Posted on November 24, 2018 at 12:04 AM
by Craig Klugman, Ph.D.
Jump to The Resident (Season 2; Episode 8): Fraudulent medical devices; Unfinished stories; Jump to The Good Doctor (Season 2; Episode 8): Vaccination, Stories and Marital Counseling; Jump to New Amsterdam (Season 1; Episode 8): Undue influence; Cultural accommodation; overworked physicians
Henry is a young boy who comes to the ED after he has a grand mal seizure on the little league field. A physician orders a third medication to treat his disorder. The doctor enters the orders online, which triggers a message to the pharmacy, to the insurance company for approval, and then an oversight company that reviews all records. The reviewer contacts the medical device manufacturer and tells them that the system flagged the patient as a potential recipient of their new VNS (vagus nerve stimulator) device. The device was approved under 510(k), an FDA regulation that says a medical device does not need to have clinical trials if it is substantially similar to something already on the market. Morali, the device company rep, is concerned because she learned that some companies import cheaper and less reliable parts from overseas. Her CEO tells her he does not, but the viewer senses that he is not trustworthy. The CEO talks to Bell about the device to convince him to sell it to the patient and family. The CEO says that the results have not been published but provides a pile of papers that we are supposed to believe is research results.
Henry continues his seizure and if it does not stop soon, then they will have to put the boy into a medicated coma. Morali presents the VNS option which Henry’s doctor thinks would be “a game changer” and remove Henry’s need for medication. Hawkins explains that such devices have some serious side effects, including death (This turns out to be true–the rate of death and other disability from these devices is very high). At a family meeting, Bell convinces the mother to consent for implantation of the device. Presumably the surgery takes place. Morali is suspicious and sneaks into the company’s plant where she finds workers taking medical devices out of boxes with Chinese writing and re-boxing them into the company’s own “made in the USA” boxes. The company is indeed selling cheaper products and lying to their customers. While this is an ethical issue—endangering people’s lives for profit—it is also a legal one—fraud.
In a second storyline, an older man is in the ED for abdominal pain. His wife complains that they had to wait for 5 hours and that they have a doctor who is Indian. This issue clearly presents the issue of bigotry when patients and their families distrust someone because of their race. Pravesh requests a surgical consult but the surgeon says the case is not yet surgical; he should be seen by medicine. As the patient gets worse, medicine refuses to admit him saying that with bowel obstruction, the problem either resolves or they go to surgery. While it seems as if this story is headed for a moral lesson about unethical practices, the episode never returns to the story. We simply are never told what happens. Perhaps that information is in next week’s episode or ended up on the cutting room floor.
The storylines in this episode revolved around the physicians giving marital advice to wronged spouses and the power of stories.
In the first storyline, a couple come in after an accident on their way to their 10thanniversary dinner. The husband has a dislocated hip but the wife is more severe with a ruptured fallopian tube. She lost her pregnancy. As Browne and Murphy are telling the husband about what happened, he says that was impossible because he had a vasectomy years earlier. When the wife awakens, she says that she has not had an affair and that the vasectomy must have failed. The team says they will test his sperm count (the test shows no sperm). Murphy examines the patient while her husband is in the cafeteria. She kisses him and says that she was just thanking him for saving her life. The husband learns that there health insurance has been cancelled, bank account drained, retirement account liquidated. The patient took the all the money and has been donating to community organizations. We learn she has a tumor that lowered her inhibitions, which is why she also had 4 affairs. The surgery should fix the problem but the husband feels too betrayed to support her. Browne tells the husband that through everything, she never left him and never stopped loving him. Her tumor resection is successful and we leave this story with the husband holding the wife’s hand.
In a second storyline, a teenage boy is being prepped for a hernia repair. But that is put off when he reports a sore back and fatigue. The doctors suspect a virus. The parents admit that he has never been vaccinated: They had a niece who had intestinal problems after her vaccine. The parents say they do not travel and keep him in public school so the other vaccinated children will protect him from disease (one problem is that too many parents rely on this and in many places immunization rates are below what is needed to maintain herd immunity). They know vaccines work, but think the risks are too high. Renick yells at the parents, lecturing them about vaccine safety and the risks of not protecting their son. Parke takes a tack of trying to get on their side and not lecturing them. In the hallway, Reznick says they should send the family home and refuse to treat. She shares a story of a friend whose unvaccinated child met a bad end. Parke says that do no harm means to help them now instead of sending them away. The doctors test him for polio and as Parke talks to the parents, he tells them Reznick’s story of and asks them to reconsider their choice. They do not.
While performing an MRI on the patient, Reznick criticizes Parke for stealing her story. She says, “Stories do not change minds.” He responds, “Stories are the only things that change minds. More than facts. More than fear.” This idea of the power of stories and the need to write and tell them are a foundational belief of the health humanities and narrative medicine. Parke is correct, stories are how legislators are convinced to change their minds or to support a bill, stories are how we teach students, helping them connect theory to practice, and stories are how we share our experiences with one another.
The MRI shows that the boy has two spinal cords—part of his spinal cord is split in two. At puberty the cords stretch and can lead to paralysis. Melendez suggests surgery which could fix the problem, but also could lead to paralysis. The mother comes to Parke and says that she and her husband spoke and they want vaccination as soon as possible (though this is suspicious). Immediately after the injections, the boy falls and loses feeling and movement in one leg. The surgery is a success but his temperature rises and he falls unconscious. Parke tells the parents the patient has a staph infection and that it in no way relates to the vaccination. We learn that the father did not know (the foreshadowing was correct) and the parents stop speaking.
Parke approaches the husband who is not open to hearing stories even though Parke tells another one about families staying together after betrayal. The father pushes Parke away and asks if the story was even true, Parke admits that it was not. The show is trying to show that stories have limits, but the real lesson is that false stories have limits because they lack heart and conviction. A true story might have moved this father, but a false one reinforces his sense of being betrayed. We are left with the feeling that this family is broken and divorce is inevitable.
An older rabbi has a bad heart secondary to his cancer and is faced with either having risky surgery (90% chance of dying in surgery) or going home and having about a year left. The rabbi chooses going home, saying he will have a good year and that he accepts his circumstances. Sharpe sits on his bed and says she is going to connect him with home care and hospice. Goodwin has trouble accepting this, in large part because he is about to begin treatment for his own cancer. As the rabbi is leaving, Max goes to him and confesses his health condition. He is looking for advice and support because he does not know what to do. After, the rabbi changes his mind and decides to have the risky surgery. Goodwin approaches the rabbi again and wants to be sure that his own “baggage” did not “tip the scale” in any way because that would be “unethical.” The question of whether a physician should treat their own clergy is an interesting idea. Ethically, this can best be analyzed with analogies: There is a recognized guidance for doctors not to treat their own families because they may lack clinical distance, may try things they would not with other patients, and may not be as thorough in charting. However, the question here is should a physician turn to a patient to be their clergy? We may find some guidance in the idea of whether a physician can date a patient (answer, not a great idea; definitely not until a significant time after discharge). While both are professions dedicated to helping people and hold the idea of confidentiality high, in this circumstance, the rabbi is a patient and should be permitted to be a patient. Thus, one should probably not use a patient as clergy until they have not been a patient for a significant period of time to avoid any conflicts of interest or role confusion. Although Goodwin turns to his patient because of convenience, it is likely not a good idea to turn to your current patient to be your clergy.
In a second storyline, a college student is seeing Kapoor for migraines. He has no treatments left to offer her and suggests counseling. She is a first generation Chinese-American and first in her family to go to college. Frome explains that in Chinese culture there is a stigma concerning mental illness and often the diagnosis is not acceptable. The patient leaves the doctor’s office and attempts suicide by subway car. She survives when she lands on the track and the train rides right over her. The patient’s mother refuses to hear about any psychiatric care and denies the suicide, “She slipped.” Frome diagnosis the woman with depression but she refuses treatment because she is on her parents’ insurance. Her parents would reject her. Goodwin suggests they commit fraud—report the counseling as something else. The patient rejects the idea that she would be lying to her mother. Frome wants to bring both mother and daughter in for counseling. Kapoor speaks with the mother and tells her that it is okay her daughter is not perfect because as parents they are not perfect. In the end, the mother and daughter come together and accept the offer of fraud to protect their reputation in the community. While cultural accommodation is an important aspect of modern health care with a diverse patient population, committing fraud to do it is ethically dubious (it is lying) and illegal (it is fraud!). I am not clear if the intent of hiding the insurance coding is to protect the father from knowing or the community. If the latter, how would the community even know what the insurance code is? If the former, the patient still has the added stress of lying to a parent. Asking health care providers to lie to patients, even for cultural accommodation, is not ethically acceptable as it violates the tenets of veracity. Plus, the wrong code in the medical record could cause problems later in the treatment of the patient. This accommodation is highly problematic.
Meanwhile, Bloom is moonlighting at another hospital and working long hours. She nearly makes an error—inputting that she gave a patient 20 mg of morphine instead of 2. A nurse tells her that studies show a physician who work shifts of 30 hours or more make 36% more mistakes (This is true). She is popping pills (presumably uppers or caffeine pills) and is seen falling asleep on her feet. When a patient that she said would be fine goes into a-fib, Bloom is woken from a deep sleep. She is having trouble functioning and makes an unusual medication request, which turns out to be the right choice. Physician exhaustion is a perennial problem. In this case, the violation is an ethical one because the physician is choosing to take on extra shifts at another hospital at the expense of putting her patients at risk and her own health. Given the data, Bloom is violating the concept of “do no harm”.