House of Games

April 4, 2007 -- Today Salon posted a well-written essay by Sallie Tisdale, a nurse and a noted writer, called "The Beautiful Hospital." The piece was an impressionistic take on the failure of prime time Hollywood television shows, especially Fox's "House," to convey what really goes on in hospitals. Tisdale makes some excellent points in a powerful way. She describes "House"'s physician-glorification, and its tendency to suggest that physicians do everything by themselves, when in fact physicians are often peripheral to the work that nurses and others do in caring for hospital patients. Unfortunately, Tisdale's discursive piece gives no real sense of why such shows might be this way, whether it affects public health, and if it does, what might be done about it. Nor is the piece's credibility enhanced by some unfortunate distortions and errors in its discussion of the shows. Even so, we thank Tisdale and Salon for bringing some helpful points to the attention of their readers.

Tisdale contrasts the world of shows like "House," with its "Beautiful Hospital," with her own work as a real-life oncology nurse, at what seems by comparison the "Ordinary Hospital." Tisdale says she started watching "House" because of the mysterious diseases and the lead character's charismatic anti-charm, which includes nasty put-downs that Tisdale herself sometimes "want[s] to say--mostly, to doctors." But she has become "frustrated," because the Beautiful Hospital

is staffed almost entirely by a trio of gorgeous and impossibly brilliant physicians. No one else works at the Beautiful Hospital except a few secondary gorgeous and brilliant doctors and an ever-changing cast of extras whose only job is walking down the hallways in scrubs.

And the "House" physicians aren't just pretty, brilliant diagnosticians. They are "educated in the entire gamut of medical specialties," not to mention

trained as phlebotomists, bacteriologists, geneticists, nurses (all specialties), pharmacists, a three-person advanced cardiac life support team, CT technologists, radiologists, MRI technologists, hyperbaric chamber technicians, respiratory therapists, social workers, epidemiologists, substance abuse counselors, polysomnographic technologists, organ transplant coordinators, immunologists, chaplains, pathologists and private detectives.

Tisdale says she's surprised they don't also fix the air conditioning.

Tisdale then describes an evening shift she recently worked at the Ordinary Hospital. She had four seriously ill oncology patients, who were facing things ranging from recovering from severe side effects of treatment to dying of kidney failure. She notes that the hospital rooms are cramped and semi-private. She and the other non-physicians, including a respiratory therapist, essentially conducted the care that the patients received, without any physicians--the one "doctor" she paged was actually a nurse practitioner.

Tisdale says she used to watch NBC's "ER," which she admits could not be accused of prettifying; it showed us the Ugly Hospital. Nurses and other non-physicians actually worked there, and some characters were not physically flawless, though she felt the show's obsession with "promiscuous partner-swapping" tended to get in the way of life-saving procedures. Tisdale also got tired of the "whining," and the "ceaseless parade" of really sick and/or crazy people, which is not typical of "[m]ost emergency rooms." Tisdale also suggests that recently "a lot of the nurses seem to have quit, and the ones that remain are suspiciously thin and blond." And even though the hospital is ugly, apparently the physicians are not ugly enough, as none is "obese or pockmarked."

She liked the 1980's show "St. Elsewhere," which, though it "inevitably" focused on physicians, at least depicted them as ordinary, not brilliant, and dependent on the nurses to "save their asses half the time." Indeed, she says, some of the nurses were "really bitchy" (apparently a plus), and "a few were downright brilliant."

Unfortunately, Tisdale then says, "it all turned out to be a dream." This is apparently a reference to the fact that the end of "St. Elsewhere" suggested that the entire series had merely been a dream of the autistic child of one of the main characters. We assume Tisdale is just joking, and that she doesn't really believe that ending had any significant effect on the influence of the show's depiction of hospital care. The show was always fiction requiring a suspension of disbelief, and it's unlikely to have made much difference whether it was coming directly from the writers, or channeled through a fictional child's mind.

In any case, it's a pretty good discussion of Tisdale's actual work. She describes the care of a patient with severe abdominal pain, and a number of others, focusing on the huge cast of characters, nurses and others, who work together to make a real hospital work. The team includes many nurses, and also X-ray technicians, secretaries, transporters, physical therapy assistants, pharmacists, and housekeepers. The nurses work together, monitoring patients, turning them, checking morphine drips, doing psychosocial care of the family of the dying patient, prepping a patient for surgery. At one point Tisdale does call a hospitalist ("kind of a Pretty Doctor but not quite a superhero") about the patient with abdominal pain. The hospitalist tells her to consult the surgeon, who shows up an hour later to "breezily" tell the patient he wants to "open him up and see what's going on." Tisdale and two other nurses prepare the patient for surgery, and "the Pretty Doctor appear[s] to say good luck. No brilliant diagnoses. Not even a good guess." At the end of the shift, the dying patient does die, with her family, after a visit from a chaplain, and frequent checks from Tisdale. "No doctor appeared. No doctor even called."

Meanwhile, a pharmacist tells Tisdale a joke:

There was this fisherman and he was up in Alaska, trolling for halibut, and here comes a wave and over he goes. Next thing he knows, he's in heaven. Man, everything is great! There's a big cafeteria and the buffet line has all of his favorite foods. So he's moving along with his tray when this guy in a white coat shoves him aside and cuts in. "Hey!" the guy says. "Who do you think you are?" But St. Peter comes over and says, "Ssh, that's God. Sometimes he likes to pretend he's a doctor."

Nearing the end of her piece, Tisdale appears to sum up. She argues that the "real message of medical shows is that brilliance goes hand in hand with emotional retardation." She says that has little to do with how "medicine" is usually practiced, that most physicians she knows are "collaborative and respectful," though they "fall short of model status." Then she seems to deliver the bottom line:

My biggest objection to medical shows is not that the doctors on television do their jobs brilliantly, but that they do everyone else's jobs, too. And my objection to doctors in the real world is a little like that. I sometimes wonder just how much doctors know about what goes on over the course of a day in their patients' difficult lives -- how many people are involved, how much we need each other.

Winding up, Tisdale dismisses ABC's "Grey's Anatomy" as nothing new--the same old "gorgeousness," the "sexy nurse," people bursting in on critical procedures with romantic tantrums, and pop songs playing over stunted characters looking out windows. She likes NBC's "Scrubs," though, because it's "full of chaos, anger and fear, and no particular brilliance at all. Just struggle and good intentions and richly imagined fantasies of lust and revenge. Like my world." She still watches "House," but in frustration because it ignores what she does in the hospital: "an extraordinary task with the help of a lot of extraordinary people who never get to be the central characters in television shows." They may have "some great stories, but they aren't going to make it into a 50-minute show."

Tisdale makes some excellent points in this influential medium. (In fact, we would not be surprised to see some version of this story appear in the mainstream press, as often occurs with stories from major alternative press sources.) She's right that "House" shows physicians doing the work of many other professionals, and that the physician characters are impossibly brilliant, gorgeous and caring. Her message that a great deal goes into hospital care that such shows never depict at all is also a valuable one. A greater awareness of the work of professionals like pharmacists, chaplains, and housekeepers may help the public understand the value of that work, what to expect in their own care, and why health care requires significant resources beyond what advanced practitioners bill for. Using specific examples, Tisdale shows how much the other professionals on the team do for patients, and gives some sense of how difficult it is. Her casual note that in one case the "doctor" was actually a nurse practitioner is nicely done.

Moreover, some of Tisdale's points about specific shows are well taken and well made. Her gorgeous superdoc analysis of "House" is essentially correct. The show does present non-physicians as silent extras whose work is peripheral and of no interest. And her long list of all the jobs that "House" physicians do is awesome. "ER" does have non-physician characters, and "Scrubs" does deserve credit for showing the hospital as a chaotic mix of good intentions and comical flaws. In fact, those two shows are the best for nursing and other non-physician health professions among current U.S. prime time programming.

We did have a few issues with the piece, and we explain them in some detail because of the likely influence of the piece. A basic problem is a lack of context on the real subject, namely how Hollywood's portrayal of health care differs from reality, in particular in its suggestion that physicians do everything that matters. The piece gives little sense of why things are this way, whether it matters, and what might be done about it.

For instance, how many readers will see the relationship between Hollywood and the physician conduct with which Tisdale has a real problem, judging from her stated desire to deliver House-like insults "mostly" to physicians, and her evident delight in relating the pharmacist's joke? She links Hollywood's tendency to pretend physicians do everything for patients to the asserted tendency of real physicians to be egocentric and not that focused on patients. But how do those seemingly contrary trends relate? Are they driving each other? Is physician nursing in health-related programming merely a source of isolated "frustration?"

Or could it be that the mass media plays some role in how people think and act, that it may actually have something to do with a system in which physicians have historically enjoyed unparalleled social and economic power, and in which nurses and others struggle for adequate clinical and educational resources? In fact, public health research shows that entertainment programming has a significant effect on health care views and actions, and health groups deploy significant resources to influence such programming. But without explanation, many readers will likely fall back on the standard response "it's just a TV show," which remains appealing, though it ignores the basic reality of how humans learn, form opinions, and make decisions. In addition, will readers understand that the nursing shortage--a global public health crisis--is driven in part by disruptive physician conduct, in addition to the overall undervaluation of the profession that this kind of media both reflects and reinforces? Where are the roots of these problems--in gender issues, in economic or technological forces, in a social need for traditional heroes in a bewildering modern world?

We don't expect an advocacy piece or a scholarly article, and the impressionistic approach here is not fatal in and of itself. But we might hope for a little more perspective from the lead story on the Salon site, one written by someone who is both a veteran nurse and a prominent writer. And the easy hits on physicians may come off as just that. Without some analysis of why things are this way and what it means--beyond the familiar association of physicians with God--it's easier to dismiss this as mostly a case of jealous resentment.

The piece is also marred by errors and dubious assertions about the shows, which matter because they undermine its overall credibility. It's easier for Hollywood and its tens of millions of fans worldwide to downplay criticism when it comes with errors and distortions. For instance, the main message of hospital shows is not that "brilliance goes hand in hand with emotional retardation." Most of the brilliant physicians on these shows are not shown to be emotionally stunted; they are shown to be gorgeous, charismatic, basically decent people who would be a catch for anyone. Sure, they have their Achilles heels, and sometimes they break under the pressure of saving lives, and they sleep with everyone in sight, but in Hollywood, that's a good thing. Maybe they even have trouble maintaining relationships, in a glamorous, "Casablanca"-type way. But does anyone really think of "ER"'s Luka Kovac or Abby Lockhart, or "Grey's Anatomy"'s Derek Shepard or Addison Montgomery, as "emotionally retarded"? Moreover, for characters like House, the message often seems to be that brilliance largely excuses emotional retardation. And on a point that would be too minor to note if Tisdale did not make it her concluding paragraph, network dramas do not currently last 50 minutes (we assume she means their actual length excluding all clutter). It's more like 42-43 minutes.

But that doesn't mean that Tisdale's piece is correct to suggest that there is no room on Hollywood shows for the "great stories" of the other health professions. Many of those stories do make it into the shows, especially the nursing stories, as we have shown. It's just that the shows depict the stories as revolving around the physicians, rather than the nurses, social workers, chaplains, and others who would really play key roles. In fact, the suggestion that the stories of non-physicians are not interesting or dramatic enough is actually a common Hollywood defense to criticism about its physician-centric portrayals, so reinforcing that idea is unhelpful, to say the least. And to assert, with finality, that the non-physicians "aren't" going to make it into network dramas is too fatalistic. From our standpoint, the future is unwritten.

The piece's analysis of other shows is also flawed. Much of the criticism of "ER" is unfair or inaccurate. The "ER" patient population may not be typical of "most emergency rooms," but from our experience, it's fairly representative of a Level One trauma center in a major city, which is, you know, what the show is actually about. Tisdale also has the sense that a lot of the "ER" nurse characters have quit, and those who remain are "suspiciously thin and blond." Some of the original minor nurse characters are no longer there, and there have been times when those characters have seen little screen time. But many of the original ones do remain (Haleh, Chunie, Malik, Lily), and there have also been some new minor nurse characters, such as the current Dawn. As for being thin and blond, the lone major nurse character on "ER," always thin, white and female, is now blond. No other nurse character named above is thin and blond. None is Caucasian. And the criticism that the physicians are not "obese or pockmarked" is absurd. Neither "Scrubs" nor any other current show features such physicians, and frankly, it's hard to see why Hollywood's obvious general focus on attractive people is worth comment, outside a piece on appearance discrimination. What Tisdale fails to note is that "ER" is the only drama on television to make any serious effort to show nurses as skilled and important to health care outcomes, though its portrayal remains fair to fairly poor overall. But inexplicably, Tisdale doesn't seem to hold physician-centrism against "ER, "St. Elsewhere," or "Scrubs." She should.

Tisdale's comments on "Grey's Anatomy," the most popular current hospital drama, reflect little understanding of it. It is indeed a "soap opera about surgeons." But no thoughtful person could confuse its frivolous mangling of serious health issues with what happens on "ER," nor mistake "Grey's"' aggressive contempt for nursing with what shows like "ER," "Scrubs," or "St. Elsewhere" have tried to do, however flawed those shows may still be. And "Grey's" has no "sexy nurse" in the way Tisdale means. ("Skanky syph nurse," yes; "sexy nurse," no.) Instead, it is the many surgeon characters who are presented as sexy, and smart, and life-saving, and endlessly charismatic.

Despite these problems, Tisdale's piece will probably be the first, and perhaps the only, time some of Salon's readers will ever hear that the "House" team is shown doing the important work of nurses and other hospital professionals. It makes this key point in a powerful and persuasive way. For that, we thank Tisdale and Salon.

See the article "The Beautiful Hospital" by Sallie Tisdale posted on April 4, 2007 on Salon.com. Please send your comments to Ms. Tisdale by posting a public letter at the bottom of the article, where there is a blue button to "Post a Letter About This Article," or by sending a private snail mail to:

Sallie Tisdale
Salon Media Group
101 Spear Street, Suite 203
San Francisco, CA 94105-1517

Please also send us a copy of your letter at letters@truthaboutnursing.org.

Thank you.