Doctors’ Brains

Doctors’ Brains

It’s 9:45 Tuesday night, and the house lights have just come on after the final scene of Wit–the surprise Off Broadway hit about a terminally ill English professor and her experience as a

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It’s 9:45 Tuesday night, and the house lights have just come on after the final scene of Wit–the surprise Off Broadway hit about a terminally ill English professor and her experience as a patient in a cancer treatment program (it won the Pulitzer Prize for drama this spring but missed out on the Tonys because of its venue). The audience is heading for the doors. But Tuesday nights are different from all other nights at Manhattan’s Union Square Theatre.

Wit raises such important questions about care of the dying–and all hospital patients–that once a week the cast remains after the show for a postperformance discussion of the play led by a guest moderator. A sonorous male voice thus interrupts the exodus to invite playgoers to stay and participate in the “talk-back.”

Tonight’s moderator is Dr. Peter Halperin, a psychiatrist who directs the division of behavioral medicine at the School of Medicine, State University of New York at Stony Brook. Halperin explains that he has brought several medical students and colleagues–one of them an oncologist–along with him. He begins by reflecting on the painfully realistic scene in which Professor Vivian Bearing is informed by her oncologist–in almost unintelligible medicalese–that she has advanced ovarian cancer.

Not only does the doctor fail to deal with his patient’s state of shock and feelings of terror, their conversation leads to Bearing’s participation in a course of treatment almost as devastating to her body, soul and self-esteem as the disease itself. Soon, she finds herself in the hands of her physician’s young research associate, an oncology fellow far more interested in cancer cells than in the human beings who have them. How, Halperin wonders, can doctors relate more humanely to their patients?

The cast, now dressed in street clothes, joins Halperin on stage. Kathleen Chalfant, who plays Bearing, sits to his left. The actor who portrays the senior oncologist takes his seat as well. Finally, Paula Pizzi enters. An olive-skinned young woman with long, straight black hair, she plays Bearing’s nurse, Susie Monahan. In this role, Pizzi initially conforms to a familiar nurse stereotype–appearing deferential to the male authority figures on the medical staff. Yet, to protect her patient, Pizzi’s nurse soon takes on the doctors. The latter consistently view her as their handmaiden and resist all her insights and suggestions.

Playwright Margaret Edson insists that the nurse is the hero of the drama. She is the only true caregiver in the hospital–the one character who actually connects with the patient, Bearing. Like all expert nurses, her caregiving is informed by a sophisticated understanding of disease, of the use of modern treatments and of how to monitor patients with a variety of high-tech equipment. She is not just a “naturally” loving or kind person.

Because of this, Monahan recognizes that the side effects of treatment may be too toxic for her patient, and she intervenes when she realizes that the patient’s doctors haven’t addressed vital issues like pain control and when to end futile aggressive treatment. Indeed, it is Monahan who forces the physicians to respect their patient’s last wishes. The nurse is, in fact, the only one who “gets it” both emotionally and medically. As a result, Pizzi has just received–as she does every night at curtain call–the second-largest round of applause, after that bestowed on Chalfant for her unforgettable lead role.

As the discussion resumes, Halperin’s colleague, the oncologist, offers his thoughts, and then several cancer patients in the audience recount some of their experiences with the impersonal world of high-tech medicine. For the next ten minutes, the subject of doctors and how they practice medicine continues to hold center stage.

Finally, a physician in the audience challenges those onstage and in the audience to look at Edson’s work in a different way. “It seems to me this play is about the failure of abstract, critical intelligence,” he says. “The only character who ‘gets it’ is the one who’s supposedly not that sharp, and that’s the nurse. Why are we focusing exclusively on the doctor-patient relationship when we should be looking at the nurse-patient relationship and what doctors can learn from nurses?” As he speaks, the audience erupts in spontaneous applause. More hands flash up. Behind him an elderly woman, who turns out to be the well-known children’s writer Madeleine L’Engle, adds her emphatic agreement. “The only healer in this drama is the nurse.”

Thanks to this exchange, the doctors finally begin to talk about what they can learn from caregiving and nursing. This belated consideration of caregiving illuminates much more than one audience’s response to a successful Off Broadway play. The fact that so few people publicly recognize the centrality of nursing to the play’s message–that intelligence exists not only in medicine but in the kind of caregiving traditionally devalued in our society–highlights the persistence of our ambivalent attitudes toward female caregiving in general and nursing in particular.

Edson’s play is almost unique in its reversal of the depiction of nursing we get on stage and screen, in literature and in the daily news. From Marcus Welby, M.D. to ER, TV’s medical shows portray a hospital world in which doctors do not only all of the curing but much of the caring. On Chicago Hope, which is frankly hopeless when it comes to nursing, nurses are far more consumed with charting the doctors’ love life than taking care of patients. In the show’s early episodes, the main nurse character would function one week as a critical-care nurse, the next as an operating-room nurse and the following as a pediatric nurse. Miraculously, she’d managed to be certified all of a sudden in all these nursing specialties. In the new doctor show, Providence, a physician gets more help from the ghost of her dead mother than from real live nurses.

Thanks to extensive lobbying by emergency-room nurses, ER is the one exception to the no-nurses-with-brains-please TV rule. Occasionally ER‘s nurses stand up for themselves and actually seem to know something about their work. But ER‘s doctors, on the other hand, do an amazing amount of nursing. In one of last year’s most remarkable shows, Dr. Mark Greene even pitched in as a hospice nurse–when a patient’s nurse was unable either to manage the patient’s pain or cope with her emotions.

The show’s most backhanded comment on nursing was the way producers dealt with the chief nursing character Carol Hathaway’s longstanding crisis of self-esteem. Since the show began, Hathaway has been grappling with who she wants to be when she grows up. In the 1996-97 season, she seemed to decide–she wanted to be a doctor. So she spent almost the entire season struggling to pass the exams for entrance into medical school. For months, the drumbeat of “you can only be considered smart in healthcare if you make it into medical school” rolled on. Although Hathaway finally decided to remain in nursing, she did so only after demonstrating that she could, in fact, pass the medical school entrance exam (read: she was smart enough to be a guy). And one has to wonder how many viewers felt she simply settled for second best.

Similar views of nursing are on display at the multiplex. In the otherwise excellent movie Living Out Loud, the heroine, a nurse played by Holly Hunter, is dumped by her doctor husband. After drinking herself into bed every night–and assuaging her loneliness by hiring a male prostitute–she decides to get her life together. How? By becoming a pediatrician.

Without an MD to elevate her social status, a nurse is not only dumb, she’s the butt–quite literally–of the worst kind of sexism. There is a straight line running from the porn queen in Deep Throat to the sexy killer nurse in the recent video The Nurse. The cover of this slightly more tame Deep Throat sports the ubiquitous symbol of the bimbo nurse–a headless female torso, dressed in a crisp white nurse’s uniform with opaque white hose held up with garters. In this version, a stiletto knife is cunningly slipped between stocking and flesh. The cover copy reads, “The Nurse, Registered to Kill. Pray She’s Not on Call.”

And then there are the news media, where nurses are largely absent from healthcare coverage. In 1991 several colleagues and I documented this fact in a study of sources quoted for healthcare stories in the New York Times, Washington Post and Los Angeles Times. Although reporters had added any number of female phone numbers to their Rolodexes of healthcare experts–physicians, hospital administrators, insurance company spokespeople–nurses were not among them. Indeed, nurses were among the least quoted in the healthcare universe. In 1998 another study looked at the news media and nursing and found that little had changed in the ensuing eight years. In other words, when reporters cover the latest developments in experimental cancer treatment, you can be almost certain of one thing: They will routinely question the doctors on the impact such treatments have on cancer cells, but never the nurses who can talk about their impact on patients’ lives.

Whatever the medium, the media consistently reflect the traditional Adam’s rib view of nursing, which has been assiduously promoted by organized medicine. In spite of the fact that traditional views of women as men’s handmaidens have largely been discredited, they are alive and well in healthcare. The American Medical Association and many physicians still refer to nurses as “physician-extenders,” “mid-level professionals,” “non-physician providers” or the “doctor’s eyes and ears.”

Given the persistence of such Victorian views of female caregiving, it is not surprising that so many of the critics who applauded Wit mention the play’s hero only in passing or are downright hostile to the character. In New York magazine, John Simon scornfully dismissed her as “a well-meaning airhead.” In The New Yorker, critic Nancy Franklin’s aversion to the nurse was almost palpable. She described Pizzi’s character as “an oncology nurse who embodies the milk–condensed milk–of human kindness.” (Franklin should hope that when she lies dying, none of her caregivers will present her with a can opener and the suggestion that she console herself when she rings the nurse’s buzzer.) Like the Tuesday night talk-back I attended, more extended discussions of the play tend to focus on physicians. Thus, a lively exchange in the New York Times Health Science section was sparked when a research physician wrote a commentary protesting the portrayal of the doctors in Wit.

Ironically, feminists have been slow to respond to the treatment of nurses in the media and in the healthcare system. Is it because they have been so brainwashed by the physicians’ handmaiden image of nursing that they, too, devalue a profession whose origins are firmly rooted in feminist struggle and whose contemporary battles are profoundly influenced by gender? The medical/media devaluation of nursing makes this one of the last great undiscovered feminist issues and one whose fate is increasingly relevant to us all.

As we move into the twenty-first century, the healthcare problems we face–aging, chronic illness, increased disability–are not problems medicine alone can remedy. This is nowhere more obvious than in the care of the dying. As Wit makes clear, good nursing care is the best hope for returning compassion to modern medicine. That’s why the general public needs to recognize and acknowledge the importance of nurses and support nursing organizations and unions in the fight for safe staffing ratios and other vital patient-protection measures. The fact is that good nurses are far more than doctors’ eyes and ears. They are doctors’ brains as well.

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