Doc Hollywood

Physicians have always had a symbiotic relationship with Hollywood. From Lew Ayres in the 1930s Dr. Kildare films to Andre Braugher in Gideon's Crossing and Melina Kanakaredes in Providence, movie studios and TV networks have enlisted the support of individual doctors and their organizations to provide story ideas, expert advice, and, more recently, high-tech medical equipment and snappy jargon.

As Joseph Turow documented in his book Playing Doctor: Television, Storytelling and Medical Power, medicine has exacted a high price for its cooperation and seal of approval. Directors, producers, and screenwriters once were expected to portray doctors and their treatments in the best possible light, reinforce their conservative values, and support the kind of public policy and scientific agendas doctors favor. (For example, Hollywood mirrored organized medicine's opposition to so-called socialized medicine and downplayed the limitations or failures of expensive high-tech and experimental procedures.) Many TV shows even had a doc on the set to enforce the American Medical Association's definition of authenticity.

Hollywood--along with journalism--has been an active partner in the creation of a heroic medical narrative that has shaped Americans' view of health care, inspired "consumer demand" for the latest treatments, and conferred status on medical practitioners and specialists. This narrative places physicians at the center of the health care stage. Medical knowledge and science--what Howard Gardner, author of the theory of multiple intelligences, would call abstract rational intelligence--is, in Hollywood, the only knowledge that counts. It is what convinces us that doctors should be the captains of the health care ship, in charge not only of their own practice but of nurses, social workers, physical therapists, and other health care professionals--all of whom are seen to function in servitude or in thrall to the physician's knowledge and judgment. Although real patients know that doctors do relatively little caregiving in hospitals, in the heroic medical narrative physicians do all of the curing and most of the caring. Nonphysician caregivers are all but invisible in films and TV shows; health care is presented as a series of discrete events focusing on acute illnesses or trauma.

Of course, all of this has evolved since the days of Dr. Kildare or Marcus Welby, M.D., to reflect the anxiety and irony of contemporary culture. Today's TV and movie docs have rougher edges and messier personal lives: They are less omnipotent and are wracked by ethical doubts. They may be women, African Americans, or ethnics of some type. But despite the recasting, the basic story remains remarkably true to formula and has a disastrous impact on our social image of caregiving.

Consider Nurse Betty, one of last year's popular movies. It tells the story of a sweet, credulous woman who yearned to become a nurse but wound up being a waitress married to an abusive used-car salesman. While Betty is watching her favorite daytime hospital soap, she also sees (through a cracked door) her husband being brutally murdered. In response to the trauma, she suffers a delusion that she actually is a nurse in love with the soap opera's handsome doctor star. She goes off to Hollywood to pursue her lover and lands a job as a nursing assistant in a real hospital. How does she get the job without references or credentials? She performs a life-saving medical procedure that she learned from watching TV.

In Nurse Betty, nurses are professionally interchangeable with waitresses. They're kind but stupid. They live to marry a doctor. Nursing is such a snap that anyone who's watched enough episodes of General Hospital can effectively substitute for a registered nurse. (Perhaps Senators John Kerry and James Jeffords should scrap the Nurse Reinvestment Act they've introduced to subsidize nursing education and just encourage more kind-hearted women to watch daytime TV.)

TV's doctor shows are just as bad. On Chicago Hope, egomaniacal doctors routinely shout at nurses. On Gideon's Crossing and Providence, the doctors themselves do most of the nursing. Even ER--which, on occasion, has been a showcase for contemporary nursing--doctors get the most cutting-edge and compelling scenes. Because nurses are so often cast as adjuncts, the viewer does not understand that nursing is a distinct discipline based on its own science and research. Nor does the viewer see that nursing practice is dynamic and that caregiving involves complex skills that are learned rather than instinctual.

For a moment this spring, it seemed that Hollywood was about to break the doctor-drama mold. HBO--which in 1999 produced Tuesdays with Morrie, a respectful portrait of family and friends caring for a dying man at home--signed up Mike Nichols and Emma Thompson to bring the play Wit to the small screen. The Pulitzer prize–winning off-Broadway hit is a trenchant critique of the heroic medical narrative. It is also one of the few recent dramas to depict a nurse positively.

The play's main character, Vivian Bearing, is an isolated, abrasive professor who has devoted her career to studying the Holy Sonnets of John Donne. She is diagnosed with terminal ovarian cancer. Bearing's oncologists--cutting-edge researchers--appeal to her intellectual values and competitive spirit by recruiting her into an experimental, ultimate-dose chemotherapy protocol. Then they watch, as if mesmerized, as she is devastated. Throughout Bearing's encounters with the senior doctor and his arrogant, young oncology research fellow, the play shows the physicians as oblivious to the patient's physical suffering as well as to her underlying anxieties and vulnerability.

Playwright Margaret Edson contrasts the detached rationality prized by Bearing and her doctors with the nurse's emotional intelligence, which she has described as "compassion delivered through skilled action." As Edson explained her intention: "Wit is a play about different kinds of love and different kinds of skill and knowledge."

While the play's nurse, Susie Monahan, certainly has her share of clinical knowledge, she also acts with social and emotional intelligence to help the patient. She tells the doctors that Bearing can't withstand the high-dose chemotherapy. They ignore her. She advocates for pain medication that Bearing can control--a recommendation that is vetoed by the senior physician. She tells the patient that the curative treatment isn't working. She is the only one who raises the prospect of death by informing Bearing that she can request Do Not Resuscitate status (in hospital parlance, No Code instead of Full Code). And she is the only one who respects the patient's last wishes.

In Wit's courageous ending, the nurse hurls the research fellow off the bed when he begins "alternately pounding frantically" on Bearing's chest and giving her mouth-to-mouth resuscitation in violation of the No Code order. The nurse forces the Code Team he's called to stop shocking the patient's heart. Then she physically blocks the team from even touching Bearing. As the team exits, she untethers Bearing from the medical devices and lifts the blanket off her body. Bearing steps out of bed, takes off the baseball cap she's been wearing to hide her baldness, loosens the ties that fasten her gown, and, liberated from futile heroic medicine, stands "naked, and beautiful," reaching up toward a warm glowing light. Then the house darkens.

Because it was so uncompromising, the play generated debate about the treatment and care of patients and became a teaching tool in medical and nursing schools. Bringing Wit to TV is thus a cultural and educational event. When director Mike Nichols and starring actress Emma Thompson adapted the play for television, they had a golden opportunity to help advance our understanding and respect for caregiving. Unfortunately, they have managed to soften the play's critical edge, dull its humor, and rob the central character of her moment of transformation. As rendered on TV, Wit is simply a touching portrait of a dying woman.

One almost wonders if Nichols and Thompson had been lobbied by physicians who didn't like the play's rendering of their profession. In the video, the doctors are good-hearted but socially inept and more respectful of their patient than in the original script. Nichols and Thompson show Dr. Jason Posner--the eager research fellow who in the play doesn't have a doubt about his preoccupation with the cellular aspects of cancer--staring sorrowfully at the comatose Bearing as though regretting the ordeal he has put her through.

In fact, Nichols and Thompson have skewed the dynamic of the play. The research fellow seems to reconsider his moral outlook, and Bearing is denied her epiphany. In Wit (originally W;T), the sterile scholasticism of Bearing's life is captured in a debate about the use of commas versus semi-colons in Donne's Holy Sonnet Six, "Death Be Not Proud." When Bearing was a student, her mentor, E.M. Ashford, insisted that she had compromised the meaning of the sonnet with inauthentic and "hysterical" punctuation. The poem, Ashford insists, is about "overcoming the seemingly insuperable barriers separating life, death, and eternal life." According to Ashford, the last two lines of the sonnet should read: "And death shall be no more, comma, Death thou shalt die," so that "only a comma separates life from life everlasting. It is very simple reallyädeath is no longer something to act out on a stage, with exclamation points. It's a comma, a pause."

But, Bearing, Ashford scolds, has relied on subsequent editions that sacrifice this meaning by punching up the punctuation. As Bearing faces her own imminent death, she reverts to her youth and recites the poem's last lines with the emphatic punctuation: "And Death--capital D--shall be no more--semi-colon! Death--capital D--thou shalt die--ex-cla-mation point!" She then resigns herself as she sees that the line doesn't work.

Deprived on TV of this transformative struggle, Bearing slips into a coma, and her heart stops. Instead of ending the play with the nurse's liberation of Bearing and her naked embrace of the light, Nichols and Thompson substitute a voice-over of Bearing reading from "Death Be Not Proud." In a death-scene cliché, Thompson's shorn head morphs into a picture of the character, pre-cancer, pre–hair loss, smiling at the camera and reading the last two lines of "Death Be Not Proud," with a comma and a period--and easy acceptance.

If Wit is the best that television can do, we're in trouble. Instead of lending class and authenticity to dumbed-down television and thus challenging the heroic medical narrative, it distorts a compelling story about caregiving. We could laugh off Nurse Betty. But with the stellar credentials of Wit's star and director, the HBO telecast will be taken as an authentic rendering of the play.

In an era when we have shortages in all the major caregiving professions, this failure is significant because it cloaks the very things we need to learn from serious contemporary art. If Hollywood--and journalism--would risk taking a broader view of the drama that really goes on in health care, "reality" entertainment would be more realistic. Plus, nursing and other caregiving professions might seem more attractive--and real-life caregivers might get more public support in their struggles for recognition, respect, and reward.

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