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01/23/2018

BioethicsTV (January 21-22, 2018): The Resident-Our Most Unethical Hospital System

The Resident (Season 1; Episode 1): The Most Unethical Hospital Ever

This new Fox show begins with newly minted MD Devon Pravesh’s first day at a fictional Atlanta hospital. In the first 3 minutes, a surgical team takes photos over a patient’s body during an appendectomy (and break the sterile field). The patient wakes up during the surgery and the surgeon has tremors leading him to cut an artery and the patient bleeds to death. The surgeon, Dr. Bell, then tells the team that the death that the patient was the patient’s fault because he was a poor risk. Bell tells the team, “I’m the chief of surgery at the end of a 30-hour shift.” They all agree to lie about what happened. The team spins a tale that the patient died of a heart attack and write that in the patient’s record. They also erase the photos. Bell is a star doctor and the focus of the hospital’s advertising and fundraising. The staff has nicknamed him HODAD – “Hands of death and destruction.” Bell writes his own online reviews, steals wealthy patients from other surgeons, displays arrogance, and takes credit for other doctor’s successes. As a strawman, he is the worst of every possible trait in a doctor, lacking professionalism, altruism and compassion.

I probably do not need to say much about the list of problems here in the first few minutes: Taking photos of a patient without consent, not attending to a patient carefully, lying, faking records, conflicts of interest, and protecting a dangerous doctor.

Pravesh is assigned to senior resident Conrad Hawkins who is smart, handsome, an incredible diagnostician, direct, crude, rude, and white. He is set up as the savior of lives and of the medical system. Pravesh runs his first code on Chloe, a young girl with endocarditis who is a drug user, combatant and just wants her next fix. Hawkins says he’ll give her dilaudid if she agrees to stay and take the antibiotics [is it okay to negotiate and give a patient a substance for recreational use in order to save a life?] When she codes, Pravesh keeps working on her body after Hawkins tells him to stop. But Pravesh works until her heart starts beating, long after her brain has been starved of oxygen. With Chloe on a vent, Hawkins tells Pravesh,

“You didn’t save a life; you saved a brainstem. Now the repercussions on her family will be catastrophic. There’s no way they’ll accept this. Chloe looks alive and they’ll think she’ll wake up. So, they will hover over her; tend to her for days, weeks, maybe years waiting for a miracle to happen that’s utterly impossible…. All we want to do is help our patients but what they don’t teach us in medical school is there’s so many ways to do harm.”

Nurse Nicolette Nevin tells Pravesh that the hospital will be thrilled at the money they make over Chloe being in the ICU: “Medicine isn’t practiced by saints; It’s a business.” She tells him that medicine is the third leading cause of death [turns out that this is a true fact]. Later in the show, Hawkins walks into the patient’s room, closes the blinds and turns off her ventilator. A moment later a nurse walks in and he flips the vent back on.

Dr. Okafor is a physician from Nigeria and is supposedly the best technical doctor in the hospital. However, she lacks bedside manner. She is tasked with updating three families on their loved one’s conditions. In the crowded waiting room, she moves quickly from family to family as she tells one pair that the patient is doing well. The second family she informs that their patient is in the ICU and “it’s touch and go.” The third family she says, “He’s dead.” She then walks briskly out of the room. Clearly, this is an example of the worst communication skill possible.

However, Okafor’s skill is demonstrated by her prowess with a new robot surgery. She has studied for months to become proficient. Bell steals her robotic surgery case. Okafor tells him that he cannot just step in and do this surgery since he has never touched the machine before. Bell threatens her with deportation. She agrees to help teach him and he ends up mutilating a piece of fruit—he will not learn the delicate skills in the time remaining. In response, he self-medicates. When Hawkins can’t convince Bell to step aside, he arranges for the surgery to be streamed live on the internet. Off camera, Okafor conducts the actual surgery while Bell is on the video manipulating a set of dummy tools.

The show draws on unfortunate racial and gender tropes: The actual hero and the marketed hero are both alpha, white males. The two female characters are a nurse (who stands by when an inexperienced resident attempt to put in a central line and doesn’t try to stop him and is having a sexual relationship with Hawkins) and the Nigerian resident. Both female characters are presented as subordinate to the three male leads. The show places women in an objective status in its first half hour, when Hawkins is flipping through an online dating app, staring at females in occupational therapy and asking Pravesh what kind of women he prefers (or men, he adds). Of course, this treatment of women is not surprising given that the medical consultant is under review for sexual harassment violations for his work on another medical show. In a change for many medical shows, two main characters are minorities: Indian-American and African. One is shown as brilliant but lacking all people skills and the other is a newbie, out of his element.

The Resident (Season 1; Episode 2): Musical Hearts

As this show begins in its regular time slot, the opening title sequence is short, but flashes several principles: “Death before dishonor,” a phrase that is also tattooed on Resident Hawkin’s back, and “Do No Harm,” a reference to the first principle of medicine.

The first storyline is about a 28-year old school teacher with a heart condition. Soon after he collapses, UNOS calls with a match. Meanwhile, a Congressman and lobbyist hunting with Bell—the star surgeon—and Dr. Hunter—start neurooncologist—ends in a shooting and a heart attack. The primary concern of the administration is not taking care of the patient, but about spinning the story to not look bad for the hospital. The Congressman (VIP with the heart attack) is 63 and a smoker; he also needs a new heart. Bell says that if the heart coming for the patient needs it, then they will “unallocate it” for their VIP patient. As the first patient is being wheeled into the OR, Hawkins is informed that the surgery was canceled and the heart is going to the Congressman. When Hawkins questions Bell on whether the reallocation was a medical choice or a financial choice, Bell points at himself and says he’s the chief; he points at Hawkins and says “resident.” Such power trips are common here, such as when Hunter tells Nevins to never question her in front of staff.

In reality, this heart recipient switch could never happen unless the first patient was unable to accept the heart and the second patient was the next on the list. Unless there is a cause, once allocated and received by the hospital, reallocation does not happen. As this show continues with its themes or race and economic inequality, it’s important to note the first patient is not only much younger, but he is also black. The second patient is much older, much wealthier, and very white.

Oddly, there is a second heart potentially available in the hospital: Chloe-the 16-year-old girl from the first episode. The first issue here is that unlikely scenario of two hearts being available for two HLA compatible patients at the same hospital. Second, instead of dealing with the issue of who gets the heart, the show dodges that ethical decision by magically making a second heart available—each of the needy patients gets to live.

As the residents discuss Chloe as a potential donor, Okafor says, ”That’s no longer a human being; that’s an organ farm. What’s the problem here?” No health care provider should ever speak so callously about a patient, even one in PVS. Hawkins can’t speak with the girl’s family because, as he says, a physician with a patient needing a heart transplant cannot ask a family to donate a loved one’s organs. Hawkins asks Bell to talk to the family and Bell refuses. Bell says that as long as the family can handle the financial burden, the hospital will keep Chloe on full life support in the ICU.

In order to fight for his patient, Hawkin asks for a new HLA matching test for the Congressman, and he changes the blood sample to ensure that there will not be a match. Hawkins seems built in the vein of House MD, but in general, a physician should not lie and the ends do not justify the means. However, Chloe’s heart is a match and this move forces Bell to convince the family to donate her organs. “He’s finally helping us do the right thing….For all the wrong reasons.” Moments before Hawkins could not speak to Chloe’s family because his patient needs a heart, but it’s okay for Bell to talk to the family even though his patient needs a heart? Logical consistency is not a strongsuit of this show. Between Bell and Hawkins this is a “king of the mountain” fight and it seems that patients are hurt in their battles.

In another storyline, the files of a patient recovering from cancer are transferred from the hospital to Hunter’s private server and her private clinic. Hawkins explains that this way if the patient is doing well in a clinical trial, Hunter can personally profit from patenting the treatment. She stands to gain financially and works to maximize that potential.

The sexism theme is repeated when a patient who has recently had heart surgery sets off cardiac monitoring alarms because he is watching a porn on his cell phone titled, “Naughty Nurses.” Nevin is shown as very competent and pursuing her doctorate in nursing, but she is still shown as a handmaiden and lovesick with Hawkins—i.e. ruled by her emotions. Hawkins is willing to flirt with all women to get what he wants or needs. And the women fall for his attentions. Using one’s looks and flirting skills, even if in the goal is getting needed resources for one’s patients, is clearly wrong. On the other hand, Okafor is shown as lacking emotion and is only interested in “advancing her career” (an actual phrase she uses)—the patients are secondary to that goal. Together the only two female characters represent the typical stereotype that woman are ruled by emotion or they have to be “cold” to compete. In a bar scene, when a man tries to pick Okafor up she says she works at the hospital; he asks “as a nurse?” and when she responds “No, as a surgeon,” he walks away. This attitude toward women is unacceptable. A 2018 show, born in the era of #METOO, the Women’s Marches, Emily’s List, and Times Up should not be treating its main female characters so poorly.

Another ethical concern with this hospital is its overwhelming concern with money—patients get care, and even access to organs, based on their ability to pay and make donations to the hospital.

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