Progress and Regress

New Amsterdam pushes reform—but through the same old physician-centric narrative

On the NBC drama’s first season (2018-19), maverick medical director Max Goodwin and a half dozen physician colleagues shake up conventional care at an overburdened public hospital. But aside from a few plotlines involving the minor nurse character Casey Acosta, it’s more of the same damaging Hollywood model, with nurses as silent servants to the brilliant physicians who call all the shots and save all the lives.

May 2019 – The NBC drama New Amsterdam focuses on a large public hospital based on New York’s Bellevue. The lead character is the new medical director Max Goodwin, a charming maverick bent on applying creative disruption to U.S. health care’s many problems. There are about five other major characters—all physicians. And for the most part, New Amsterdam’s nurses are peripheral subordinates who play no significant role in care, perhaps reporting vital signs or taking “orders” to give drugs. Occasionally they are portrayed as inept or even hostile obstacles to good care. There is one minor recurring nurse character, the competent emergency department (ED) nurse Casey Acosta. Casey is essentially a bantering sidekick to the chief ED physician Laura Bloom. Casey does show some knowledge when he interacts with her about cases, and he even calls her out on her substance abuse, at one point explaining that he has been correcting her errors to protect patients. But she is clearly his boss. Indeed, there are no apparent nurse managers on New Amsterdam. The nurses report to the physicians, and ultimately to Goodwin, who seems to function as the hospital CEO—a common theme in Hollywood shows, which tend to assume that the highest-ranking physician must essentially run the hospital. In the first episode, nurses are identified as one of the overlooked lower classes of the hospital that the equality-minded Max is supposedly going to start paying attention to. He even speaks Spanish to them! But this is really just about establishing who Max is. The concerns of actual nurses—like about understaffing—get no real attention. Meanwhile, the New Amsterdam physician characters spend time doing things nurses do in real life, especially providing psychosocial care and patient education. Max Goodwin is presented as a visionary, but there is nothing new about the New Amsterdam’s regressive portrayal of nursing. David Schulner created New Amsterdam, based on the memoir Twelve Patients: Life and Death at Bellevue Hospital by physician Eric Manheimer.

Nurses know better

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Nurses know better

Apart from Casey’s limited appearances, New Amsterdam’s portrayal of nursing in the first season is very much in the low-skilled handmaiden category. Nurses are generally silent background figures who provide basic support to the physicians who give all the care that is worth noticing. There are really no nurse managers, and it’s clear that the nurses report to the physicians. Occasionally this is stated directly, as in episode 14, when a temporary chief ED physician got Max Goodwin’s agreement to change the ED nurses’ schedules to a seniority-based point system. Physician characters do things that nurses do in real life, from defibrillation to giving medications to psychosocial care. Often nurses other than Casey seem to be clueless in the face of serious care issues, and although they may have some knowledge, in general they must await physician direction. In episode 16, when the ED physician Bloom is at an inpatient rehabilitation facility treating her addiction, a fellow patient there overdoses. A nurse seeks Bloom’s help, and despite the restrictions on Bloom’s practice, she has to rescue the patient because the nurses are useless; they are able to report vital signs, but that’s about it.

Occasionally nurses serve as the face of bureaucratic indifference or hostility, in modern battle-axe mode. In episode 1, a traumatized teen psychiatric patient encounters one of these nurses who moves to call security on her for no great reason, until a sensitive, holistic psychiatric physician intervenes. Later, a desperate young Liberian patient arrives at the hospital, only to encounter an apparent ED triage nurse who is an indifferent list-keeper, determined that patients will be seen by physicians based on order of arrival rather than any evaluation of acuity. She seems to have no clue that the patient is very ill, and no concern, until he collapses in the waiting room. (Of course, real ED patients are waiting for an ED triage nurse, not a physician, to identify the severity of their condition in the first instance.) Later, as the physicians work to diagnose this patient, who turns out to have Lassa Fever, only Bloom and Max seem to know about infection control. They have to instruct the nurses about that. And when the patient crashes, only Bloom can rush into the isolation ward to help, while the nurses slow her down, not helping well or fast enough. 

Indeed, indications of nursing skill are rare. In episode 3, Max takes a potential hospital donor to the NICU, where volunteers are providing kangaroo care to premature babies; Max explains the benefits of skin-to-skin care. Because no nurses are involved, viewers will not know that they play a central role in such care, much less that it is largely a nursing innovation. It seems to be something that physicians like Max pioneered. On the other hand, in episode 14 an apparent neonatal ICU nurse does explain the concept of “rooming in” to the oncologist Helen Sharpe, who has become attached to a baby with neonatal abstinence syndrome (NAS). The nurse notes that NAS babies are “sensitive to stimulus and the PICU’s a noisy place.” And she adds that rooming in involves skin-to-skin contact and frequent feeding by mom in a calm environment.

Nurses do play roles in a few scenes in early episodes designed to showcase how different Max is from the standard physician executive. In the first episode, Max overhears two apparent nurses and a custodian discussing him (the new medical director) in Spanish. They appear to assume the unfamiliar scrubs-clad man nearby is not Max, or at least that he would never know Spanish. The custodian says he has heard that Max fired everyone at some clinic in Chinatown that he recently turned around. But one of the nurses says she is not worried, as medical directors never speak to nurses, much less fire them! Of course, Max immediately proves that wrong, warmly assuring them in Spanish that he will be meeting weekly with nurses and custodians “so we can make your work here more rewarding, efficient, and harassment free.” This sounds nice, but it also tells viewers that the chief physician supervises nurses, which is damaging and wrong. Naturally, the nurses are speechless at this unprecedented recognition that they do actually exist. But of course New Amsterdam is not really interested, and there is little followup. In fact, Max rarely does speak to nurses. In episode 5, he passes some nurses in a hallway who are complaining about patient satisfaction surveys—one got dinged for not changing a TV channel fast enough, another because her name brings back bad memories to a patient. In a friendly way, Max tells them, “If you don’t like the answers, change the questions, nurses know better than anyone.” OK, but do the nurses have the power to do that? And without specifics or followup, how will viewers know what nurses should be judged on? Do they play any important role in care? In this same episode, alert viewers may notice a sign on the wall of the ED telling patients to give feedback about their care to the “charge nurse.” But it’s not clear that we’ve ever been shown any charge nurses.

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Casey—no one uses his surname—is the one bright spot, a confident and secure nurse whose occasional appearances suggest that nurses can at least be skilled assistants to the physicians, if not their peers. Casey is a man, and a person of color, supporting diversity in the profession. And he is the main sidekick to the chief ED physician Bloom. She is clearly his boss — no need for a nurse manager — but he does display skill as he reports vitals, suggests treatments, and sometimes deals with patients directly. As with most TV nurses, though, he seems to be there more to help the physicians than the patients. Casey does act with some independence in the season finale (episode 22), when he helps to manage a lawyer patient the police bring in because he is aggressive, apparently as a result of a cocaine overdose. Casey reads the radiology scan and archly tells the lawyer that in his “professional opinion,” there is a large balloon of cocaine in the man’s stomach.  

Probably the most notable Casey theme this season is his increasing efforts to flag Bloom’s addiction, efforts that build on their easy, bantering relationship. In episode 4, the highly-strung Bloom confesses to Casey that she is taking Adderall for ADHD. He expresses concern that she is working too hard. But she continues to do so, and in episode 8, he confronts her again: “Studies found that docs working shifts of 30 hours or more end up making 36% more mistakes.” She claims to be polyphasic sleeper who can get by with naps. Bloom wants Casey to give a patient 20 mg of morphine. Casey: “Is she dead?” She says she meant 2 mg, it was just a typo and she was going to proof it. Casey responds, “36%,” referring to the mistake statistic. Later, Bloom seems to admit that he has a point and goes to lie down. He wakes her for help with a crashing patient. She prescribes a medication which both Casey and a resident physician doubt, although it works. But things come to a head in episode 9. Bloom and Casey meet an ambulance, and a paramedic informs them that the patient is allergic to Cephalkem. Bloom tells Casey that that is a “fancy kind of penicillin,” which suggests that low-skilled nurses would not know such a thing and that they’d need the information dumbed down as a lay person would. Later Bloom actually asks Casey to give the patient this same drug, apparently forgetting about the allergy. She walks away before realizing her error, then returns. Casey tells her that he is giving “Levofloxacin—just like you said. Need me to make any other adjustments?” Clearly he caught her error and fixed it. She tries to apologize to Casey, but he isn’t having it: “It’s happened before. I correct your EMRs [emergency medical records]. Put patient notes on the right charts. Pull doubles…” Bloom makes excuses, but he concludes: “Dr. Bloom, I think you need help.” And he reminds her that the allergic patient could have died. Bloom seems shaken. By episode 14, she is at an inpatient rehabilitation center. 

On the whole, these plotlines show Casey to be a strong and knowledgeable assistant to Bloom. There is no sense that he is an autonomous professional, and it’s clear that he knows a lot less than Bloom does about health care. But he does illustrate the role that skilled nurses can play in checking physician errors and, by advocating, potentially saving lives. He persistently challenges the safety of her excessive hours and her substance abuse. In addition, while Casey is not exactly a peer of Bloom’s, he is certainly qualified to be a work friend / foil, what with the bantering and the frank talk. Still, it’s also important to remember that Casey is not a major character, and he only appears for a few minutes, at most, in each episode. As on other physician-centric hospital shows with only one significant nurse character, the vast majority of the New Amsterdam’s scenes have physicians providing all important care, with or without silent, anonymous nurse assistants.

Please send your thoughts and concerns to the creators at:

Twitter @NBCNewAmsterdam, @davidschulner, and @peterhorton

or by mail at:

David Schulner, Peter Horton, David Foster, Michael Slovis & Kate Dennis, Executive Producers
Pico Creek Productions
1007 Montana Ave.
Ste. 608
Santa Monica, CA 90403
USA

or call at:

+1 310-394-7522

Please copy us on your thoughts at @TruthAbtNursing or letters@truthaboutnursing.org. The producers do not seem to have a website.