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"Why not tell it the way it is, for a change?"

January 3, 2006 -- Today the lead health stories on the New York Times site illustrated some of the more subtle ways in which the public's notion that nurses are peripheral may be reinforced. A "Cases" piece by Abigail Zuger, MD, "Cleaning Up the Mess of Medicine in the Pages of Posterity," describes the essential human struggles, screwups, and dramas of front-line health care that are not recorded in the "medical journals." Though Zuger never explicitly takes credit for nurses' work, her persistent use of the undefined term "we" in describing care activities in which nurses actually take the lead, along with her almost complete failure to mention nurses, will reinforce the impression that most readers already have that physicians do everything of importance, including handling difficult, abusive, messy ED patients, and providing the full range of bedside care. Of course, a significant part of the problem is that physicians provide the vast majority of expert health content to the mainstream media, and as if to prove this, two of the three lead health pieces on the Times site today were written by physicians. The other, Richard A. Friedman, MD's "Well-Served as Patients, Dissatisfied as Customers," manages to discuss hospital patient satisfaction without using the word "nurse." It seems to us that nurses will never get full credit for their work by waiting for others to provide that credit. Instead, nurses must do everything they can to speak up for themselves in the media.

Zuger's piece is structured around a large "Unknown White Male" (UWM) who shows up at the ED where she works. UWM is "urgently ill," unresponsive and with poor vitals. We learn that "[w]e" went to work, and because UWM "needed" IV fluids and antibiotics, "[w]e" gave those to him. Because "we" needed various specimens to figure out what was wrong, a needle "touched" UWM's skin. UWM immediately woke up and "hit and bit and punched and writhed. Tubes shattered, blood spattered, bottles of iodine disinfectant toppled." "We" hollered for reinforcements, and "we" got the spinal tap "with every available hand holding him down," such that "we were drenched in sweat and working in a sea of carnage out of a battlefield." Zuger then heads to the lab with "our hard-won tubes," reflecting that this sort of thing never makes it into the journals, where at most it would be described as "[c]ultures were obtained." This patient, whose care Zuger describes as "backbreaking," woke up after a few days and left the hospital after a few weeks, without the staff ever determining exactly what was wrong with him. This leads her to a discussion of the contrast between the messy reality of front-line health care and the dignified prose that records it for posterity. In real life, things are not neat or straightforward, and many problems remain unresolved. But the medical literature will not reflect whether there has been any "drama finding a vein," or getting a claustrophobic person into an MRI scanner, or debating with a pagan about getting a blood test.

Evidently, the literature--in the form of pieces like this article--will also not reflect that nurses, who spend far more time with patients than physicians do, are far more likely to be engaged in the activities described above than physician are. In fact, nurses take the lead in managing most of those activities. Thus, nurses are far more likely to be the victims of assault by such patients, as recent research has shown. And nurses are the ones whose backs tend to be broken by patients like UWM. But the impression readers will get from this piece is that this is the life of a physician, and thoughtful readers might also guess that nurses are helping out. Indeed, the piece's sole mention of nurses, tucked at the end of the 13th paragraph, is consistent with that minor helping role. After all we have heard, Zuger urges medical journals to actually publish articles about the "wildly agitated" patient who is "lurching off his rolling gurney and taking his doctors and nurses down with him." Zuger says she sometimes feels that it's a disgrace that the medical literature ignores such things: "Why not tell it the way it is, for a change?" As nursing advocates, we can't improve on that question.

It's not that we have any particular reason to believe that Dr. Zuger set out to marginalize nurses. On the contrary, some time ago she published a good piece in the Times with the specific purpose of highlighting how vital nurses are to the care of hospital patients. But pieces like today's do seem to reflect a vision of care as being primarily a function of physician efforts, if not a specific intent to give patients and the public the impression that physicians in fact provide all significant care. The public receives this impression from the vast majority of mass media products that cross its path, from elite newspapers to Hollywood television shows. So when a physician tells the public that "we" did something important or exciting (even if messy or scary) on the front lines, virtually no one is going to get that nurses played a significant role, and certainly not that nurses may be many times more likely to be involved in that work. Instead, readers will have their physician-centric assumptions reinforced.

Friedman's piece is about how the current hospital business model of treating patients as consumers can conflict with patients' own best interests, especially in the area of mental health. Friedman tells the story of a patient with borderline personality disorder whose anger with her psychiatric resident was taken very seriously indeed by the hospital's "patient care representative," even though, in the author's view, switching therapists would have actually been "anti-therapeutic." This is fine as far as it goes. But by continuing to present the public with a health care universe consisting only of "hospitals and doctors," such pieces add to the prevailing sense that nurses are of no significance in handling very difficult patients. That, as we have seen, is wrong.

We do not believe that the most basic lesson to be drawn from pieces like these is that physicians in the media tend to take credit for nurses' work, or even that they cannot be trusted to provide a fair picture of that work, though there is plenty of evidence to support both of those ideas. Nor is it that even elite media entities like the Times generally fail to question whether the physician-centric vision of health care they present is a complete or accurate one, though that also seems to be the case. The most important thing we think nurses should consider is why the Times has so many health care pieces written by physicians--this is not the first time that the majority of a day's lead health pieces have been written by them--and so few pieces by nurses. It may well be that the public will never receive a fair account of nurses' work, and that nurses will never receive the resources they need to do that work, until that imbalance changes.

See the article by Abigail Zuger, MD, "Cleaning Up the Mess of Medicine in the Pages of Posterity," in the January 3, 2006 New York Times.

Also see Richard A. Friedman, MD's "Well-Served as Patients, Dissatisfied as Customers."

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