Posted on January 11, 2020 at 10:18 PM
“Exploring ethical issues in TV medical dramas”
The Resident (Season 3; Episode 11): Keeping information from patients; Capitalism and medicine do not mix; Chicago Med (Seasons 5, Episode 10): Doctors and the opioid epidemic; different approaches to treating patients
by Craig Klugman, Ph.D.
The Resident (Season 3; Episode 11): Keeping information from patients; Capitalism and medicine do not mix
Austin’s patient has an infection of the chest that can be cleaned out with surgery and then scar tissue removed in the hope that she can breathe again. She has, apparently, beaten her cancer. The surgery, however, is risky. Austin and Nevins take a good cop/bad cop approach in giving the patient the risks and benefits. The patient is an outdoor person and wants to live her active life: She chooses the surgery. Cain has just introduced a new RVU system—doctors are paid by the procedure rather than flat salaries. Cain does not want Austin doing this risky surgery because the potential for throwing off his stats are too high. As a cardiac surgeon, Austin performs some riskier surgeries. Cain tells Austin not only do not do the surgery, but do not tell the patient about DNR orders—Austin is ordered to keep the patient alive, no matter what, to help his stats. Austin tries to do the right thing, so he tells the patient about the DNR anyway.
In reality, DNR for a surgery is unusual. In most places, DNRs are suspended (often without telling the patient) for surgery because an arrest could be caused by something in the surgery that is easily reversed and also because a death on the table would be bad for doctor’s stats. Still, ethically, a change in DNR status should always be discussed with the patient. Cain is not a doctor at least in the sense of an ethical and virtuous healer: He is a business person interested in making as much money with as little exposure as possible. He is, simply, the worst kind of surgeon. Austin calls Cain out after a successful surgery, saying he has forgotten about the “sacred contract before the surgeon and that patient, that which distinguishes us from all other physicians. We cut people open, we inflict wounds to make them better, they trust us with their lives. And I don’t cut for prestige, the cash, the stats, or the RVUs. I do it for the patients.”
In another storyline, two new interns start at Chastain under Pravesh. A patient comes in with a cough and the intern, without checking with Pravesh, orders a pulmonology consult and they immediately recommend a bronchoscopy. The procedure goes wrong with the patient aspirating and has a heart attack. Pravesh tells his intern that the procedure was not indicated by the patient’s presentation: She made a mistake. However, based on the RVU system, she helped maximize income through the consult—what she did was bad for the patient but good for the bottomline. The intern recognizes her error and Pravesh says that will make her a good doctor because she displayed humility. They do not tell the patient about the error, instead saying that everything was fine. The intern asks why they didn’t tell the truth. Pravesh said he believes in telling the truth but in this environment, contradicting the chief of medicine would likely get her fired and only the patients would suffer. Pravesh then explains the RVU system and that’s why pulmonology was so fast to recommend the bronc. This incidence is further proof that medicine and capitalism do not mix.
Chicago Med (Seasons 5, Episode 10): Doctors and the opioid epidemic; different approaches to treating patients
Jesse is a 6-year-old boy with a burned foot. His mom, Lynn, says he made oatmeal in the microwave and dropped it on himself. Mom is acting odd, jittery and incoherent. Lynn has a drug addiction after Halstead, four years ago, told her she could take oxy daily for her pain. Now she tries to score drugs on the street. Manning is concerned about releasing Jesse into his mother’s care—she wants to call child protective services. Halstead asks her to break protocol and just admit Jesse to the ICU: He fears losing her child would send Lynn off the deep end. Halstead recommends a rapid detox protocol—withdrawal under sedation in 24-48 hours. The protocol is risky but will help keep the family together. Manning is concerned about Halstead’s approach—was Lynn informed of the risks? Did the hospital approve? Halsted is asking out of a sense of a need to fix Lynn since he is at least partly responsible for her addiction. Jesse later shares with Manning that he carries around Narcan in his backpack and knows how to use it; we learn he has had to use it. Manning calls CPS which takes medical custody of Jesse. Halstead had promised to keep the family together, a promise that he now cannot keep. In the last scene, Lynn is brought by ambulance, unconscious to the ED: Narcan is ineffective and resuscitation efforts fail.
In reality, over prescription of opioids by physicians was the cause of many addictions. How do to deal with this is still being examined. Given that there was marketing and incentives for prescribing oxy widely, what responsibility do doctors have having prescribed? But Halstead compounded the problem by not fully consenting the patient, giving her a risky therapy without approval, and making promises that he could not be sure that he could keep. As for Manning, although the intention to keep the family together is a noble one, putting a person in an ICU for 48 hours when he does not need it is an abuse of resources.
In another storyline, a 33-year-old male hit at the site of a motor vehicle accident is brought to the ED. His arm is broken, pulse is high, has a pneumothorax, and free fluid in abdomen. Marcel wants to do an exploratory laparoscopic surgery, but Nurse and Dr. Sexton want to go more conservative and just observe. “You’re a surgeon, of course you want to do surgery”. The patient is reluctant to agree to the surgery because his father died under anesthesia: “Is this really my only option?” Nurse Sexton offers observation which the patient chooses. When the patient later crashes, Marcel has to do an open surgery, increasing the risks and prolonging recovery time.
In reality, no one did anything wrong. Everyone was advocating for the patient, who was given his options and made his own choice. Marcel should have mentioned observation as an option and told the patient why he was against it—better communication could have avoided this problem. Sometimes, you can do all the right things and the outcomes are not great.