were in I would have called the family." Peter: "ER docs aren't the head of the class when it comes to patient follow-up. It's not a criticism, it's just not part of the job description. I just didn't want the Marshes to fall through the cracks." Kayla: "I don't let people fall through the cracks. I would've told them when the time is right. That's my job. In case you forgot, I'm the doctor here, and you're the nurse."

This exchange does several things besides highlight the difficult balance between being sensitive to a grieving family and trying to protect them from further harm. On the one hand, it shows that nurse Peter has the knowledge and initiative to act independently to try to safeguard the family's health (and his diagnosis will be proved correct). It also suggests, despite Peter's claims not to be criticizing, that maybe physicians could stand to think a little more holistically about health care. On the other hand, it suggests that Kayla really is the boss, and that she essentially owns the patient relationship, as if she can control what Peter says and does, certainly as to anything related to diagnosis. Kayla is not just saying Peter may be wrong, she's saying he had no right to speak without her permission. Their light-hearted initial exchange about her being "the boss" was a "joke," but the joke was not about whether she really was the boss, but about whether two people who were so close would ever actually need to get into such raw workplace power issues. In fact, though advanced practitioners do generally take the lead on the diagnosis of primary conditions that bring people to hospitals, nurses have independent legal and ethical responsibilities, and protecting patients' families is part of their job description regardless of what a physician thinks.

Word of Peter's HCM comments to Eric's father gets around. And soon all the parents from the prep school Eric attended are at the hospital clamoring to have their kids tested. Kayla confronts this somewhat unruly crowd initially, but Peter takes over, telling them that HCM is rare and not everyone will need to be tested. He says they'll first complete a questionnaire and have their vital signs evaluated, to see if an EKG will be needed. This brief scene again suggests that Peter has some authority and health knowledge.   

Meanwhile, the Marshes do have their daughters tested, and Kayla informs them that one, Renee, appears to have HCM. Kayla sets up the surgery to implant a defibrillator. When Kayla pops in on this surgery, the surgeon tells her what a good catch it was, since Renee's heart was "a ticking bomb" and a lot of "doctors" would have missed it. All goes well, and Renee's mother later thanks Kayla profusely, hugging her and calling her a "miracle worker" who "saved our daughter's life." Kayla notes that the surgeon did the procedure, and she looks a little awkward, but she does not mention Peter.

Later, Peter and Kayla see each other and say simultaneously: "I owe you an apology." Peter says: "I never should have given the Marshes medical advice. You're a great doctor, and you would've made sure that you had Eric's sisters tested as soon as you had a definitive diagnosis. I'm sorry." Kayla tells Peter about Renee's successful operation, adding that "the Marshes were lavishing me with praise...All I could think about was you. You saved her life." Peter says Kayla would've had Renee tested. Kayla says she was a gymnast and a cheerleader, and that "it might have been too late." Peter: "Like it could be for other kids who don't get diagnosed by a simple EKG."

This exchange is very revealing. Of course, the show is commendably showing that Peter was right, and that had he not had the knowledge and initiative to act, Renee might have died. It's also suggesting that Kayla was sensitive enough to realize this, and even tell Peter, but she does not really apologize for purporting to "pull rank," nor for failing to credit Peter with the Marshes. The show seems to be saying that a nurse might deserve private credit, but it is not questioning the need to preserve patients' view that physicians are in complete control and ultimately responsible for all patient care. Of course, the Marshes are perfect examples of this bias; even though Peter told them to do the tests, they credit only Kayla. But setting them straight would violate the code of physician domination. The saddest part is that Peter himself embraces this, stating that he never should have given the Marshes "medical advice," as if he was somehow forbidden from communicating vital health information that Kayla failed to provide.

Then the plot turns into an even more explicit edutainment vehicle for HCM screening. Kayla tells Peter that although he "annoyed" her by causing the prep school kids to flood the ER, their screening means there's not much chance of HCM striking another kid there. Peter wonders about "the kids I see every day in the clinic," and Kayla suggests that they host "an open-house at the clinic, let lower-income kids get screened and tested, at reduced costs." She also nominates Peter--the "tall and handsome man who's gonna get lucky tonight"-- to "squeeze the lower rate out of the hospital administration." Later we see Peter and Kayla at the open-house with a banner, which says: "Complete Screening -- $35." Sadly, the relief of one mother when her son does not need the EKG--the only thing that actually costs money--indicates to Peter and Kayla that turnout was light because of poverty. The more immediate reason would seem to be the badly drafted sign, but in any case, the screening does show them working together to address an important public health problem. Similarly, when Renee returns to the ED because guilt over her brother's death is interfering with her sleep, Peter and Kayla sensitively treat her together, Peter reporting good vitals and Kayla recommending a bereavement group.

Apart from the HCM plotline, which is itself a mixed bag for nursing, it's "Strong Medicine" as usual. In the main subplot, physician Lu Delgado is treating two serious burn victims who share a room, and who develop a romantic interest. In these scenes, when nurses appear, they pretty much get to put on an isolation gown and say "decreased urine output." They do not talk to the patients or family members, and they are never the focus. By contrast, the physician characters who are not show regulars do get significant lines, and some real interactions with the main character physicians and their patients. So the difference between these nurses and Peter is not just that he's a regular character. It's possible that at least some of it is that he's an advanced practice nurse, though it's not clear how much the show really understands about that. But the primary reason would seem to be the most obvious one, which is that nursing doesn't matter much.

Despite the HCM plotline and one from last month highlighting Peter's skill and autonomy, the overall nursing depiction on "Strong Medicine" is not strong. The nurses remain quiet physician subordinates who play no major role in patient care.

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