Grey's Anatomy: Have fun playing nurse!

 
August 2010 -- Five episodes from the sixth season of ABC's Grey's Anatomy (2009-2010) illustrate the two main stereotypes that the hit show continues to reinforce:  that nurses are physician handmaidens, and that they are low-skilled workers worthy only of contempt. As always, the show's 12 main characters--all surgeons--provide all the health care that matters, including vital care that nurses do in real life. In one episode, after senior surgeon Derek Shepherd asks female surgical resident Lexie Grey to monitor his own health during a marathon surgery, a male resident mocks Lexie by telling her that it sounds like she will be Shepherd's "bitch" and urging her to "have fun playing nurse." Lexie will have her revenge on her Seattle Grace colleague, but the show makes no effort to defend nursing. Another episode flashes back to 1982 to show surgical pioneer Ellis Grey (Meredith Grey's mother) as a resident fighting off a male colleague's claim that she is just a "nurse" who has no business defibrillating, though even in 1982, nurses did plenty of defibrillation. Again, there is no defense of nursing. Two other episodes include brief but damaging appearances by nurse Tyler, a bitter lackey who could not care less about patients and views his role as doing as little as possible to help the physicians who actually provide expert care. And still another episode features a rare prime time mention of nurse practitioners. Not surprisingly, it is an insult, as Shepherd suggests that another surgeon is wasting her time doing after-care since a "nurse practitioner can do this." Grey's seems to have made little progress since the anti-nurse insults of its first episodes five long years ago (e.g., "Did you just call me a nurse?"; "You're the pig who called Meredith a nurse!"). As in the early days, the show wants us to feel the pain of brilliant female physicians who must fight to avoid being mistaken for nurses, members of the backwards servant class of health care. We urge the show to consider if it could pursue its apparent mission of deifying physicians without attacking nurses quite so directly.

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Taken together, the portrayals in these episodes form a remarkable vision of the show's different ways of promoting physicians by trashing nurses, almost like a backlot tour of horror movie props. Let's start our tour, but remember--stay with the group! These influential portrayals pose a threat to everyone's health.

 
Complaining of pain

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In the October 22 episode ("I Saw What I Saw"), Seattle Grace has recently merged with another hospital. The troubled chief of surgery Richard Webber, who also seems to be the chief of medicine and CEO, presides over the ensuing chaos and a hyper-competitive resident environment, which includes a constant fear of layoffs. This particular episode focuses on the unnecessary death of a victim of a large fire named Cathy Becker, who comes into the ED with many other victims and basically slips through the staff's fingers. The episode is a degraded homage to Kurosawa's classic 1950 film Rashômon, relating the same awful event over and over from different perspectives. Here, each of the surgeons involved in the hospital's response to the fire tells a different story to Webber and a member of the hospital board, and we understand that by the end of the day, one of the residents will be blamed for the error and fired. (No one really questions whether the preliminary decision to fire one and only resident, made with little apparent knowledge of the underlying facts, makes any sense; as is common for the show, the cute residents basically just gossip and quake about it as if they had never left grade school.) It turns out that one resident forgot to look in the patient's throat, which would have shown soot, and led to an intubation that would definitely have saved the patient. Of course, the whole plotline assumes that only the physicians were responsible for the patient; nurses are not involved or consulted, and some trauma scenes are essentially nurse-free.

But not all. At one point, there is an appearance by nurse Tyler, a recurring character who has been with the show since the beginning, popping up once in a while to dump some problem on the residents in a surly way, at times even gloating about it. Tyler is essentially a plot device the show uses to stress how hard the residents' lives are. Here, he approaches residents Christina Yang and Jackson Avery and plunks a patient's chart down in front of them:

Tyler:  Whose patient is bed 1, Cathy Becker? She's complaining of pain.

That's it for Tyler, but there's actually a lot here. It's obvious that this patient is just an annoyance to him, and that her problems are nothing that he is ultimately responsible for or could do anything about, except to tell the surgeons who actually are responsible and do provide care. Tyler is a clock-puncher, not a professional with independent duties to the patient or any concern for her. Whoever's patient she is, she's not his. And note his report:  she's "complaining of pain." Tyler himself has no ability to assess that pain, to put it in the context of her overall condition, to even identify where the pain is, or to suggest what might be done about it. He can only relay what the patient actually says, as any lay person could do. He is a low-skilled bureaucrat, the kind real professionals like our surgeon heroes sometimes have to work around to get their important work done.

Sounds more like you're his bitch

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The next week's episode ("Give Peace a Chance") has the same basic subtext--surgeons are demigods--but instead of showing that through the awful results that may follow when the surgeons make an error, this episode reminds us of the Olympian heights to which they can ascend when they succeed. Here, super-surgeon Derek Shepherd goes "rogue" by performing an apparently impossible surgery on the likeable hospital lab tech Isaac, who has what seems to be an inoperable tumor wrapped around his spine. The conventional thinking is that the only way to get the tumor out is to cut Isaac's spinal cord, which will of course paralyze him, and chief Webber forbids Derek to try to take the tumor out without cutting the cord. Much of the episode shows Derek agonizing about whether and how to do the surgery, surrounded by oohs and aahs from the rest of the hospital about his god-like surgical skills, and the usual childish competition among the residents.

None of this involves nurses, of course, but there is one telling interaction between residents Jackson Avery and Lexie Grey, younger sister of lead character Meredith Grey. Avery excels in a test of micro-surgery ability that Shepherd gives to decide who will assist him in the operation. But Lexie has not even been invited to compete in this test, and she confronts Derek about why. Derek says he has a special job for Lexie, based on her own earlier comments about how difficult such operations are:  Derek wants her to monitor his own condition during the endless operation. He wants her to remind him to take breaks, bend his legs, drink water. Lexie seems pleased.

But Avery has a different take when Lexie later sees him in the hall. She is drinking water to hydrate herself, and she says they must both be nervous. But Avery mocks her, asking what she has to be nervous about when Shepherd did not even let her compete to assist in the operation.

Lexie:  No, that's because he needs me to maintain his care while we're in there. I'm his doctor, basically.

Avery:  Wow, so you fell for that. I mean it sounds...sounds more like you're his bitch.

Lexie:  What?  No...that, it's, I'm I'm not...You're gonna need to take a break, eventually. And you're gonna need to stretch. You're gonna need to pee. And when you do, I'll be there to take over.

Avery:  Yeah. I don't take breaks. ... I've done it before. But that's because I know to stop taking fluids before a long surgery. Have fun playing nurse. It sounds...neat!

Lexie says no more, just looks thoughtful. She sees someone who looks like a nurse restocking adult diapers down the hall, and this gives Lexie an idea about how to stay in the surgery without taking a break. Although Lexie is at first embarrassed about wearing a diaper, she eventually embraces the idea as a hotshot surgeon thing, at one point telling Avery that he can "kiss my hard-core diaper-wearing ass." 

Although Derek's first attempt to remove the tumor seems to consist of 10 hours of staring at it, he tries again and ultimately succeeds, to the expected universal acclaim. And Lexie does turn out to play a key role. First, she gets Derek's old friend, plastic surgeon Mark Sloane, to come to offer moral and technical support. At one point, after Derek thinks that he has accidentally cut the spinal cord and then learns that he has not, he asks Lexie to remove his mask, so he can vomit. She forces him to rehydrate, noting that he's stressed and dehydrated; she needs to become pretty aggressive to get him to do it. And when Avery starts cramping at the 21-hour point or so, Derek asks Avery if he's had anything to drink, and of course the answer is no. Derek suggests that Avery went without fluids so Lexie could not get her hands on the retractor. Derek asks Avery to step aside and Lexie to take over--just as Lexie predicted would happen.

From a nursing perspective, this plotline is fascinating, though ultimately damaging. On the one hand, despite Lexie's comment about being Derek's "doctor," the monitoring and advocating that she does here really is closer to nursing, as the show suggests with Avery's comment, which is never directly refuted. OR nurses are responsible for everything that might affect a patient's well-being during a surgery, including the condition of a surgeon. If the surgeon is clearly not up to the task, OR nurses can and do take steps to protect the patient. On the other hand, Lexie also gets to take over from Avery as assisting surgeon, which the show sees as care of a higher order. So what will viewers conclude? That her care for Shepherd really was a "nurse" role, and it's kind of important, just not as important as a surgeon role? Or that it was really a special "doctor" role, as Lexie said, just one that Avery did not understand? Lexie did ultimately prevail, so her perspective may well be more persuasive to viewers. So perhaps this is just more of the show's physician nursing, with physician characters getting credit for the kind of care that nurses do in real life? Of course, no nurse character plays any noticeable role in the plotline.

On balance, it's unlikely that this ambiguous plotline can overcome the powerful impression made by Avery's core insults:  that Lexie will be acting as a "nurse," which is like being Shepherd's "bitch." Sure, Lexie has the last laugh, but no one defends nursing directly, and it's more likely viewers will simply conclude that she prevailed because she's a promising physician, not because nursing really is an equally valuable profession with a wider health focus. Thus, the plotline functions a lot like Lexie's sister Meredith's "Did you just call me a nurse?" one from the series premiere in 2005.  There, as here, an obnoxious male resident (Alex Karev) accused a female resident (Meredith) of being a nurse. As here, the man got his comeuppance, but not from a nurse and not because anyone defended the profession. As here, he got it because the intellect and persistence of a young female physician carried the day. In other words, you may call us "nurse," but we'll show you! You're wrong to treat us like those low-skilled throwback females whose work is trivial! We're going to be great surgeons! In diapers! Hard-core!

High-class care

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By the January 14 episode ("Blink"), chief of surgery Webber has been in decline because the various pressures in his life have led him to return to heavy drinking. A couple months prior to the episode, Webber made a serious surgical error, cutting the common bile duct in an emergency cholycystectomy (a gall bladder removal). That error, which has not really been acknowledged since it occurred, appears to be bothering the chief so much that he has stopped operating completely. Attending surgeon Miranda Bailey, a protégé of Webber's, has been covering for him, handling the patient's post-op visits personally to keep the mistake hidden, especially from the patient. But at one point, Derek Shepherd ends up doing one of these follow-ups for Bailey, noting that it is "easy" and he'll handle it, so she can go to lunch with a radiologist Shepherd is trying to set her up with.

Derek meets with the patient, and is surprised to learn that the patient is still getting weekly follow-ups with Bailey herself. Derek sees that Webber did the surgery, and becomes suspicious, because he knows something is wrong with Webber. The patient explains to Shepherd that Bailey was worried because he "turned yellow" after his first surgery, showing Shepherd a photo to illustrate. Later, Derek confronts Bailey about the patient.

Derek:  He's getting some high-class care. Six visits with a surgeon? A nurse practitioner can do this.

Bailey:  Yeah, I like to do after-care myself.

Shepherd points out that it wasn't even her patient, but Webber's, and he suggests there was an error. Bailey claims she's seeing the patient herself because she has a "thing" for the patient, which is unlikely and Shepherd does not buy.

To our knowledge no nurse practitioner (NP) has ever appeared on Grey's, so the superstar Shepherd's contemptuous reference may be pretty much the only image of NPs that the show's viewers ever get. Shepherd could have made his point about the cover-up of Webber's error by noting that such follow-ups are not really the right job for a surgeon, because their skills differ from those of NPs. Or he could even have just said that "NPs usually do this," which would have said nothing about the professions' relative skills. But instead, he said that the patient was getting "high-class" (meaning far better) care because the senior surgeon Bailey was doing the followup. In addition, Shepherd said NPs "can" do this, meaning it's easy enough for them; in fact, he specifically called the follow-up care "easy." So viewers will clearly get the message that this is relatively simple care that requires little knowledge, not that it is a job for NPs because they are so observant and skilled in interpersonal relations, good at monitoring patients' progress and explaining how to cope with a difficult recovery from surgery.

Nursing must've left

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The February 11 episode ("Valentine's Day Massacre") focuses on the care the surgeons give to victims of a roof collapse at a romantic restaurant packed with diners on Valentine's Day. One victim is a waiter who has had a thing for a regular customer for 15 years, though she is now married to someone else. The waiter is a sympathetic character, and surgeons Meredith and Alex, who do all of his interpersonal care, seem to genuinely like him. The waiter's injuries do not seem severe compared to those of the woman he loves or her husband. At one point, surgeon Alex Karev returns to check on the waiter, stopping next to the nurse's station, which has a clear view of the inside of the patient's room by way of a large window. Alex sees from the hallway that the patient's bed is empty, then turns to nurse Tyler, who stands at the nurse's station looking through what seems to be a chart.

Alex:  Where's my patient?

Tyler (glancing briefly at the room):  No idea. He must've left.

Tyler returns to whatever he's doing, utterly unconcerned, while Alex enters the patient's room. Alex looks at the bed, and starts to do something with the chart he holds. A bill falls from it--a tip that the waiter patient had earlier given Alex to place his bed next to that of the woman he loves. The money lands just under the bed, and Alex gets down on his knees to retrieve it. As he does so, he notices that on the floor on the other side of the bed lies the patient, seizing. The patient has fallen out of bed. Alex yells for help. It later turns out that the patient has undetected bleeding in the brain, and he does not survive, even with the efforts of the mighty Shepherd.

This episode, which is the work of the same writer as the October "complaining of pain" one, again presents Tyler as someone who can just barely bring himself to do anything for his physician masters, and who is basically indifferent to the fate of the patients. Once again it is clear even from Tyler's few seconds on screen that the patients belong to the physicians alone (compare this scene's "Where's my patient?" line by Alex to the earlier episode's "Whose patient is this?" line by Tyler). Tyler has no professional responsibility to the patient. Although the episode is not suggesting that Tyler or anyone else could have saved the patient, this scene is even worse than the earlier one. There Tyler was at least reporting something about a patient to the physicians. But his dramatic role in both scenes is to deepen our sense that the physicians are surrounded by adversity and our concern about what they will do to help the patient.

In real life, it's certainly possible that a busy nurse would not know where a patient is at any given moment. And it's even possible that a patient would fall out of bed, though a conscientious nurse would have had side rails on the bed to prevent such falls. But what isn't likely is that a professional nurse would display no concern whatsoever for the well-being of the patient in his care, and make no effort whatsoever to locate the patient. Instead, a real nurse would try to find the patient, to ensure that the patient is not in need of help (could he have fallen down? could he be having a seizure? could he have an undiagnosed bleed in his brain? could he have hung himself in the bathroom?), and of course to help a physician who has arrived to check on the patient and deserves some assistance in that task if the nurse is available, especially since surveillance is a nursing role. Although shows like Grey's tend to have the physicians monitoring patient conditions, that is of course a central nursing responsibility. But the show is not interested in showing Tyler to be an autonomous member of the health care team with his own responsibilities to patients. It is interested in presenting Tyler as a minor dramatic foil who pops up to emphasize plot points and to draw a contrast with the surgeons who actually have the skills and the desire to save patients.

I'm not a nurse!

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The episode aired on February 18 ("The Time Warp") returns to the pressing need for female physicians to distinguish themselves from nurses. As in prior episodes, no one disputes that nurses are low-skilled servants, or that the word "nurse" is rightly considered an insult; the only issue is whether it's fair to call a female physician that, and how she should prove the attack to be unfounded.

The episode focuses on a "teaching day" at Seattle Grace in which three of the main characters describe to an auditorium full of other physicians cases from their past that profoundly changed their careers. And of course each case promotes the general idea that surgeons, though imperfect, are awesome and brilliant and single-handedly save lives. One of the storytellers is former chief Richard Webber, who has been in rehabilitation for his alcoholism, and may return to the hospital as a general surgeon. As part of his introduction, Webber observes that "you learn from everything in your residency...the patients, the nurses, the attendings...but you don't realize how much you learn from each other." That sounds nice, but a passing statement like that will mean little to viewers, especially when nurses are grouped with those who have no health care skill. It may be that you learn from nurses simply because they are human beings, or co-workers, or (like Tyler) the kind of petty bureaucrats everyone must learn to deal with in life.

Webber describes the time when he, an African-American, and the legendary Ellis Grey worked together in 1982, when both were Seattle Grace surgical residents fighting the contempt of what the show portrays as the pompous white boys' club of surgery. We see a group of residents, including Webber, trailing an attending as he enters a patient's room. The patient is coding. Ellis, already in the room, is yelling at the nurses for being too slow in getting the crash cart and preparing to defibrillate the patient herself. One of the male residents tries to shove her aside.

Male resident:  This is no job for a nurse! I'll take it from here!

Grey:  You know very well I'm not a nurse. Back off!

She wrestles the paddles back and does the defibrillation, reviving the patient. Back in 2010, Webber tells the listeners in the auditorium that Grey often faced that kind of abuse, including being called "nurse," a word that actor James Pickens, who plays Webber, utters with an appropriate level of disdain, to show how it was used against Grey. Back in 1982, Grey and Webber eventually determine that their patient has AIDS, though they face abuse from the patient and the other surgeons in doing so. When the patient finally returns to the hospital with Karposi's Sarcoma, only these two brave surgeons will treat him. No nurses, it seems.

Of course, it's clearly plausible that a male physician looking to insult a female physician might call her a nurse (and if any male surgeons could not come up with that on their own, there are now lots of episodes of Grey's Anatomy out there to give them a helpful hint!). We have no problem with the show suggesting that "nurse" might be used this way. As always, the problem is that the show gives every indication that it shares the basic view that being a nurse really is worthy of such contempt. There is no real defense of the profession, from Grey, Webber, or anyone else. The focus is to make sure we understand that Grey is (as she says) not a nurse, but instead a fierce, brilliant life-saver on her way to surgical immortality.

Of course, the fact that the surgeons are not nurses does not prevent them from spending a lot of time doing cool things that nurses do in real life. First, there's defibrillation, which even in 1982 nurses did all the time; today, nurses are the ones who generally do defibrillation in critical care settings. So although the show does not question the basic premise of the 1982 insult--that only physicians can defibrillate--it is false.

More broadly, the episode has a number of scenes in which surgeons assume the duties of patient advocacy, constant patient monitoring, using a holistic approach to get to the root of patients' problems, and even holding patients' hands while they die--as Grey and Webber appear to do with the AIDS patient. Nurses are far more likely to be doing these things in real life. But the constant crediting of physicians for nurses' work reinforces the public's view of physicians not only as the smart ones with all the knowledge and skill, but also as the tough yet sensitive patient advocates with advanced interpersonal skills--that is, the providers of all meaningful health care.

Calling me a nurse

Obviously, the common theme in these plotlines is that nurses are inconsequential servants of the physicians. In dramatic terms, nurses help the show maintain its overriding theme that physicians are a kind of demigod class, flawed and mortal to be sure, but clearly in total control of their immediate environment, commanding a group of seemingly vacuous subordinates who carry out their every "order," usually without question. The show's physician characters usually don't even seem to see the nurses who actually provide most of the care in hospitals, just as any master class may not really see the servants or the great mass of the dispossessed who surround them.

Of course, promoting diversity as to race, gender, sexual orientation, and body mass (as Grey's does) is hard work. With so many traditional targets off-limits, such dramas may feel they have to look down on someone. Disrespecting nurses may seem okay because the judgment seems to be based on genuine merit. Why shouldn't we look down on nurses--they really are just dim helpers, if not ciphers, right? (Are they even allowed to vote?) And this inclination may be especially strong for a show that is so focused on female advancement in the workplace. It's critical to distinguish ambitious modern career women from the traditional "female" jobs of prior generations, which are presumed to be of lower value because men did not generally do them. Or to put it more colorfully, it's critical that smart modern women not be anyone's bitch.

It may sometimes seem that the people who make Grey's Anatomy actually hate nurses. But it's more likely that they just have never been given a good enough reason to question their deeply held assumptions about health professions. We urge everyone to give them that reason.

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