by Craig Klugman, Ph.D.
The Resident (Season 1; Episode 3): The Cost of a Life The episode opens with residents and nurses attending a required meeting on billing by a “billing consultant”. The consultant’s message is to charge more: “Bill proactively,” “Upcode to what the disease could eventually affect.” Later, the consultant suggests running more tests. She distributes a brochure named “The Art of Upcoding” that is about getting more dollars out of each patient. In one case, a patient scheduled for hernia surgery has his surgery canceled to get additional testing even though the surgeon says more tests are not needed. Just before the MRI begins, nurse Nevin stops it and tell the consultant that she’s making medical decisions without a license: The patient has a metal implant that would be ripped out in the MRI.
In a second related storyline, Luisa Rodriguez is a 22-year-old transport worker and college student who technically works for a subcontractor that does not offer insurance. The consultant interrupts Rodriguez’s exam to inquire about the patient’s insurance. The docs want an MRI and the consultant thinks that a x-ray would be fine. If the consultant was acting out of the patient’s interest—i.e. not burdening a person with extraordinary and burdensome medical bills—then her point might make sense. But her motivation is that the hospital is unlikely to be paid this money, so go for the cheapest test. This is practicing medicine without a license and not practicing in favor of the patient’s best interest: Expertise comes second to the bottom line. In an age where expertise is dismissed and considered unimportant (you can look everything up online after all), the dollar outweighs the expert.
An MRI scan shows an invasive retroperitoneal sarcoma. She needs immediate surgery. The patient is not only uninsured, she is a dreamer hoping to go med school. The consultant’s response is “No more tests. No more treatment on our dime. This hospital isn’t a charity.” There is some truth in this idea, though it could have been stated more compassionately. Hospitals do need to cover their costs or they close. The hospital CEO is concerned that the patient would not be able to be released on her own and will need a great deal of rehab and hospitalization for her care. She would be a, “perma-patient” (I could not find a reference to this term through Google). Their cost estimate is $500,000 to $2 million for her care. The CEOP talks to the CEOs of two other hospitals to see if they would take the surgery and as an incentive, she says her hospital will pay a one-time $250,000 fee. They counter, asking for 5 Medicare patients and $300,000. No deal.
Dr. Hunter has a foundation to help pay for patient care, but it does not apply to the undocumented. She says, “We do the best we can as often as we can. We can’t save everyone.” That is a true point and would apply if the issue was about a disease that could not be treated. However, this is about not treating a person because of their status as a sick Dreamer. That judgement reeks of social injustice.
Dr. Bell says it clearly, “The money has to come from somewhere. If we treat Luisa, our other patients will suffer, Service will be cut, hours, staff. I don’t like the idea of putting a price tag on life…but the system doesn’t run on air.” He points out the problem of too much need and not enough money. The show believes that part of the problem is physicians who are too comfortable and not willing to risk their $400,000 a year jobs to buck the system or go against administration. The show claims the problem is doctors who are not willing to do the right thing over the (economically) safe thing.
Of course this would not be a drama without some craziness. The CEO has the consultant call ICE. The surgery has begun and no one can interrupt that. Immediately after surgery, Bell and the CEO try to get her walking because if she can reach the door, then they are no longer responsible for the cost of her care. However, since she is unable to even sit up Bell tells the CEO, “$2 million.” The hospital will be responsible for the patient. The CEO explains to Hawkins that she has to pull the money from patient care, “Be prepared to be woefully understaffed for the next 12 months.”
The Resident (Season 1; Episode 4): “We deserve to be paid” An eighty-year-old female is initially diagnosed with gall stones which turns out to be gall bladder cancer. Hunter, the oncologist, suggests an experimental, expensive surgery. The procedure is risky since it requires removing part of the liver—the risk for cutting a blood vessel is high. The radiologist suggests that the complications and her age make palliative care a better choice. Hunter recommends Bell as the surgeon: He is the hospital star but also suffering from hand tremors—a problem that he is hiding from others in violation of his “do no harm” oath.
In a montage, we see the Intern spending four hours on the phone with Medicare trying to get approval for the operation—suggesting that the insurers being difficult is the problem in medicine. In the meantime, the patient wants to leave AMA to get married to her boyfriend because they are old and do not have time to wait. After arranging a wedding at the hospital, the surgery is successful. After the procedure, Hunter and Bell are congratulating themselves and then asked if they would have done the surgery if Medicare had refused to pay. They both answered no: “We save lives and we deserve to be paid for it,” Hunter says. This demonstrates the show’s main problem with medicine, that the prime motivating factor in medicine is making money, not providing patient care.
The Good Doctor (Season 1; Episode 14): Gender Confirmation in a Young Teen Quinn, a young female pre-teen comes to the hospital for what is believed to be appendicitis. This patient presents two surprises: (1) The patient is biologically male and with her parents’ permission is on puberty-blocking drugs to prevent the development of secondary male sexual traits and (2) The patient has testicular cancer. The team suggests a radical orchiectomy, removal of the cancerous testicle. When the patient expresses concern over developing male characteristics, Murphy blurts out that they could remove both testicles which would leave the patient with the same level of testosterone as a genetic female. The patient’s grandmother is against the idea, suggesting that the child is in a phase, is a child, and may someday wish to have children. The parents respond that the decision is not the grandmother’s. Quinn says that she’ll have gender confirmation surgery the moment she turns 18, so why not do this now.
Dr. Lim, attending on the case, charges Murphy and Kalu with creating an SDA—a Shared Decision Aid. Such aids, according to the Mayo Clinic’s Shared Decision Making National Resources Center, are “tools to share information and create a conversation about the options and their relative merits and downsides.”
The grandmother files a child abuse complaint against the parents for the puberty blockers and for “making her [their daughter] think that being trans is okay, as a form of emotional and physical abuse.” The hospital does not believe the allegations but they fear the grandmother could go to court for custody. With this pressure, that parents agree to the surgery, “Do want Quinn wants, do the bilateral surgery.” Glassman convenes a “Challenging Patient Consultation Process” which is a space for conversation or what in ethics we call the Family Meeting. We learn that Quinn dressed as a girl at home and her parents forced her to dress as a boy in public, a situation she hated. A year ago, Quinn made a suicide attempt. Meanwhile, Quinn explains to Murphy how dressing like a boy made her feel different, like she was pretending so she withdrew and kids made fun of her. She is happier when her parents let her be her. Back in the family meeting, two surgeons come down with opposite opinions on what to do—(pro) do the surgery because she is living as a female versus (con) do not do the surgery because data on the outcomes is thin, removal of the second testicle is elective and not medically necessary, and keeping a testicle preserves future fertility options.
In a twist, the tumor causes a torsion that requires immediately surgery: A decision must be made immediately. The parents are convinced by the grandmother and decide to only do what is medically necessary, allowing Quinn to make her own decision when she is older.
There is no law that prevents a minor from having such surgery—with parental consent. However, most insurers will not pay for gender confirmation surgeries in minors. The use of puberty blocking hormones has only been acceptable since 2009—by providing a time for the child to mentally mature but not physically, they have an opportunity to verify that they are transgender before surgery is done. However, the long term effects of these drugs are unknown. With the law silent, the ethics leans toward family autonomy—a decision a child makes with the (hopeful) support of their parents and knowledgeable health care providers.
Chicago Med (Season 3; Episode 9): Fetal End-of-Life, Minor Abuse, Awake Cardiac Surgery The episode begins with a 25-year-old woman pregnant at 22-weeks gestation being wheeled into the ED. She is with her husband and is in labor. Halstead and Manning explain that the baby is too young to survive and would the parents want to take all aggressive measures or comfort care only. The parents choose comfort care. When she gives birth, the baby is alive and moving. The neonatologist says that since the baby is under 500grams and given his age, there is no chance of survival. However, Manning sees a moving baby and begins hinting to the parents that maybe, just maybe their baby could survive. Halstead emphasizes that survival would come with severe deficits if it does survive. The mother visits the baby and is holding him when he codes. She immediately changes her mind and asks them to resuscitate the baby. The father arrives and the parents bond with the child, seeing his every movement as a sign that he hears and sees them. When the baby codes a second time, the doctors are unable to resuscitate him again. One odd feature is that the baby’s care is provided by Manning and Halstead, not by the neonatologist. Manning regrets “pushing the parents.” However, because this show believes that health care providers rarely do wrong, the parents thank her because they held their child and got to “let him feel their love.” Halstead asks what she would do next time.
In a second storyline, a 14-year-old girl is brought to the ED suffering from exposure. She was found living on the street. After warming and feeding her, they discover a cockroach living in her sinus cavities, feeding off of her cerebral spinal fluid. The child had been hit by her mother’s boyfriend. Choi and Sexton debate calling child protective services. Goodwin tries to find a placement in a halfway home but no beds are available. Choi makes the decision to call social services. When the social worker arrives, the patient is gone—Sexton saw the girl preparing to leave and did not stop her. In Illinois where this show takes place, health care providers are required reporters—that means that Sexton and Choi do not have a legal choice as to whether to report: They are required to. Ethically, they may feel that reporting is not in the patient’s best interest since most likely social services will bring her back to her mother. Even if the mother claims the boyfriend will not be around, nothing prevents him from being—social services is too strained for resources to check on her often enough. Choi and Sexton make their way to the encampment where the kid has been living to check on her and bring her medications and a warm jacket. The show wants us to believe that this is compassion and health care providers truly caring for their patients instead of leaving the child to a dysfunctional system. However, in both the first two stories, the doctors went above and beyond to care for a single patient/family. Can they do that for the next patient, and the one after that, and the one after that? The challenge is that by bucking a system, you may help one person, but you end up not helping many more. What needs to happen is to work to change the system and that is so much harder.
A third storyline has a renowned heart surgeon from South Africa in the hospital for his own heart surgery. The patient demands to be awake for his own surgery to observe. However, during surgery he takes issue with the approach and starts directing the procedure. When he asks for a different surgeon in the middle of his surgery, Rhodes begins by putting the patient under general anesthesia. From the beginning, Rhodes was concerned about the wake surgery, believing that it placed the patient at undue and unnecessary risk. In reality, unless medically necessary, awake surgery poses a risk that does not outweigh any non-medical benefits.