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Christmas in July syndrome?

September 22, 2005 -- Tonight's 12th season premiere of NBC's "ER" went out of its way to acknowledge that veteran nurses play a role in coping with "July syndrome," which occurs when new physicians arrive in U.S. hospitals to begin their internships. The episode included nurse character Chunie Marquez acting to prevent several dangerous intern errors, and nurse Haleh Adams critiquing a new second year resident's intern teaching. For a major network television show, this is extraordinary, and we thank episode writers John Wells, Joe Sachs, MD, and Lisa Zwerling, MD. Unfortunately, the episode seemed to present these veteran nurses mostly as assistants to the senior physicians. Rather than directly teaching the junior physicians and giving them a chance to improve, as real nurses generally would, the nurse characters simply reported the problems to the senior physicians. And of course, the whole focus of the episode's clinical scenes, as usual, was the training of physicians. The show has never addressed nurse training in any significant way.

In this episode, "Cañon City," the new second year residents whose development is now the show's main work-related concern struggle with their new responsibilities as teachers of interns. New "R2" Ray Barnett seems uncomfortable fielding questions from the interns and explaining what he is doing clinically while also trying to do it. In one procedure where this is evident, nurse Haleh Adams peers at him, looking dissatisfied, but says nothing. Later, chief of emergency medicine Susan Lewis asks Haleh, with Ray standing there, whether she wants "to give Dr. Barnett some feedback." Haleh responds: "There wasn't much teaching. You seemed distracted by questions from the interns." She turns to Susan: "His frustration prevented the team from working together. There was a lot of tension in the room. It could have caused a delay in diagnosing the splenic lac." Ray whines to Susan: "And since when do nurses evaluate the residents?" Susan replies: "Haleh's been here longer than anyone. She knows."

We also see that nurse Chunie Marquez has been monitoring patients and assessing what the physicians are doing, correcting the errors and omissions of an especially clueless intern--by going directly to R2 Neela Rasgotra. Neela tells the intern that Chunie has been having her correct the plans ("it's micrograms, not milligrams"). Yet the intern still apologizes only to Neela and thanks only her for fixing it. Chunie also alerts Neela to an urgent problem in an emphysema patient, and politely questions Neela's subsequent request for albuterol and atrovent, noting the patient's high theophylline level and that he's throwing PVC's, which the same hapless intern has failed to mention. Outside, the intern praises Neela for having taken control, and apologizes to her for "the theophylline thing," noting that he'll "have to thank Chunie for fixing it." Neela, in her ensuing tirade, reminds the intern that she (Neela) has been fixing his "med. orders" all night. No one--not Neela, the intern, or the patient--actually does thank Chunie for catching all the errors.

Obviously, one message here is that nurses are skilled health workers who play an important role in addressing July syndrome, catching and correcting potentially dangerous intern errors, and providing input as to how the residents are doing. This gives attentive viewers at least a fleeting sense that part of what veteran nurses do is to participate in the training of physicians. That's something that we can't recall seeing a recent prime time U.S. drama do in any significant way. We also noted Susan's enlightened physician management practice of considering the nurses' views in assessing her junior physicians, which is not common, though it seems only fair, given that most senior physicians are not shy about expressing their views of junior nurses. Of course, it's important not to overstate what happened here; these interactions occupied no more than a few minutes of a one hour-long episode that, as usual, focused overwhelmingly on the training of physicians. But among current prime time shows, only "ER" would likely even think of doing something like this.

Yet consider the more subtle messages. Rather than showing the nurses as acting autonomously to protect the patients, the show has them going to the senior physicians. There is no direct suggestion that the nurses are acting because they have an independent responsibility to protect the patients. Instead of speaking directly to the junior physicians, the nurses simply report to the senior physicians (Haleh waits to be asked), as if the nurses were simply the physicians' agents, rather than educators. Chunie, at least, is sensitive in what she actually says. Haleh seems unduly harsh, as if she took some delight in putting Ray down on his first day as a teacher. Certainly some nurses are more sensitive than others, but most nurses would, we hope, at least try to provide their feedback directly to the physicians, and to do so in as collaborative a way as circumstances permitted. And although the episode certainly shows the critical role Chunie played in dealing with the clueless intern, it seems to credit Neela unduly, never lingering on what Chunie has done and encouraging viewers to think that she really acted more or less as a skilled extension of Neela.

We thank "ER" for telling the more than 14 million U.S. viewers who saw this episode that nurses play a substantive role in addressing July syndrome. We just wish that role had been as nursing professionals, rather than physician assistants.

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