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May 23, 2006 -- The season's final two episodes of Fox's popular "House" featured the usual high level of physician nursing. The show seems to care only about physician diagnosis, but that has never stopped its brilliant physician characters from providing all key bedside care. Here, one physician even helps a post-surgical patient walk around and use the toilet. On the rare occasions when nurses appear, they often seem to be summoned into existence literally out of nowhere by the physicians to silently do a simple physical task. Such "House" nurses are nothing new, and we've referred to them as "wallpaper nurses." But given the metaphysical musings of the season finale--and House's own reference in the prior episode to the number 613 as "Jewish," presumably because the Torah has 613 commandments--these nurses reminded us more of the golems of Jewish folklore. Golems are mute, brainless humanoids crafted from inanimate material for basic tasks by the wisest and holiest, notably early rabbis: assistive creations of the most godlike. Now, can we think of any characters on "House" who might be described as godlike? The May 16 episode, "Who's Your Daddy?", was written by Lawrence Kaplow and John Mankiewicz and had 22.4 million U.S. viewers. Tonight's season finale, "No Reason," was written by series creator David Shore (story by Kaplow and Shore), and it drew 25.7 million U.S. viewers.

In these two episodes, as always, the physicians on the House team mostly debate what mystery illnesses their patients have. But they also do virtually all patient monitoring, psychosocial care, patient advocacy, and therapeutic care. They guide patients through all tests and procedures. They answer all questions. They give all medications and fluids. (We realize the team also flits absurdly through a range of physician specialties they would actually have no clue about, but we doubt surgeons, for instance, are really hurting as a result.)

In the finale, hunky young physician Robert Chase even walks a patient with major facial swelling problems around after his surgery; perhaps a physician has done this, but we've never heard of it. Pushing the fantasy even farther, when the patient has to use the toilet, Chase takes him. While this is going on, the patient becomes agitated about a sudden and painful engorgement in a new area. Chase quickly moves close to examine this area, and gets quite a surprise when the body part in question essentially explodes. We suppose it's all part of providing all bedside care, all by yourself. The attentive might note that virtually all of this episode, including this scene, seems to turn out to be a dream or hallucination of the House character. But it's no less credible than the rest of the show as a vision of how care might actually occur in a modern hospital.

Despite the show's physician omnipresence, nurses do have their uses. They can be conjured into existence at any time to perform unskilled tasks that would just get in the physicians' way, or to hand them tools, which has the added benefit of underscoring the physicians' authority and importance.

The May 16 episode offers two good examples, mere minutes apart. At one point, Chase is in a room with a young female patient and her father. Chase is giving the patient a chelating agent by IV to help her body dispose of unwanted iron, and explaining that to the father. Naturally, the nurse who would actually do this is not there. The patient suddenly goes into respiratory distress, and a monitor beeps. Chase calmly says "crash cart." Within five seconds, two nurses are in the room with a crash cart. Without further speech from Chase, one of the nurses hands the great man an intubation tool and he saves the patient's life. Throughout, the nurses say nothing.

Not long after, House is alone with this same patient and her father in her room. No one else is shown in the room. The intubated patient suddenly has a breathing problem. House wants to eject the father, ostensibly so he can do some really complex or scary procedure (actually he just wants to continue berating the patient, who is supposedly starting to breathe on her own). House turns to a nurse who simply was not there before--she seems to be doing something of no consequence beside another (empty) bed--and commands: "Get him out of here." The nurse mutely complies. She says nothing, expressing no concern for or interest in the patient. She doesn't cite the latest nursing research on the benefits of family presence. After all, she serves House and House alone. In this case, of course, the director used editing to insert the nurse. Perhaps the show could offer this same trick to nurses who are short-staffed in real-life, as we're sure they would appreciate an on-demand nursing colleague when things get busy. Actually, it's the least the producers could do, after doing so much to encourage the kind of disrespect for nurses that leads to short-staffing in the first place.

It's true that these instant nurse creations tend to occur in situations where the patient has taken a sudden turn for the worse, and monitors would alert real life nurses to such events in cases where nurses were not close enough to catch them themselves. But the nurses' arrivals on the scene are well before any mortal could have responded to a monitor, or to the physicians' commands. The nurses appear instantly when the physicians summon them, or just think of summoning them--and for the most part, only then. The nurses appear to have no autonomous responsibilities, and they would never think to address themselves to the patient, to express a view, or even to ask a question. They exist to carry out simple physician commands.

In essence, most nurses on "House" are golems. In Jewish folklore, golems are beings made from inanimate material, such as mud or clay, by the spiritually advanced. The word "golem" originally referred to a raw or unshaped form, and in the modern Jewish languages it appears to be associated with stupidity, clumsiness, servitude, and lack of cultivation. Stories of golems have been part of modern legends, and they have featured in a wide variety of popular culture products, including video games and a 1997 "X-Files" episode. Like "House" nurses, golems are typically mute, rudimentary beings created by the advanced to perform basic physical tasks. They appear to display no personality, and can follow only the simplest direction. It's true that many golem stories involve violence, and golems can be malevolent; we are not aware that the "House" producers have introduced that element yet. However, that may simply reflect the completeness of the mastery House and his team have over the nurses. Earlier this season, House was facetiously musing on his own divinity. When the patient he had commanded to arise and walk fell down and needed to be picked up, House joked that this was "exactly why I created nurses." Of course, the "House" producers may wish to consider that many golem stories appear to involve the golems evading the control of their masters and wreaking havoc.

Why does "House" see nurses as golems? We believe possible reasons include: entrenched biases and stereotypes which remain strong even among the media elite; Hollywood's continuing reliance on familiar conventions, notably the heroic physician narrative; the fact that nursing remains overwhelmingly female, yet has not been embraced by most media "feminists," who associate it with menial, subservient work they are glad to have left behind; the fact that Hollywood receives virtually all meaningful technical health care advice from physicians; a failure to take nurses' concerns seriously, again owing to the perception that they are handmaidens; and perhaps a measure of "PC-fatigue," coupled with the fact that nurses' concerns run counter to the idea many producers seem to have that their shows are having a positive social impact. The producers of "House" may believe they are helping women and people of color, showing them as brilliant physicians. It's unlikely that such producers are glad to hear that they are damaging public health by reinforcing inaccurate views of a predominately female profession in the midst of a global crisis.

"House" appears to be the only current, prime time U.S. hospital show to have made no effort to respond in the show itself to nurses' concerns about its misportrayal of nursing. We realize that House's own ignorant anti-nurse comments earlier in the season may be the show's response, a middle-fingered salute that would not trouble us if nurse characters were given a fair chance to respond, or if the rest of the show did not reinforce the same blind contempt for nursing. We actually think a nurse character would be a good ongoing foil for House, since he or she would of course not report to him, but to nursing management. And needless to say, it would not be something the show's viewers would expect. Imagine a nurse ruthlessly mocking House's anti-holistic, diagnosis-uber-alles medical model, or correcting the many errors a real physician of his arrogance would doubtless make. Imagine a nurse interfering with House's domination of his team by teaching them they can save ten times more lives by washing their pretty hands than by spending their lives chasing a few obscure diagnoses. If the show is unwilling to introduce a strong nurse character, it might at least have nurse characters do some of the tasks they do in real life, like monitoring, explaining things to patients, giving medications, and defibrillation. Or perhaps the show could start be giving its 20 million plus viewers some evidence that nurses, unlike golems, can actually speak.

We urge the show to move beyond its golem portrayal of nursing, and to do all it can to help avert the nursing crisis that is taking lives worldwide, in part because of a lack of understanding of the important role the profession actually plays in patient outcomes.

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