An Inconvenient Truth

May 15, 2006 -- Tonight's two-hour season finale of ABC's "Grey's Anatomy" featured a remarkable level of physician nursing, even by the no-nurse standard the show has maintained since its two January 2006 nursing strike episodes. Those episodes now seem like a token effort to get nurses off the show's back, so it could go on with its inaccurate and damaging portrayal, regardless of the central role nurses actually play in hospital care--a reality that seems to be no more than a minor inconvenience to the show. In the finale's main care-related subplots, physician characters do everything that matters, with no nurses in sight. And an enormous amount of what they do would have been done by nurses in real life. Physicians do all patient monitoring, all patient emotional support, all family relations, all patient advocacy, and virtually all supportive and therapeutic care. When nurse Olivia does briefly appear, she is presented as a timid physician lackey whom senior resident Bailey drags in to take over heart-pumping for intern Izzie, who has lost her heart to transplant patient Denny, and her mind to the show's producers. As in other post-January episodes, no one here directly suggests that nurses are sluts or losers, and perhaps nurses' protests have at least achieved that. The first episode, "Deterioration of the Fight or Flight Response," was written by Joan Rater and Tony Phelan; the second, "Losing My Religion," was written by series creator Shonda Rhimes. This initial airing drew an estimated 22.5 million U.S. viewers.

In the finale, the main care-related subplot concerns heart transplant patient Denny. Denny is in line to get the new heart he badly needs, but apparently another patient across town is just ahead of him on the United Network for Organ Sharing (UNOS) transplant list. So Izzie, who has fallen in love with Denny, decides to actually cause Denny's condition to worsen to such an extent that he will move back to the top of the list. She does this by cutting his LVAD wire, and many surreal plot twists later, Denny gets the heart. Izzie's fellow surgical interns reluctantly cover for her. The show does make it clear that she has done something wrong, though the fact that she succeeds in subverting the system and that all involved seem to escape any real punishment make the episode yet another in the show's growing list of horrifically damaging transplant episodes. This one suggests that your donated organ's fate might be determined by the whims of some crazed, love-addled intern, rather than a rational and fair health policy. The fact that Denny ultimately dies, and that Izzie quits, does not change that basic message.

Izzie and the other interns provide virtually all care to the pre- and post-op Denny. They debate the merits of various courses with him and each other, they monitor his condition, perform a code after Izzie succeeds in nearly killing him, do tests that will be needed to prove his worthiness to UNOS, give him emotional support, and so on--all without a nurse appearing. As in so many other "Grey's" episodes, the interns are his nurses, although not good ones. As for the transplant operation, of which we see little, it goes without saying that only the surgeons receive significant attention.

One nurse character does briefly emerge from the wall-to-wall physician care. That is nurse Olivia (memorably described by Izzie herself in a prior episode as "skanky syph nurse"). In this episode, the interns' stern chief resident Bailey discovers what they have been doing. Bailey appears in Denny's room with Olivia in tow--the first time we have seen a nurse. (From this, we can confidently conclude that nurses check in on patients when told to do so by chief residents.) Bailey orders all the interns away from Denny. Izzie refuses, as she is "pumping his heart." Bailey commands: "Olivia, take over for Dr. Stevens" (Izzie). Then Bailey orders Izzie to leave. Olivia approaches Izzie cautiously, and gently begins: "Izzie..." Izzie snaps: "No, do not touch me!" The supposedly tough Bailey retreats: "Olivia, stay with Dr. Stevens. Help her if she'll let you."

These scenes presents Olivia as a mousy, indecisive helper, someone who serves the physicians, rather than the patients. Olivia takes no initiative. She does what Bailey asks, and indeed, she needs Bailey to ask her, since neither she nor any other nurse has visited Denny for the entire adventure we have seen. In real life, nurses would provide a critical patient like Denny with care almost constantly. They (not a group of interns) would be with him all the time, providing most of his physical and psychosocial care, and of course playing a central role in any efforts to revive him. If the nurses were meeting their duties, they would also be defending Denny from the likes of Izzie and her crew, since nurses have legal and ethical obligations to protect patients from the kind of dangerous misconduct we see here. We'd like to think that no nurse would have permitted Izzie's effort to subvert the UNOS rules, a gross violation of sound public health policy.

Of course, "Grey's Anatomy" could not easily show that even if it wanted to, as the show continues, despite all nurses' input, to believe that nurses report to physicians. Here, Olivia's role as a meek subordinate to Bailey is crystal clear, and it is underlined by Bailey's command to "Olivia" to take over for "Dr. Stevens." (One does not address peers by their given names in the presence of servants or children; for servants and children, of course, given names are an essential hierarchy-reinforcing tool.) In real life, hospital nurses are autonomous professionals who report to nurse managers and executives, and who typically address the physicians with whom they work by their given names.

Later, Denny gets his heart and seems headed for recovery. But suddenly, he simply dies, alone and with no rescue efforts, just as Izzie is on her way to see him. (Too bad the hospital has no real nurses to detect his sudden change in condition and possibly save his life.) Later, we see intern George arrive outside Denny's room, having been summoned by Olivia. Olivia: "I didn't know what to do, I didn't think you guys would want me to call the chief, but..." George asks where Izzie is, and she is in bed with the deceased Denny. The remainder of the scene involves the interns' efforts to persuade Izzie to let go, which include suggestions from intern Alex (who clearly speaks for the show here) that there is something sick and degrading about tearfully embracing a just-deceased loved one.

Olivia's action in seeking help from Izzie's fellow interns is plausible, given all the other plot elements, because the interns probably would be best placed to help Izzie grieve. But the way it plays out here again presents Olivia to most viewers as a physician subordinate. Most will likely assume that Olivia would have gone to a physician for help no matter what the issue, even if it had been a nurse in bed with the deceased Denny, since nurse managers have never existed on the show. Moreover, the show seems at least as concerned with getting Izzie off of Denny because it views her actions as inappropriate as it is with helping her grieve. Of course Izzie's relationship with her patient was always inappropriate, but the time when that was an issue for the show seems long past. And the show's apparent notion that there is something unhealthy and perhaps necrophilic about grieving for a deceased love one through physical contact is bizarre. But perhaps it is not surprising for a show that seems to get no real input from those who are actually experienced with the emotional effects of death in clinical settings, e.g., nurses.

The show loves to have senior physicians angrily tell the interns to monitor a patient 24/7, sometimes as a punishment, sometimes because the patient is so critical. The interns are typically then presented as literally staying with the patient constantly, with no nurses in sight, suggesting that hospital patients are monitored primarily by junior physicians, and that this task requires commitment, but no great experience or skill. Thus, in another significant care-related subplot of the finale, the chief of surgery directs all of the interns to do nothing but care for his teenage niece, whose ovarian cancer has returned, as a punishment for their actions in fraudulently getting Denny his new heart and failing to say who exactly was responsible. In the romantic fantasyland of "Grey's Anatomy," this mostly involves arranging for a prom to occur in the hospital so the patient won't feel left out. But it still reinforces the view that nurses play no significant role in patient monitoring, patient relations, or bedside care. It also degrades the care nurses actually do provide by suggesting that a bunch of surgical interns could do it, even though they have no training or experience in nursing.

On the whole, this season finale is more of the same from the massively popular "Grey's Anatomy"--an ostensibly realistic depiction of hospital care in which physicians do everything that matters, including huge amounts of nursing, and the rare nurse who does appear is an irrelevant servant. We urge the show to reverse course, and to do all it can to help avert the nursing crisis that is taking lives worldwide, in part because of a critical lack of understanding of the important role the profession plays in patient outcomes.