Posted on January 25, 2019 at 4:11 PM
by Craig Klugman, Ph.D.
Jump to The Resident (Season 1; Episode 11): Listening to patients; Jump to The Good Doctor (Season 2: Episode 12): Paying the Piper; Jump to New Amsterdam (Season 1; Episode 12): Impaired Colleagues, Robin Hood docs;Jump to Chicago Med (Season 4; Episode 12): Maternal/Fetal Conflict and Giving Bad News
Marisol, a woman in her early 30s, comes to the ED complaining of abdominal pain, with a history of an ectopic pregnancy (lost her right ovary) and a stillbirth after a C-section. She has seen many doctors about her pain but felt that none of them listened to her. Pravesh promises to believe her and take good care of her. An MRI scan shows an abscess on her left ovary. At the aspiration, Marisol screams in pain (through sedation) when the needle barely touches her. A quick ultrasound shows no blood flow to the ovary. The laparoscopic situation is complicated—the ovary is twisted on itself and because of the position of the mass, they need to remove the ovary. Pravesh advocates for his patient, asking for an open surgery (much harder recovery) which might offer a chance to save the ovary because Marisol wants to have children. When the surgeon opens the abdomen he untwists the ovary and finds a surgical sponge—clearly left from a prior surgery. After surgery, her pain is gone and she says she’s grateful.
This storyline demonstrates the importance of listening to patients and, in general, believing their complaints. Pravesh did not perform the abscess drain, the laparoscopy, nor the open surgery—what he did was listen to his patient and advocate for her, even when the tests did not show a cause for her complaint.
In a second storyline, a patient (and previous resident) died, most likely from a bad heart valve. The manufacturer tries to blame surgeon error. In the end, Bell puts “heart disease” on the death certificate to protect both his financial arrangement with the manufacturer and his surgeon. A visit from a previous pediatric patient suggests that his implantable brain stimulator might be malfunctioning, suggesting a future problem with devices from this manufacturer.
In most medical shows, unethical and sometimes illegal behavior is forgiven if the patient had a good outcome. That trope has also been the direction of this drama, until this week. A Department of Public Health review of the outbreak crisis from the previous two episodes found that Lim “nonconsensually dosed a man who was not even a patient with Haldol which is not only unethical, it’s a crime” and that Melendez “ignored a written DNR which is also a crime.” The DPH is recommending suspension of their licenses to the medical board. Andrews offers an impassioned defense of his doctors—the ends justifies the means—by saying how people were alive because of those actions.
In reality, Melendez’s action of ignoring a DNR order is not an unusual occurrence in the hospital. Traditionally, civil claims about ignored DNRs—i.e. wrongful prolongation of life—have not led to monetary damagesfor the patient or their family. However, more recent court cases have moved in the direction of penalizing doctorswho ignore advance directives or DNR orders.
The viewer is told that there will be a hearing and it will be interesting to see if the emotional appeal—“but they saved lives”—wins out over ethical and legal violations—they assaulted people.
This episode starts with Goodwin’s signature line “How can I help you?”. In a montage, we see Goodwin walking alongside several department heads presenting him with their recommendations and problems and Goodwin saying “yes, he will solve that issue.” Among the ethical issues presented are the need for total transparency (to deal with conflicts of interest), increasing diversity in clinical trial subjects, hiring translators for climate refugees, and telling a department flagged for providing too much care for patients lacking insurance coverage not to worry. This segment offers a brief hotlist of current social and ethical problems in healthcare.
In one storyline, Frome notices an elderly surgeon who is displaying physical symptoms that suggest he should not be operating. Goodwin explains that there is a system for reporting impaired physicians, but Frome is afraid to destroy a career. Goodwin says there needs to be a formal report, no innuendos, fake names, or hypotheticals. Goodwin schedules a medical evaluation for the older doctor, who has been practicing for more than 40 years. With the exam scheduled, the surgeon moves up an operation to prove that he is still skilled. Goodwin talks to the surgeon in the scrub room about leaving medicine as a legend rather than as the doctor who didn’t know when to put down the scalpel. The surgeon steps out of the room. Later, rather than let him go, Goodwin offers the surgeon the position of director of telemedicine—he can still practice but won’t be performing surgery. In reality, reporting a colleague for being impaired whether due to age, drug use, or illness is a difficult thing to do. But it is also a physician obligation and is required under nonmaleficence—not putting patient’s in danger through one’s actions (or lack of action).
A second storyline revolves around Miguel who is brought into the ED by his best friend, Ivan. Both are climate refugees, having moved to NY as fruit pickers following their loss of everything after Hurricane Maria in Puerto Rice. In the fields, they were exposed to illegal pesticides, food rot, rats poor living conditions, and homemade wine. Bloom and Sharpe disagree on the diagnosis and treatment, a reflection of a personal argument. Bloom locks Sharpe in a room to treat patients based on her hunch, which was correct. Disagreeing with a colleague is common but locking one up in order to follow a hunch, rather than building a rational and evidence-based argument is unprofessional and illegal.
In a third story, Kapoor is working with Madam Thomas, a mother who is blind. She has a history of organ failure after the birth of her daughter. She has a tumor that has caused her blindness but is a bad surgical candidate because her liver cannot handle anesthesia. Kapoor offers a new, non-surgical treatment—MRI focused ultrasound. But she first needs a heart valve repair that Kapoor promises can also be fixed without anesthesia—a promise he does not know if he can keep. Reynolds explains that the procedure requires a $3 million machine that the hospital does not own, but it’s sister university hospital does. The claim is that the patient’s insurance will not cover care at the university hospital which is why they cannot simply transfer her. Thus, to accomplish this subterfuge, Reynolds pretends to be the previous chair of cardiothoracic surgery who had privileges there. Reynolds is careful not to cross the technical line—he says he is “chair” but never uses the previous chair’s name. He lied and committed fraud, but cleared his conscious by not assuming someone else’s identity. This is less than a philosophical difference, it’s self-delusion. Could they not have asked for emergency privileges or an approved exception? The heart procedure is successful but a common side effect means the patient must lay flat on her back and not be transported. Kapoor will have to perform his procedure at the other hospital, where he also lacks privileges. When they run into one of Kapoor’s former fellows, he figures out that the doctors are “thinking outside of the box”, trying to treat their patient from a resource poor hospital by being creative—stealing time and resources from another hospital. Since the patient’s insurance will not cover the procedures and New Amsterdam hospital will not reimburse, the reality is that they are stealing resources away from university hospital and its patients. Stealing from the rich to help the poor is still stealing. The surgery succeeds and as usual, the message is that the ends justify the means.
Beyond committing fraud, identity theft, and outright theft is the problem that Kapoor made a promise (heart surgery without anesthesia) that he had no way of knowing could be kept. The professional rule is clear, never make a promise that you are not certain you can fulfill. Though the show presents Kapoor and Reynolds as heroes, in reality, they should be suspended, their actions should be investigated, and each should be punished (if not jailed) for what they did. Again, despite the recurring philosophy in these shows, in reality, the ends do not justify the means. More specifically, we should not see doctors who throw away useful protocols and expend all resources on their one patient (thus leaving nothing or little for others) as heroes. Medicine must take a broader view and see that limited health care resources are something everyone shares. To give extra to one patient means another goes without. I will agree that finances are a poor way to distribute care (as we currently do), but we have to recognize that not every patient can have everything they want, that their doctors want for them, or even that they need. Like it or not, health and medical care are limited resources.
In the first storyline, Barbara is 25 years old and 21 weeks pregnant when she got dizzy and passed out in class. She has Down’s Syndrome and tetralogy of Fallot, which was never treated. Barbara is with her mother who is her only caregiver. Rhodes determines Barbara is in heart failure and needs surgery, a complicated procedure that could threaten the fetus. Barbara says no to the surgery because she doesn’t want her baby to be harmed. The mom says “You aren’t capable of making a decision”. She tells Rhodes, away from the patient, that she has Barbara’s power of attorney (not clear if this is a guardianship but the show treats it as such. With a regular power of attorney the mother could not override her child, but with guardianship she could) and they should do the surgery. Rhodes says he heard the patient who does not want the surgery and he isn’t going to perform it. However, without the surgery she dies (as does her fetus). Goodwin holds a meeting with Rhodes and Bekker. Rhodes says patients should make their own decisions and not have them made against their will. Bekker says the mother has power of attorney (guardianship?) and without the surgery the patient dies. Goodwin says that the mother has legal authority and gets to decide. While Barbara is wheeled up to the OR, Barbara is screaming that she doesn’t want the surgery. The fetal heart beat drops and Rhodes increases the bypass rate of flow to give more blood to the baby: Bekker points out that the increase risks injuring the mother with permanent brain damage. The surgery is a success and everyone survives. This is a classic case of fetal/maternal conflict where the mother’s health needs endanger the health of the fetus (though the opposite can also occur). There is rarely a right answer, only difficult choices.
In a second storyline, Mr. Flores is in the ED with intense abdominal pain that Curry diagnoses as appendicitis. While in radiology, Flores has a bad reaction to the contrast dye—an unknown allergy. The patient codes and Curry is ordered to run the resuscitation attempt. The patient dies anyway. Curry has to tell the wife and when an attending offers to go over what to say, she says “no” because she heard a lecture about giving bad news in the second year of medical school. Curry offer the news in a matter-of-fact, emotionless tone, using technical language. Her body language is protective—arms crossed. What she does not address is the patient’s emotions—acknowledging the sadness and holding her while she cries. Sexton provides this aspect of delivering the news. What is clear is that Curry heard the words she was told to say in her second year lecture, but she missed the lesson—it’s about compassionately connecting to another person and addressing their needs, not simply delivering a speech by rote.