A nurse’s shift

A former academic finds personal fulfillment—and a different set of intellectual problems—amid health-care shortfalls and patients who face matters of life and death.

By Theresa Brown, AB’87, PhD’94
Illustration by Allan Burch

As an English PhD, I didn’t have the chance to start many conference papers this way: “My patient that day had an abscess in his rectum.” But now I’m a nurse, and this past fall I was invited to an academic conference not for my expertise in literary theory but because I write for the New York Times Well blog, and because President Obama had quoted one of my posts in a speech he gave to nurses about health-care reform.

I am a hybrid: a bedside nurse who puts my literature background to use by writing about nursing. Working on a medical-oncology floor at a teaching hospital in Pittsburgh, I do 12-hour shifts, giving pills, consulting with doctors, checking IV lines. I feel lucky if I have time for lunch, and really lucky if I actually get to listen to my patients and try to understand what they’re going through.

I write about what I see at work, and my August 19 Well post, “A Nurse’s View of Health Reform,” caught the White House’s attention. Staff members there excerpted it on their own blog and a month later invited me to Washington for a meeting between President Obama and nurses. There I had the thrill of meeting the president and hearing him quote part of my blog post as he spoke to the gathering. It was a proud moment for me and for nursing—the president of the United States quoting a floor nurse.

In his speech Obama said how important individual stories are to understanding the debate about health-insurance reform and then retold the story I had written:

A few weeks ago, Theresa wrote a blog post about a patient of hers. He was in his 60s, a recent grandfather, a Steelers fan, spent the last three months of his life worrying about mounting medical bills.

And she wrote: “My patient thought he had planned well for his health-care needs. He just never thought he would wake up one day with a diagnosis of leukemia. But which of us does?” she asked. And then she wrote: “That’s why we need health-care reform.”

As a nurse and a writer, it’s not always clear how much of a larger effect my work has. It was gratifying to see that by combining both jobs I could contribute to the national conversation about health care.

To continue that conversation, I agreed to participate in a small conference with the editorial board of the critical-theory journal boundary 2, held at the University of Pittsburgh. The gathering included a panel on health-care reform. But as the date approached I found myself confronting anxieties I thought I had discarded years ago. Would I be able to put my ideas into the proper intellectual framework? It had been so long since I’d read or heard academic discourse—would I be able to find the appropriate words? Paul Bové, editor of boundary 2, University of Pittsburgh English professor, and the conference organizer, reassured me that expressing myself in everyday language would be just fine. Then the paper came pretty easily.

My English background comes to the fore more than I imagined it would in my nursing work. In thinking about health-insurance reform, I found myself recalling Shirley Jackson’s short story “The Lottery.” I taught writing for three years as a Tufts University lecturer, beginning my Politics and Writing class with “The Lottery” to get students thinking about what a society may be willing to sacrifice to secure a greater good. “The Lottery” describes a small farming community in 1940s America on the town’s Lottery Day in June. It’s obvious during the story that the lottery makes the townspeople nervous, but the horror of being the person who ultimately draws the marked chit becomes clear only at the end. The lottery determines who will be the yearly victim of the town’s ritual killing, and the townspeople stone Mrs. Tessie Hutchinson, a neighbor and friend, to death.

It’s a chilling story—and a striking analogy for thinking about the American health-insurance system. The challenge was translating what I consider the cruelties of our system into a persuasive argument. For me, the way to do that, as in the earlier post on health-care reform, was to find the right patient story to tell.

Considering the analogy I wanted to draw, beginning with a graphic image seemed important, so I described the patient with the rectal abscess. He was scheduled for discharge, and it was my job to get his paperwork in order. Home was a four-hour drive away, and he could only sit for 30 minutes at a time. Because three drainage tubes protruded from his backside, his skin needed regular application of a protectant to save him from his own corrosive secretions.

By the time he finally left the hospital that day, he had the medications he needed, but he and his wife were delayed for hours because his insurance company required specific doctors to sign off on some of his prescriptions. He was in incredible pain despite huge doses of narcotics. It was late November, and he and his wife would make their long journey home in the cold and the dark, held up by bureaucratic requirements that seemed to have no purpose other than making it harder to get him the care he was in theory entitled to.

Then I told a second story. A patient who was dying needed to go home on IV antibiotics. His wife told me, quietly and secretively, that their insurance no longer covered IV antibiotics, and they couldn’t afford the drugs. I called the nurse practitioner, who brought in the social worker, and in this case also the family went home with the care they needed. But the memory of the wife’s embarrassment and shame stuck with me, making me feel embarrassed and ashamed to be part of a system that makes people literally beg for care.

I called my conference paper “Playing the Health Care Lottery” and said these two stories illustrated a “continuum of health-insurance indignities” perpetrated by our for-profit health-care system. The first story, about the patient with the rectal abscess, falls at one end of the continuum, and the second story falls somewhere in the middle, since not getting the IV antibiotics would have hastened this patient’s already inevitable death. At the farthest end of the continuum is death, the deaths of the uninsured and the underinsured, who can’t afford proper health care.

People who lack health insurance, or good health insurance, are dying when they needn’t. Like the townspeople in “The Lottery,” we all think we’re safe, and covered, until an illness or injury reveals that we have drawn the marked chit that says “deductible not met” or “drug not on the approved list” or, simply, “claim denied.”

The paper was a success, the pleasure of presenting my ideas to a live audience tangible, and the fun of being back in a university English department quite real. And yet, sitting in the wood-paneled room and listening to the other papers, I found my mind wandering back to the hospital. What was happening on the floor? It was Halloween—were they having a crazy shift while I listened, concentrating hard, to the delicate and intellectually complex ideas presented?

Toward the end of the day, I tried to observe the other conference attendees with more objectivity. I marveled at how much time they had to pose questions, to push ideas to their logical limits, to find the chink in the armor and ask whether that small weakness revealed a much bigger problem. They all seemed to have a wealth of time, and I envied them that luxury.

But I did not envy their deep attachment to the world of ideas. As an undergraduate at Chicago, I grew to love ideas and believed that smart thinking could make the world a better place. That idealism may hold some truth—at least I hope it does—but in my own life I took a more practical route. At work now I worry about what to do if a potassium level is dangerously high, if a patient cannot breathe, if a third round of chemotherapy has failed to make a dent in someone’s disease.

In my graduate work at the U of C, I wrote about women writers who used what I called “storytelling” to narrate and come to terms with the traumatic events that had shaped their lives, particularly if they belonged to a minority ethnic or racial group. Now I tell the stories of my patients’ medical traumas and also describe the pain we nurses feel watching and helping them fight for their lives.

The short answer to why I left academia to become a nurse is that I became a mom and afterward wanted something different. My son is now 13, my twin daughters 10, and despite all the mess and exhaustion that go with mothering and nursing, the children remain the inspiration for my work. I want a job that, however crazy-making, roots me in the ground.

At universities there is always time for thinking, talking, and writingÑall things I enjoy and believe are important. But only in the rush of hospital nursing did I find the work environment I craved—to fight for and care for real people rather than struggle with ideas and words. Still, in working with those people, I found my way back to words, and to a seemingly endless supply of heartbreaking, inspiring, and important stories to tell.

Theresa Brown, AB’87, PhD’94, has been a nurse since 2007. Her book Critical Care: A New Nurse Faces Death, Life, and Everything in Between (HarperStudio) will be published in June.

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