Posted on September 27, 2019 at 1:28 AM
The Good Doctor (Season 3; Episode 1): Cancer Diagnosis and Dementia; The Resident (Season 3; Episode 1): Profit over patients; New Amsterdam (Season 2; Episode 1): Social Justice; High Cost of Insulin; Carol’s Second Act (Season 1; Episode 1): Stereotyping Age; Grey’s Anatomy (Season 16; Episode 1): Too soon to die; ageism
by Craig Klugman, Ph.D.
Welcome back to the new Fall season of medical dramas. This year is a return of familiar shows which may indicate the current interest in these shows has peaked (seems that legal shows are cycling back). Although #ChicagoMed also premiered this week, there was no bioethics related issues in the season premiere. One theme in common with many of these shows this week is that of ageism—when is someone too old to practice medicine, or to start their practice.
A 70-year-old man comes in thinking he has kidney stones. He is diagnosed with cancer. With surgery he can live another 3 to 5 years. The doctors tell him of his diagnosis. Hours later, the patient has no memory of the conversation and is asking why they didn’t tell him he has cancer. The patient clearly has some dementia. His wife won’t hear of it and says she won’t stop caring for him just because it’s hard. Park believes they should not do surgery and let him enjoy what time he has left. Reznick says that the man is funny and loved by his family. She says he has a curable cancer and is not terminal. Later, Renick sits with the wife and explains the situation. When the patient complains about back pain (from the biopsy) he wonders why he had a biopsy for his kidney stones. The wife lies to him, says he was fine and going home. She chose to make the most of the time they have left rather than subjecting him to surgery, chemo and radiation which will cause suffering that he will not be able to understand or remember. From a bioethics standpoint, doctors are always supposed to tell the truth unless the truth will cause harm to the patient. In this case, the wife tells the lie, not the doctors, and the repeated learning of his cancer diagnosis would cause greater harm. Even if the doctors had told the lie (with the wife’s permission), it would have been acceptable.
In a second storyline, a young groom brings his bride into the ER. She is bleeding. The team diagnosis her with invasive cancer. Murphy’s proposal is to take all of her major organs out of abdomen, cut out the cancer and then reassemble her. The risks are severe, ranging from needing to live on dialysis, to being diabetic, to death. Chances of success are small. Without surgery, on hospice, she might have a year. The patient tells her new husband to go find a healthy person to be with. He says he would never leave her so they choose to go through the surgery. She survives but will need a colostomy bag for the rest of her life. In reality, there is not right answer in this situation. Autonomy says that a patient gets to decide. The question is whether this risky surgery was too risky to have been offered in the first place?
A theme of this show since its beginning has been how the patient has become lost to the pursuit of profit. In this new season, that theme continues.
A mother with her baby approaches doctors taking a break outside the hospital. She was hoping to visit the free clinic which has closed. She’s avoiding the ER because the last time she was there, the hospital gave her a $6,000 bill. It seemed like she was waiting for a doctor to come out and take pity to help her child. In the ER, her baby is diagnosed with RSV and bacterial pneumonia. The baby is taken to the NICU and presumably the mother is stuck with another huge bill she can never pay.
The hospital has been bought out by a conglomerate, Red Rock Mountain Medical. The new corporate owners make it clear from the beginning that doctors are valued for their billing and not their skill. Bell, chief of medicine, is expected to kowtow to the new bad boy surgeon, Barrett Cain who bills over $80 million a year. On the other hand, a talented surgeon, Voss, who only bills $2 million is at risk of being fired. We watch Cain perform a brain surgery that takes 5 minutes: Once the patient is prepared and the skull open, he removes the tumor and then leaves, ordering an unsupervised resident to close. The patient seems inconsequential to billing. As Voss points out, to bill that much, a surgeon must run multiple ORs, overbills, and has side deals. Bell points out that “health care is a business” and doctors that focus on the bottom line are the future. Such disregard for nonmaleficence and putting patients at first would be shocking in most circumstances but is just another day in the office on this show.
This season begins with a series of mini-lectures on social justice as each character welcomes Goodwin back to the hospital. First, Reynolds says that black patients are less likely to get their pain treated so can the hospital add treating pain irrespective of a person’s race to patient rights. Frome tells Goodwin that his transgender patients are being denied all care because of “religious freedom” laws that allow any health care provider or institution to discriminate against anyone who violates their religious beliefs. Much of the discrimination falls on LGBQT people. Kapoor mentions that 30% of doctors are over age 60 and when they retire there will suddenly be a huge gap in care with not enough doctors. Goodwin turns this around and says the problem is that doctors are not retiring when they are past their prime and so they need to have older doctors do more mentorship and have lower patient loads.
While these are all issues, there is some truth to the facts. According to the Federation of State Medical Boards, thirty percent of physicians are over age 60 and there will be a shortage when they retire. Also, older doctors tend to have mortality rates higher than younger ones unless the older doctors have high volume practices. There indeed is racial bias in pain treatmentbased on racist beliefs about how different groups feel pain or even beliefs about who “deserves” care. While many have argued that the new religious conscience rules will permit physicians to refuse to treat LGBQTpatients or anyone else, the rules are new and the fallout is still evolving.
One patient in the ED is ill because she has to ration her insulin. She tells us that when first diagnosed, the cost of insulin was $20 and now it is $250. In the patient’s words, “I can’t afford to live.” Goodwin decides to take on big pharma, cancelling the hospital’s drug contract and sending a truck to Canada to buy insulin there. His efforts to talk to the pharma company and to bring back the drugs from Canada fail. But he does arrange for his one patient to get a lifetime supply of insulin. In reality, the high cost of insulin is forcing patients to ration their supplyand skip doses (This topic was dealt with on The Resident last year.) As a result of self-rationing of insulin to avoid the increasing costs, more people are dying avoidable deaths. The patient thanks him for her supply but wonders about everyone else who needs insulin. Goodwin says that he was fighting for her, who was his patient today. Tomorrow, he will fight for someone else.
This is a new comedy featuring award winning actress Patricia Heaton. That’s the best that can be said about this piece. The premise is a school teacher who decides to go to medical school after her divorce. Press says that the character’s age is 50 but, on the show, it is not clear. Sometimes she talks about her peers retiring and other times she comes across more middle-aged. Most of the first episode was simply a series of jokes about Carol being old: At first her peers think she is the chief resident. The jokes that are not about age are about her being a former school teacher, making her empathetic and able to draw on her “long” life experience to help others: “I’m not an old lady, I’m an old doctor” Carol yells at her chief resident. The only time that Carol was shown positively is when she is breaking news of a new cancer diagnosis to another resident’s patient. Carol breaks the news because the assigned resident is young and has had no bad things in his life from which to draw to show empathy. The message is that her years of experience mean Carol is better at connecting with patients than her younger colleagues. The episode ends with her three other fellow interns wanting to hit on Carol’s daughter, and Carol treating them like they are 5thgraders: “Put your napkin on your lap.” In pursuit of cheap laughs, this show furthers damaging stereotypes of people based on age. Perhaps the creators wanted to show the opposite, that age is no barrier to changing careers and that there are advantages to having life experience. But a character who only speaks in terms of anecdotes, “I had an uncle who had this problem”, “My friend suffered from this” simply reinforces stereotypes that anyone over 30 is “old” who rambles on with stories of their youth. I usually give shows two episodes because the pilots are often stiff and have to do the heavy lifting of creating an entire mythology in a short time. However, with flat characters and jokes that draw on tired and injurious stereotypes, I don’t think I can give this show a second look.
A 35-year-old patient was hiking when he and his wife climbed to the top of a mountain. While taking a selfie, he took a step back and fell off the mountain. He suffered from two shattered legs and his wife prevented him from falling further for hours. They are discovered by two doctors returning from a camping trip. The patient is on life support, unconscious and no one can figure out why. Shepard recalls a patient she had before with a similar situation who ended up having fat embolism syndrome. She runs into the patient’s hospital room while the residents are about to extubate the patient and let him die: “We’re climbers. He wouldn’t want to live like this” his spouse says. The treatment continues over many days and seems to have no effect. The wife is screaming “I promised that I would never let this happen. We promised each other. Stop. Stop. Stop. What if this makes him just better and not that he can’t die. What if this makes him just better enough that he’s just stuck in this body for another 20 years. My husband is living his worst nightmare.” Luca tells her that it is not time to give up on him. A week later, the wife has found a good long-term care facility and is more accepting of her husband’s condition. However, the doctors have a surprise: The patient is awake and will be okay.
In part 3 of “you’re too old to practice medicine” this week, Weber is interviewing for a new job. The interviewer says that yes, they are looking for someone with experience, but not too much experience. Then she asks if he was thinking of retiring. Weber pauses and says that he was not thinking of retiring. In case, anyone is ever interviewing a prospective employee, please be aware that federal law makes it illegal to ask a person’s age.
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