"You should reprimand him...make him change bedpans."

April 10, 2005 -- Tonight's episode of ABC's "Grey's Anatomy" featured rampant physician nursing, as the show's surgical interns did many important things that nurses do in real life, while nurses themselves were portrayed as peripheral subordinates. At the same time, the show doesn't seem able to get through an episode without at least one specific expression of contempt for nursing--in this case, a playful remark that associates a certain well-known nursing task with punishment for a junior staff member. Once again, show creator Shonda Rhimes wrote the episode, and the medical advisor was Karen Lisa Pike. ABC is already calling "Grey's Anatomy" one of the biggest new hits of the season, and this episode had a reported 18 million viewers.

Even by the standards set by this season's new hospital shows, this episode, "Winning a Battle, Losing the War," has a high level of physician nursing. The surgical interns keep talking about how they're dying to spend all their time in the OR, but they actually spend almost the entire episode coordinating care outside the OR. They do the work of ED nurses by being the only hospital staff to play a significant role in the intake and care of ED patients, notably bike messengers and pedestrians injured in an annual street race. They do the work of ICU nurses by monitoring critically ill patients in the ICU. They do the work of post-anesthesia and surgical nurses by monitoring the progress of a patient who has just gotten out of surgery. They conduct all patient interactions, do all the patient monitoring, and provide all psychosocial support to patients and families. One intern is even seen starting to change a bed! Is it possible that the show has the surgeons spend so much time nursing because it doesn't think the work of surgeons, for all the macho posturing associated with it, is actually interesting enough to sustain the whole show? We're just asking. Anyway, during all this, no nurse provides any significant bedside care. No nurse speaks to a patient.

Perhaps the most striking example is the interns' actions as both the clinical and procurement transplant coordinators. (Yes, really.) In reality, transplant coordinators are highly trained professionals, most always nurses, who take the lead in the variety of tasks involved in matching organ donors with recipients, including the extensive logistics and provider relations, as well as discussing options with patients and families. Few if any of these key tasks would be entrusted to a new surgical intern. But here, the interns do it all--they do the matching (stumbling upon a match among their bike messenger crash patients), they negotiate among the providers, they take the lead in locating and dealing with the family, and most ridiculously, one inept intern is left to get consent for multiple donations from the distraught wife of the donor. It's all part of learning to be a nurse! Oh, sorry...we mean, it's all part of learning to be a Hollywood physician character, which means doing the work that nurses, social workers, respiratory therapists, and other health care professionals do in real life.

Nurses do occasionally appear in the episode to move an object or take orders. Our favorite was when one of the interns told a nurse staffing a desk to find the family of the brain dead donor, and the wide-eyed nurse asked if they wanted to do to that in order to arrange organ donation. This presents the nurse as a passive clerk unconnected to patient care. Indeed, it's not clear that this nurse is directly responsible for any specific patients; apparently she just waits around for a fledgling physician to tell her what to do. In reality, nurses actively take the lead in coordinating the efforts of the health care team on behalf of their patients, which would include locating and supporting the family of a patient like this, and working with the transplant coordinators. No ICU or ED nurse would need a new intern to tell her that a young brain dead patient was a potential organ donor, or to initiate the process.

The episode's poor presentation of organ donation may be troubling to nurses and organ donation advocates as well. The show's basic idea seems to be that it is hard but necessary for people to let go of an irreversibly brain-dead person when another life can be saved, and that health care workers should be sensitive in facilitating this. But viewers will not get that dedicated professionals have developed practices to assure that this process is conducted with competence, care and sensitivity. When the inept intern brusquely asks permission to transplant the donor's skin, the family seems terrified that the physicians want all of it, which would preclude an open casket viewing. Viewers are not told that such a skin donation would affect only discrete areas that would not be noticeable in a viewing. Likewise, after the main organ donation, two interns come back to sew up the donor's open chest cavity as a kind afterthought, as if that was not standard procedure. Thus, despite the episode's effort to show the value of organ donation, we fear that its inaccurate vision of donation mechanics will actually have a net negative effect on such donations.

The organ recipient, an old friend of the chief of surgery, is a genial man who spends much of the episode playfully flirting with an awkward male intern, even as the intern's colleagues all seem to be under the mistaken impression that he is gay. When the chief of surgery asks how the hospital is treating his friend, the patient teasingly says fine, "except that beautiful boy [the intern] won't let me smoke. You should reprimand him...make him change bedpans." And who is usually associated with changing bedpans? Yes, this is a joke, and bedpans are not pleasant, but the obvious message is that changing bedpans is a punishment for junior wrongdoers, not something that serious professionals do as part of their health care assessments. Perhaps the show's creators don't know that changing bedpans is a vital opportunity for nurses to assess life-threatening hemorrhage, bowel obstruction, infection, dehydration, diabetes, intestinal trauma or herniation, bowel or uterine prolapse, parasitic infections, kidney, gallbladder or liver disease, dementia, mobility and independence problems--just to name a few. (A recent "House" episode revolved around the physician characters' difficulty in identifying a condition that a nurse's basic examination of the critical patient's bedpan could have revealed--if the show had any nurse characters or understanding of nursing.) Interns are not qualified to make these assessments. It's not surprising that the show would present this important nursing role as a mock punishment, but it still reinforces the stereotypical undervaluation of the profession's work. There is a reason the patient did not joke that the intern should be made to take part in bowel surgery, and the reason is that, unlike bedpans, that is not seen as a mindless task for uneducated servants. Like the show's other anti-nurse comments, this is not in and of itself a problem of accuracy; such a patient might really have said this. The problem is that the statement reflects a common stereotype that the public does not realize is inaccurate, and that the show gives viewers no reason to question the stereotype.

Perhaps the episode's oblique link between homosexuality and nursing is an appropriate one. Just as many have feared to express "the love that dare not speak its name," the episode's relentless depiction of its pretty young physician characters doing key nursing tasks suggests a secret affection for nursing--even as the show's creators continue to present ostensible contempt for the profession. Is it possible that the producers are simply afraid to confess their true feelings for the widely disrespected nursing profession by having nurses do the nursing that the episode presents as central to patient outcomes? If so, we can only encourage them to come out of the closet and, in the words of one of their intern characters, get "down with the rainbow."

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