Malcolm will keep you company

June 9, 2009 -- Tonight's episode of Fox's summer drama Mental illustrates the peripheral subordinate role played by the show's one recurring nurse character. It also reminds us that, despite the two nurse-focused summer shows that have received recent attention, physician-centric shows like Mental and USA Network's hit Royal Pains continue to attract many more total viewers--especially if you count the summer re-runs of Fox's House and ABC's Grey's Anatomy, Private Practice, and Scrubs. Mental is essentially a variation of House. In both shows, a brilliant hospital physician uses unorthodox, at times outrageous methods to diagnose and treat challenging conditions, amazing his less gifted fellow physicians and earning the tolerance of a long-suffering female boss. The twists in Mental are that the patients all have psychiatric problems, so instead of inside views of patients' bodies, we explore the troubled patients' minds. Also, Mental's lead character Jack Gallagher is charming and social, rather than a witty but obnoxious loner. Jack and four other physician characters provide all important patient care, including psychosocial care. Nurse Malcolm Washington does care about the patients. In one scene here, he reports a basic symptom, one that anyone would notice. In another scene, he briefly advocates for the patient, making a point that is understandable but uninformed. In general, he seems to be on hand to perform basic physical tasks and keep patients company, as Jack puts it at one point. And Malcolm's manner is more that of a faithful assistant than a college-educated professional. The episode, "Book of Judges," was written by co-creator Dan Levine and drew 4.7 million viewers.

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Showtime's Nurse Jackie and TNT's HawthoRNe have rightly received media attention, but those nurse-focused shows seem to be capturing only a small number of the total summer hospital show viewers. Jackie and HawthoRNe both appear to be doing well by the standards of their respective formats. But even limiting the analysis to summer shows, the two new physician dramas--the hit Royal Pains and Mental, which seems to be struggling--together appear to be drawing roughly twice as many total viewers as the two nurse shows together are. And that's not even counting the primetime re-runs of all the physician-dominated regular season shows noted above.

The main patient in this episode of Mental is Gideon Graham, a famous author played by David Carradine in one of his last roles. Gideon and his wife are struck by lightning on a hiking trip in the Sierras. His wife is killed, and Gideon appears to have refractory catatonia. Jack, the medical director of a Los Angeles psychiatric unit, must engage in his usual maverick methods to reach Gideon. Jack negotiates for his treatment ideas with his administrator boss, his physician colleagues, and Gideon's daughter, who is, of course, an Oxford-educated New York supermodel. Jack's methods include transcranial magnetic stimulation (TMS) and a range of personal interactions, from friendly to berating.

Consider nurse Malcolm's role in all this. In an early scene where the team of physicians performs the TMS, Malcolm is there to help get Gideon settled in bed. When Gideon starts to seize, Malcolm rushes in to help restrain him. Malcolm says nothing in the scene.

Later, we see Malcolm in a wet suit holding the unresponsive Gideon in the middle of a pool, slowly rotating. Jack enters.

Malcolm:   Hey, boss.

Malcolm invites the fully-clothed Jack to jump in. Jack smiles and sits at the side of the pool.

Jack:   "Do we seek the womb in aquatic environments, or is it simply the nearest we humans come to flying?"

Malcolm (seeming baffled):   That's nice.

Jack:   Gideon wrote it.

Malcolm:   Really? You wrote that, Mr. G?

Jack gets into the water and tells Malcolm to take a break, meaning he will hold Gideon. Malcolm's expression makes clear that a physician doing such manual labor (in his street clothes no less) is unheard of.

Malcolm:   You're a real trip, doc.

Jack takes Gideon and starts talking to him about the scars he got from the lightning strike, and the remote chance of being struck. Gideon becomes rigid, clenching his fist. Later, Jack and Malcolm speak at poolside, with Gideon in a chair nearby.

Malcolm:   That was weird.

Jack:   Never happens with you?

Malcolm:   Him tensing up like that? No. Gideon loves the water. You want to see something even weirder?

Malcolm shows Jack that Gideon kicks his shoes off when Malcolm tries to put them on, explaining that it happens every time. Jacks finds that interesting, but does not discuss it with Malcolm (it turns out later to relate, apparently, to the fact that the lightning strike shocked Gideon right out of his shoes). Malcolm wheels "Mr. G" away in his wheelchair.

"Mr. G?" Jack always addresses the patient as "Gideon." Malcolm's references to him as "Mr. G" point to a friendly but subordinate relation--Malcolm is just a nurse, after all. And Malcolm's reference to Jack as "boss" simply makes explicit what the rest of the show implies. In fact, Malcolm would not report to Jack, but to a nurse manager. Even calling Jack "doc" suggests that Malcolm is peripheral. It's possible a nurse would address a physician that way, but it's the kind of term someone who's not in a health care field would be more likely to use, and it underlines the sense that Malcolm does not play a meaningful role in the patient's care, certainly not as a peer. It's hard to imagine Malcolm calling the lead physician "Jack," as a real nurse likely would.

Later, as Gideon's daughter is wheeling him around outside the hospital, Jack and Malcolm approach. Jack tells Gideon he would like to "borrow" his daughter for a moment, assuring him: "Malcolm will keep you company." Malcolm takes over wheelchair duty without a word, and the show focuses on Jack's conversation with the daughter. In no scene does Malcolm interact with Gideon alone, even though that would be the vast majority of such a sick patient's interactions with hospital care givers.

Later, Jack figures out that Gideon is more or less faking the catatonia, hiding in a world of his own creation in an effort to keep out the pain of his wife's death. Jack reaches that conclusion partly through analysis of Gideon's latest book, "Book of Judges," and an extramarital affair Gideon recently ended. So Jack decides to try to shock Gideon out of this world by removing all signs of Gideon's former life in Gideon's room, including his photos. (The show seems to be suggesting that Gideon resides partly in his actual physical location and partly in his mind, but that he has at least some conscious control over his status; we have seen that the internal part features scary scenes with Gideon's wife on a stormy mountaintop.) Jack leads Malcolm and one of the junior physicians to Gideon's room and gives them empty boxes, explaining that they have been making it too easy for Gideon, filling his new world with comforting reminders of the past.

Malcolm:   He lost nearly everything. Seems to me he deserves some of his stuff around to make him happy.

Jack:   Guys, we've been enablers. You want to see Gideon have a chance at recovery, help me cut him off. Help me give him a reason not to stay where he is.

They comply. Malcolm's reaction is understandable, and it's good that he is advocating for Gideon. But we know that Jack is right, and the way Malcolm presents his concern is very much the way a lay person would. Rather than whether Gideon deserves his stuff, you might think a skilled nurse's focus would be on whether the objects could play a role in the patient's recovery, or whether comfort is the best they can hope for given the patient's apparent lack of response to treatment. If Malcolm is thinking about any of that, he does not articulate it.

In the climactic scene, Jack prepares to try the TMS again in a last effort to bring Gideon back. Jack harangues Gideon about being a coward, "judging" and exiling himself to his own private world, but leaving his daughter alone to fend for herself in the real world. No nurse appears in this scene, though what they are doing is dangerous enough that one of the other physicians must run to another room to fetch a drug they think they may need when Gideon seems to be in distress. Of course, nurses generally give drugs like that. In any case, it appears that Jack's words and the mere threat of further TMS are enough to bring Gideon at least partly out of his condition, since the injured man reaches out to try to strangle Jack.

Near the end of the episode, Gideon's daughter decides to take her recovering father back to New York with her for more treatment. At a distance, we see that Gideon is still in a wheelchair, with his daughter at his side, as they prepare to exit the hospital. Malcolm is the wheelchair escort, but he has no lines. Instead, Gideon's daughter approaches Jack and another physician, and thanks them for their work.

The most charitable interpretation of the episode's presentation of nursing is that nurses are faithful assistants who do the physical labor of health care and spend time with patients. They may even tell physicians if they notice something obvious, or question a care plan that would seem pointless or unfair to a lay person. But the physicians do everything that matters, all the thinking and the meaningful treatment, including psychosocial care. A nurse certainly could provide key psychosocial care while pushing a wheelchair, but we don't see that here. Of course, Malcolm clearly does care about the patients, and the show gets diversity points because the character is a black male, underrepresented in real nursing. But even the ways in which Malcolm interacts with other characters, the form and content of what he says, underline his status as low-skilled support staff.

It's pretty hard to reconcile this vision of nursing with an autonomous, life-saving profession that requires years of college-level education. But it's easy to reconcile with the fact that nursing is in the midst of a crisis driven by widespread undervaluation. A key factor is the influential mass media, including entertainment television, which public health research shows has a real effect on people's views and actions.

Gideon began his journey back from his dream world toward reality, in part to reconnect with his daughter and care giver. We hope network television shows like Mental will make a similar move away from illusions and toward the reality of nursing.

 
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