"The N Word"

November 11, 2007 -- Recent episodes of Larry David's HBO sitcom "Curb Your Enthusiasm" offered portrayals of nurses who, despite the improvised verité dialogue, embodied low-skilled handmaiden stereotypes. The October 28, 2007 episode touched (unintentionally) on a key issue: what can a nurse do when a physician with more power is bent on doing something that is plainly not in the patient's interest? In "The N Word," a black surgeon overhears Larry relating a story in which another white man had used that racist word. The furious surgeon, wrongly assuming Larry is the real bigot, takes revenge on the next white man in his path by shaving the head of his next patient. This happens to be Larry's friend Jeff, who, once bald, himself becomes the subject of discrimination. An OR nurse weakly tries to stop the surgeon, but soon ends up handing him the clippers. Another nurse later tries to cover up what the surgeon did, suggesting to his wife that it was accidental, before the surgeon orders her from their room so he can apologize. Of course the show is poking fun at how we handle some stereotypes, but that doesn't stop it from reinforcing others. Viewers will see these nurses as timid physician assistants, rather than patient advocates. In fact, some nurses would have stopped this surgeon. Of course, many nurses do not feel they have the power to resist when physicians are about to endanger patients, as some notorious cases show, but few viewers will get any sense that this is a real issue. Similarly, in the November 11, 2007 season finale ("The Bat Mitzvah"), a nurse at a gastroenterology office responds to Larry's reluctance to first tell her about a sensitive condition not by describing her skill and autonomy, but by claiming unpersuasively that the system saves important physician time--an undervaluation both of her role and of nursing in general. Once again, the scenario could happen, but presenting only this vision of nursing effectively reinforces harmful stereotypes. Could the show have avoided that without killing David's inventive plotting and sharp social comedy? Yes.

"The N word" episode (including 3 film clips)

"The Bat Mitzvah" season finale episode (including 5 film clips)

"The N Word" episode

In one scene, while in the hospital men's room, Larry overhears a white man on a cell phone, complaining to a friend that he hurt his hand because some "300-pound n***er" was not doing a good job of helping him move furniture. Larry is aghast at the man's use of this word. He returns to the hospital cafeteria, and begins telling the story of this bigoted "jerk" to the physician he is dating. But just as Larry reaches the critical quote containing the "n" word, the black surgeon is passing his table. Outraged at Larry's use of "the most vile word in the English language," and with no interest in Larry's stammering efforts to explain, the surgeon berates Larry, calls him a "bald son of a bitch," and stalks off.

See this clip on the "n" word scene on YouTube

Next we see Jeff lying unconscious on an operating table, receiving anesthesia.   We know he is in the hospital for a procedure to eliminate his snoring. The camera pulls back and we see the white male anesthesia professional behind Jeff, a white female nurse standing beside Jeff, with her hand on his wrist (presumably the scrub nurse), and another female behind her doing something with instruments (perhaps the circulating nurse).

Scrub Nurse:   Wonder what's keeping Dr. Page.

The black surgeon, presumably Dr. Page, charges in.

Page (angrily): Why hasn't this patient been prepped?

Scrub Nurse: He is prepped, sir.

Page moves forward to examine Jeff's hair, forcing the nurse to step back.

Page:   Excuse me, nurse.   ...   Clippers!

Scrub Nurse:   Sir, clippers are not required--

Page:   Do I have to do everything myself? I know what I'm doing here! Clippers, please!

The scrub nurse hands Page the clippers, and he thanks her softly. No one else does anything. From Jeff's perspective, we see Page move in towards Jeff's hair.

See this clip on the nurse-surgeon interactions on YouTube

In the next scene, we hear Jeff in a post-op room, screaming. His wife Susie enters, and we see Jeff looking at himself in a mirror a nurse beside him has apparently provided.

Jeff:   Oh my God! Look at me!

Susie:   What the hell happened to you?! What happened, nurse?

Nurse (apprehensive): Dr. Page accidentally shaved Mr. Greene's head, and the--

Susie:   Wait a minute.   Accidentally?

Jeff:   They operated on my head?

Nurse (awkwardly): No, the procedure was canceled. The operation is going to be...rescheduled.

Susie:   So he didn't have the surgery. Oh, you look horrible. Jeff!

Page enters.

Page:   Nurse, would you please excuse us?

Susie:   Doctor, what the hell happened?! Look at him.

Page:   Mr. and Mrs. Greene, I am so sorry. I was coming to see you in the operating room, and I had just been victimized by a terrible incident in the cafeteria.

Page apologizes repeatedly, explaining how upset he was by the "despicable bald man" who used the "most vile word in the English language to refer to a black person." Susie, never a fan of Larry's, quickly establishes that it was he.

See this clip on the effects when nurses fail to advocate for their patients on YouTube

Because we're always looking for the bright side, we'll start with that. Neither of the nurse characters here is too timid to speak at all, and they are not inarticulate. The scrub nurse makes a small effort to stop Page from cutting off Jeff's hair. And the post-op nurse shows some interpersonal skill in trying to manage Jeff and Susie, albeit for the wrong reasons. Maybe the show deserves credit for showing nurses at all--many shows would have had physicians provide all the care. And maybe it even deserves a little credit for the Page character's off-and-on politeness to the nurses; rude at some points, he also uses words like "excuse me," "please," and "thank you." He also avoids explicit anti-nurse comments.

But let's face it:   Page is the master and the nurses are the servants. The post-op nurse must leave the instant Page arrives, as if she is a minion with no important business of her own with Jeff. Page addresses the nurses as "nurse" or with no name at all; they are not worthy of names. But to them, he is "Dr. Page" and "sir." Page's comment about doing everything himself is a throwaway, but it still subtly suggests that all the nurses do are simple tasks, like handing him things, that he could do himself if he was not too busy and important. In fact, surgeons are not trained to do what nurses do, and they could not do it without nurse training.

Could these health care colleagues really relate to each other in this degrading, regressive way? Some do, and this power imbalance is a huge problem, one that contributes to poor communication, nursing burnout, and poor patient outcomes. But don't imagine that this "subversive," "iconoclastic" show is questioning this, or is even aware of it. It simply presents this backwards situation as normal, effectively reinforcing it. How many viewers will even notice? How many will say:   "Wait--those nurses are like servants to that flawed but godlike physician. Isn't that a huge threat to public health?"

The irony is that the plotline could not have gone quite the way it did if the nurse characters had done their jobs. These nurses are not patient advocates; at most, it seems to be their job to protect the Boss from his own misconduct. In fact, it is the professional responsibility of OR nurses to protect patients from surgeons who may cause harm, whether because of incompetence, error, substance abuse, or emotional imbalance. Why not call security to have this lunatic removed from the patient's side? Many OR nurses have saved patients from such things, and others have been unable to do so. Of course this plotline is trivial--Jeff's hair will grow back--but in fact this dynamic is true to life, and lives are at stake. However, the show seems to think the answer is that people like Page should not be so touchy about taboo words, or not so quick with their uninformed assumptions (hmm...). Or maybe there is no answer.

But should Larry David (who writes the show's basic stories) have to alter his plotline? After all, if the nurse stopped Page, Jeff would not be bald and the remainder of the episode--in which Jeff feels the pain of anti-bald bigotry--could not happen. Some might also say David should get a pass because the episode is trying to examine damaging stereotypes, albeit in a somewhat reactionary way, suggesting they may be bad but people overreact or perhaps imagine them (the bald plotline). David does focus on skilled, intelligent black and female physicians. But the world is full of art that explodes some stereotypes while reinforcing others, often unconsciously. It's still bad for ya.

This issue reminds us of what Bobbin Bergstrom, a nurse who works on the set of Fox's "House," reportedly told a writer for Oncology Times in an April 2007 article on nurses in the media. Bergstrom argued, apparently without irony, that it was actually better that "House" largely omits nurses from its clinical environments, constantly telling millions of viewers that physicians provide all important care. Bergstrom asserted that if "House" included nurses, then either (1) the nurses would fail to stop House's patient-endangering stunts, thereby making nursing look bad, or (2) the nurses would stop House, thereby killing the plot and the show. But failing to stop House is what the show's physicians spend much of their time doing, with no evident loss of social respect, and when they do stop him, the show somehow soldiers on. The drama, of course, is in the conflict, and there is no reason nurses can't be part of that. (Incredibly, Bergstrom also argued that "House"'s rampant physician nursing is required by the prevailing social view that physicians are godlike and nursing is dull and unimportant, as if shows like "House" were not among the main drivers of that inaccurate view.) Absurd arguments like Bergstrom's are simply rationalizations for the chronic reinforcement of deeply embedded social bias--which is, after all, easier than challenging such assumptions.

A Proposed Statement About Patient Advocacy:
I Am Your Registered Nurse

This episode got us thinking about patient advocacy in clinical settings. We propose a basic statement that nurses might consider showing to their patients, perhaps when they first meet. Patients need to know that nurses are their advocates. And it may be a good idea for nurses to remind themselves. The statement might go something like this:

I am your Registered Nurse. During your stay here, it is my job to protect you from all harm. That means any harm from your illness or its symptoms, from external forces including the care environment, and from other people, if necessary even those involved with your health care or health financing. As an autonomous health professional who reports only to senior nurses, it is my job to protect you from poor or misguided health care from any source. I am your advocate. I vow to do my best to protect you as if you were a member of my family.

Print a copy of this statement, or your own revision, and paste it on the wall of your patients' rooms! Please click here for a pdf printable sheet.

"The Bat Mitzvah" season finale

In the November 11, 2007 "Curb Your Enthusiasm" season finale, Larry has a "tickle in his anus."

Intro and scene setup -- film clip on YouTube

Interactions with the clerk / nurse -- film clip on YouTube

Larry goes to visit a gastroenterologist recommended by Matt Tesler, a director. Tesler's wife's cousin, who turns out to be a nurse, works at this gastroenterologist's office. Tesler assures Larry that she "runs the office for him" and "can open all the doors." Larry goes for his visit. He is greeted by a woman at the desk in a blue patterned scrub top which looks like a garment many nurses wear. Viewers are unlikely to know whether this person is a nurse or not. There is a sign-in sheet on the raised part of the desk facing the waiting area.

If you watch the film clip, click here to skip over the dialogue to return to the analysis.

Clerk / ?Nurse: "Sign in please and have a seat. It shouldn't be too long."

Larry: "I have a little problem with these sign in sheets. My name's right out in the open here. It's a bit of a privacy issue."

Clerk / ?Nurse: "There's no shame in having to come to the gastroenterologist's office."

Larry: "It's a little embarassing maybe. We could just put up a sign on the wall that says Larry David was here. Why don't we do that."

Clerk / ?Nurse: "You know, I have to tell you that I've worked here for 4 years and never had anyone come in and, like, cruise the list of patient names for any reason."

Larry: (giving her the chart to maintain on the lower part of the desk near the clerk, where it is not easily visible): "What if you are in charge of this, so this is down here. You keep that."

Clerk / ?Nurse: "I don't like that. First of all, I only get paid $9 an hour, so it's a little more responsibility than I'm used to, to keep track of patients. Second of all I can't even make decisions. You'd have to take it up with the home office."

Larry sits in a chair to fill out patient information on a clipboard and flirts with a fellow patient. He goes for his exam and later returns to find the woman he was flirting with is now gone. He re-approaches the clerk / nurse at the desk:

Larry: "Hey, what happened to the sign-in sheet?"

Clerk / ?Nurse: "I called corporate headquarters at your suggestion and they loved it. So there's a new policy."

Larry: "What?"

Clerk / ?Nurse: "It's private just like you wanted."

Larry: "No, no, I don't want that. Don't listen to me. I don't know what I'm talking about. Put the sign-in sheet back up."

Clerk / ?Nurse: "I can't. Nooooo."

Larry David: "What?"

Clerk / ?Nurse: "You can't see this now."

Larry: "Alright, first of all. I gotta tell you something, ok? I want to apologize for the way I behaved earlier."

Clerk / ?Nurse: "Mr. David. You don''t have to play games with me."

Larry: "I don't?"

Clerk / ?Nurse: "Noo... Are you looking for ... Christopher?

Larry: "No..."

Clerk / ?Nurse: "Andrew?"

Larry: "Keep going..."

Clerk / ?Nurse: "Paula?

Larry: "Ahhh...

Clerk / ?Nurse: "You cannot tell. I could get fired."

Larry: "No, no."

Clerk / ?Nurse: "I have no formal education."

Larry: "No, no, no."

Clerk / ?Nurse: "OK. (She gives him a slip of paper.) Be careful. She looks like a live wire."

We see several problems in these exchanges. The clerk character says she earns $9/hour, that she can't make any decisions, and that she has no formal education. Of course this could all be true of an office receptionist, and we can't expect the show to have her mention in passing that she's not a nurse, which would never happen. But the clerk dresses in a way that is very similar to nurses--as actually occurs--and many viewers may assume she is a nurse. Those viewers will not receive an accurate or favorable impression of nursing. Instead, the character's statements will reinforce the common belief that nurses are poorly educated physician servants. The show is not responsible for the way real health workers dress, but we have to say that this is the kind of depiction that leads many ambitious students to think that nursing is too lowly for them

Health history with actual nurse -- film clip on YouTube

Fallout of nurse having divulged private information -- film clip on YouTube

If you watch the film clips, click here to skip over the dialogue to return to the analysis.

Once Larry gets to the examining room, a middle-aged nurse enters, wearing a printed scrub top much like the one worn by the clerk out front. They exchange greetings.

Nurse:  "So let me ask you, Mr. David, why are you here to see the doctor?"

Larry:  "Um...I'd just as soon tell the doctor."

Nurse:  "That's OK, I'm going to take all the information, then I just give it to the doctor. So why don't you just tell me, what's the reason you're here?"

Larry: "I know, but if the doctor is gonna come in here, why not just tell the doctor?   I don't see why I need to tell you and then you tell the doctor, why not just tell him directly? I'm going to New York, why am I stopping off in Florida?"  

Nurse: "Uh-huh.   The policy is that I take the information down first, then I give it to him. He'll come in and go over this, so he'll have it all written down, he won't have to go through all of the questions again."

Larry:  "This whole thing is askew, your system. The doctor should be in here right now, we could be saving time--"

Nurse:  "Well, he's got other patients that he's dealing with, so what I'm here, I pretty much cut the time in half for him--"

Larry:  "Cut his time in half?   What, do you intercept him in the hall?   He's gonna get the information, and then, what, run to the Internet to look it up?   No, he's gonna hear it from you, he's gonna come in here--"

Nurse (starting to lose it, talking at the same time as Larry):  "The doctors and the nurses work hand in hand, we're (inaudible), I just need the information, if you could just give it me--"

Larry:   "I'm not that comfortable telling you, frankly--"

Nurse:   "Well, I need to take it down before I can leave."

Larry.   "OK. I have a gerbil up my ass. That's my problem."

The nurse is nonplussed, and there is a pause while she tries not to react.

Nurse:  "How long has it been there?"

Larry:  "Two days."

Nurse (leaving):  "OK.   Thank you, the doctor will be right with you."

Larry:  "OK.   Happy?"

We cut to a scene after the physician has entered. He and Larry exchange greetings.

Physician: "Now I was wondering if you could tell me, what seems to be the problem?"

Bright side? The nurse actually is as pleasant as we could expect her to be in this situation; she's not a battleaxe. But this is still a celebration of widespread social ignorance. Sure, Larry's a jerk, but we are meant to find some of his railing persuasive. Here, the show has created a situation in which it really does seem to make no difference whether the nurse meets with Larry first. We conclude that it is a waste of time that you have to deal with some nurse before the physician. The nurse can only cite the "policy" in response to Larry's argument that she is nothing but a needless pass-through step. And the physician's question at the end destroys any remnants of the nurse's justification. We see clearly that she has not cut the time at all--why does her job even exist?

In fact, even if we just stayed with the saving-physician-time rationale, the show completely misses how the nurse's role here really could be valuable. First, a skilled person performing an intake role will in fact provide time savings to others because they will filter out irrelevant information, take the time to deal with troublesome individuals (like Larry), and reduce the relevant material to a concise, organized written form.   This may not sound like much if the only information is "gerbil up my ass for two days," but the actual situation is generally more complex, and there may be a good deal of relevant information to be gathered and assessed. In addition, people can absorb written information far more quickly than they can oral information, especially when presented in an efficient form. This nurse could cut the time an advanced practitioner spends in half.

But that rationale itself grossly undervalues nursing. The nurse has an independent professional responsibility to the patient, and she is obliged to explore his condition so she can perform her own assessment, regardless of the physician's duties. Nurses have special health knowledge about how patients respond to illness, and they have unique skill in eliciting and imparting information to patients about their conditions. In general, nurses are likely to take the time to listen to patients and ask follow-up questions, to reach a deeper understanding of what is going on that may be critical to good care. And nurses are trained to teach patients about their conditions in terms they can understand. To suggest that nurses exist merely to save physicians time is a threat to nursing and to public health. And this nurse character's reaction to Larry's apparent situation is an insult all by itself. This experienced nurse seems unable to handle the scary alternative situation of the gerbil up Larry's butt, but real nurses would be at least as able to deal with the situation as a physician, to ask relevant questions, and to provide constructive advice. We won't even get into why the physician is New York and the nurse is Florida.

Larry manages to anger Tesler, the director who referred him, and Tesler proceeds to spread word of Larry's apparent condition all over Hollywood, causing Larry a great deal of embarrassment and driving the remainder of the plot. (We never learn if Larry really has a gerbil up his butt--a gerbil has gone missing at his house--or if it was just something he said to mock the nurse and illustrate why a patient might not wish to share details of his condition with an ignorant peon like her.) Of course, though the show does not explicitly blame the nurse, her disclosure of what Larry told her to the director is a gross violation of her ethical responsibilities that would presumably endanger her license.  

Could a nurse in an outpatient setting act as this nurse did? Yes. But again, by presenting as normal only this vision of nursing, with no counterexamples, the show invites viewers to embrace the stereotype of nurses as physician handmaidens with no independent scope of practice and no important role in health care. Of course, the show presumably had no idea about any of this. But we hope no one is saying "it's just a sitcom." Health research shows that even sitcoms affect how people think and act as to health care. And because of his comic gifts, Larry David's work in particular has a way of staying with you.

But could David really have built a good plotline if the nurses were not shallow physician servants? Or is Bergstrom right--we need to just omit nurses completely, because there's no way Hollywood could ever present them in a way that was not damaging? Even Shakespeare couldn't do that, right? Well, it seems to us that there are a few ways David could have achieved his dramatic goals and included nurses without stereotyping them.

Take the bald Jeff plotline. How could David have gotten Jeff shaved by a black person who was angry at Larry's utterance of the slur? First, the nurse might have been with Page when he encountered Larry, and shared Page's outrage. True, then the nurse would have been part of Page's misconduct in the OR, but at least nursing would not have been damaged relative to medicine. Or the nurse in the OR might have tried hard to bar Page from the patient, and simply failed to do so, perhaps because Page physically overpowered the nurse in a slapstick scene in which they struggled with the clippers.

Or Page himself could have been the scrub nurse. Again, that would have involved a nurse in misconduct, but not stereotypical misconduct. But wait, that's crazy--smart, articulate, authoritative males like the Page character would never be stuck as nurses.

Unless they were bald.

Take Action!

Please send your comments to Larry David, show creator of Curb Your Enthusiasm on HBO's web form. And please send us a copy of your letter at letters@nursingadvocacy.org. Thank you!

The URL for this page is www.nursingadvocacy.org/news/2007/nov/11_curb.html
© 2003-2008 The Center for Nursing Advocacy, Inc. All Rights Reserved.