Posted on December 19, 2019 at 3:39 AM
by Craig Klugman, Ph.D.
The Resident (Season 3; Episode 10): Padding stats, gaming the system, losing perspective
During brain surgery, an 89-year-old white male with advanced dementia starts “breaking down”. Cain tells his resident to open the brain. Voss says that the brain is herniating: “Given his physical and mental status before surgery and given his brain herniation, he will have zero quality of life, even if you can call it life…He’ll be a body in a bed, a vegetable. It’s the compassionate choice at this point [to let him go].” Cain Responds, “I’m only going to say this once. Nobody. And I mean nobody, dies in my OR.” Cain later instructs his resident to tell the patient’s son that everything went well, that the patient is stable, and to do so with a smile when delivering this “good” news.
In reality, the choice is not the doctors’ to make. This possible outcome should have been discussed with his medical power of attorney, in this case his son, beforehand and certainly could be discussed in the moment (since there was time to discuss it in the OR, there should be time to discuss with the family). Quality of life is a personal determination and one that should be made by the patient and family (or guardian) but not by the physician who can speak to the physical capacities and abilities the patient may have, but cannot judge whether this is a life worth living. Also consider that we no longer refer to insentient patients as “vegetables”, a term that is not respectful to use in regards to a person. In addition, Cain has ordered his resident to lie to the family by withholding some information (what happened, likely prognosis) and by telling an untruth (it’s good news). There are very few circumstances in which a physician can lie to a patient (or their family) and this is certainly not one of them.
In a related, second storyline continuing from Episode 9, a mother is unconscious and has been since her surgery. Cain tells the daughter that there is good news, her mother can go to rehab. The daughter is confused because her mother “doesn’t move.” Cain says “your mother is a fighter. She survived the surgery…Don’t give up before the miracle.” At the long-term facility, the EMTs inform the admitting nurse that they have another body for the “vent farm” from Cain. She says there is not a bed available and park the patient in the hallway with the others. Clearly Cain is known for bringing insentient patients there. Bell confronts Cain, saying the timing of the transfer was interesting because if the patient makes it past 90 days, then the outcomes of the surgery are considered good and the surgeon’s stats remain good. In addition, the patient was transferred to a long-term care facility owned by the same corporation that owns the hospital. When Bell exercises his right to call a meeting of the Board so that he can reveal the wrongdoings, he is stripped of his chief of surgery position, a role then given to Cain.
In reality, doctors should offer hope, but they should not offer unrealistic hope. Doctors should not make medical decisions to prolong life (or shorten it) merely to make their own stats or their own program’s stats look better. Bell and Voss note that Cain has upcoded, let residents do unsupervised surgeries (with no attending anywhere to be found), and operated on patients who were poor candidates and then left them to linger, all to improve his stats and income. This storyline also points out the problem of arbitrary metrics (like 90 days for survival)–health care providers are smart enough to make their metrics look good for personal benefit, even if it hurts the patient. And certainly, they must disclose (if not completely avoid) conflicts of financial interest.
In a third story, a teenage football player is brought to the ED by his mom when she can’t wake him. He took some sleeping pills, but she says it is okay because they were prescribed. As we learn, he was cut from the football team and took an overdose of acetaminophen and sleeping pills to die. He survives but needs a liver transplant. Conrad says that acetaminophen is the major cause of liver failure in the U.S. [and he is correct on this point]. However, knowing that there is a suicide attempt means the patient would likely not be approved by the transplant board at this hospital (selection criteria differ from hospital to hospital). Pravesh, who is known as a moral standard of right and wrong, suggests that they do not report the attempt” “I’ve seen more shades of grey than I used to. Sometimes to be right, you can’t follow the rules.” The idea that to do right requires rebelling against a corrupted system is a foundational tenet of this show. When presenting to the transplant committee, the chair outright asks Conrad if the overdose was a suicide attempt. He responds, “Absolutely not”. Even when advocating for a patient, physicians should not lie—the liver that this patient may get, to which he may not be due, means someone else won’t get a liver. After the transplant, Conrad tells the patient that he wants him to have counseling for the suicide attempt. However, when Conrad says this, he is unaware that the surgeon is standing behind him—his lie is revealed and he is fired—not necessarily for this decision (which is the excuse) but for his previous role (season 1) as a whistleblower.
In a fourth story, Okafor’s friend’s mitral valve regurgitation worsens. When she blows the valve, Okafor wants to do surgery on the patient even if it costs the life of the baby. Austin states that the patient made it very clear that the baby’s life comes before her own and that he can save them both. The baby is delivered (5 weeks premature) and he puts the mother on bypass in order to repair the valve. Beyond the maternal-fetal conflict issues presented in this case (more clearly in Episode 9), the major concern raised in this episode is Okafor’s loss of objectivity and professionalism.