Monday, April 16, 2018

The Resident: Learn the Lessons, Laugh at Everything Else

A new medical TV show, The Resident, made a big splash in the social media- largely for a perceived negative portrayal of physicians.  One EM physician even published a long editorial on NBC news condemning it as reducing trust in the entire medical profession.  The creator of the show, Amy Holden Jones, has been viciously attacked on twitter for the show, and even accused of causing patient deaths by decreasing trust in the medical establishment.


In full disclosure, I have been far too busy to watch much of the series, but have now caught the first few episodes.  There are many inaccuracies, and many cringe-worthy moments.  (The first episode features the main character pull a nurse into a hospital room and initiate a sexual encounter- its arguably sexual assault, and unarguably extremely unsanitary).  But as I watch the show, I am reminded of a philosophy that is adopted by many medical students and residents particularly in surgical specialties: learn what you can, ignore the rest.

The reality is that as a trainee, and even as an attending, almost everyone in medicine has something to teach you.  I had a mentor, a renowned surgeon, whose OR mannerisms could best be described as... intense.  Many refused to work with him, others were left in tears at some of his comments.  But, he had amazing patient outcomes- easily in the 99% percentile for his specialty.  I learned how to approach operating in a systematic manner, with constant quality improvement to achieve surgical excellence.  He abandoned a technique he used for 20 years after a single complication, in favor of a different one that avoided that complication.  Almost any other surgeon would have attributed that incident to bad luck and kept going, but not him.

There was even a brutal scrub nurse, who seemed to take delight in tormenting the residents and medical students working with her- before they became attendings and out of her power.  Nonetheless, by ignoring her barbs and being open to teaching, I learned several tips on how to hold instruments and move more efficiently- lessons that she had learned from decades of watching master surgeons at work. 

What does this have to do with The Resident?  There are a lot of lessons in that show which the American public should be more aware of, regardless of the packaging it comes in.  Medical errors are a large problem, though the show repeats the "medical error is the third leading cause of death" claim which is conclusively false.  Medicine is a business, and numerous decisions are made for business reasons which affect patients without them ever knowing about it.  The first episode features a senior surgeon with no experience in robotic surgery subtly convincing a rich patient to let him operate on him.  And in reality, untrained surgeons using the Intuitive Surgical DaVinci robot is a significant issue the profession grapples with today.  (Not mentioned- a very high possibility that many patients who don't need robotic surgery and it's higher costs with increased risks from learning curves are getting it)  One episode depicts a business manager marching around demanding doctors "upcode" patients and order more tests, a common phenomenon- though it never takes place the way it's shown on the show.  Another episode features a new nurse hired to replace an older one making a critical triage mistake and killing a patient.  Firing or demoting older and more experienced nurses (and physicians) to save money is another terrible practice at many hospitals, leading to significant decreases in quality, though rarely would anyone be foolish enough to place a brand new nurse on duty in ER triage.  In another episode, a hospital CEO trades patients with other hospitals like they are prized mules- which just doesn't happen.  But trying to shift poor or difficult patients to other hospitals or to the street (known as patient dumping) was once far more common, and is still a practice today.  Once the patient is stabilized, a private hospital is under no obligation to provide something like advanced cancer care free of charge, and can freely discharge the patient with instructions to follow up at a public institution- or just transfer the patient directly to a public hospital if they find an accepting physician.  For that matter, by cultivating relationships with fire departments and ambulance companies, areas can be divvied up so that socioeconomically depressed areas wind up in the catchment areas of certain hospitals to begin with.

And this gets to my main criticism of the show- a lack of nuance, and inaccuracies where they actually count.  No one cares if the show's depiction of how a central line is placed is hilariously off (it would cause a stroke if it was put in the way it's depicted)- this isn't a documentary.  But it does matter that profiteering in medicine is depicted as involving a villainous administrator wandering around demanding additional tests from individual doctors.  In reality, additional tests are ordered for a host of reasons, fear of malpractice being one, lack of time with each patient to take a proper history and thereby focus the tests being another.  The way administrators pressure doctors to order more tests is far more subtle, and involves changing of "care protocols" and memorandums from on-high.  For example, a hospital manager can point out that if a non-invasive dopplar is ordered more often, the hospital can collect more in reimbursement.  If that is the case, since there is no downside to ordering it (the test is non-invasive and doesn't even involve an IV), physicians may well be far more inclined to order them repeatedly.  A relatively negative depiction of simultaneous surgeries (though with a twist ending in the episode) ignores the reality that for certain procedures, especially complex cardiac operations like valve replacements, having a surgeon who does 300 valves a year by doing simultaneous surgeries is much better for the patient than a surgeon who does only 50 with no simultaneous operations.  And significant data suggests no ill effect.  Most egregious is the opening episode- a depiction of a medical team openly conspiring to hide a catastrophic error during an extremely routine surgery.  In reality, hiding of errors is far more subtle- colleagues see a medical decision that is dubious, but say nothing.  Sometimes, it's because there is a small chance there is a legitimate therapeutic reason for it- the questionable action having been taken by a doctor in a different specialty.  Also, saying something will likely lead to that clinician not referring patients to the whistleblower, leading to a loss of revenue.  The code of silence in medicine is far different than the one in police work- in the latter, obviously unethical or erroneous actions are openly covered up by peers; in the former no one other than doctors or nurses suspect that anything wrong even happened- and even that suspicious doctor is often unsure.  This erroneous and out-of-date depiction of medical errors and business practices leads to a situation similar to that of the movie The Wolf of Wall Street: it's depiction of horrific abuses and open deception of potential investors was something that the industry had long moved away from.  Subprime mortgages, targeting of vulnerable, financially illiterate individuals with risky loans, the unethical practices of large firms, and other modern practices and abuses aren't shown at all, and thus the public was left thinking that cocaine-snorting salesmen were the source of the financial collapse.  While some problems in medicine are depicted spot-on in The Resident, many many others are completely warped and not depicted accurately at all- and that really does a disservice to the conversation around improving medical errors.

And for the negative depiction of physicians: is it likely to lead to poor patient outcomes from diminished trust in physicians?  Maybe, but probably not.  There have been decades of shows and movies about police officers behaving unethically and framing suspects- The Shield, The Wire, Training Day, and waves of news stories detailing repeated instances of shooting unarmed African American and mentally-ill suspects.  And yet, police officers remain one of the most trusted professions in America.

In fact, depictions of physicians on screen have changed dramatically over the years, and this new show is hardly out of the norm.  In the 1960s, shows like Marcus Welby, MD had to get their scripts approved by the American Medical Association, and depicted physicians as uniformly and perfectly professional.  By the 1970s, movies like The Hospital and the publication of the book House of God (a clear inspiration for The Resident) were significantly less positive.  Indeed, some of the concepts in House of God- performing procedures for the sake of profit which hurt the patient, secretly euthanizing patients- are directly depicted in The Resident.  By the 1990s, the legendary television show ER had storylines in which a heroine of the show, Dr. Corday, paralyzed a patient by operating too quickly in her haste to get to a dinner appointment, and numerous other examples of less than professional behavior.  Has any of this reduced trust in the medical profession?  The opposite has occurred: the American public's trust in medical doctors has increased from 56% in 1970 to 65% today, and medical doctors remain some of the most trusted of any profession- nursing being the most trusted of all.

In the end, The Resident is a work of fiction, meant to entertain.  And parts of it are indeed quite entertaining.  Is it going to convince anyone to not undergo needed medical treatment who wasn't going to refuse such treatment anyway?  I doubt it.  And it does depict many problems with the modern practice of medicine, which are valuable to take to heart regardless of the show's flaws.  But it does a real disservice to the national conversation over healthcare in falling short of accuracy where it counts.  I don't expect to watch this show and learn how to accurately do a central line, or the differences between a internal medicine physician's and emergency medicine physician's scope of practice; but I don't think it is unreasonable to expect accurate depictions of how medical errors are concealed, how business and administration truly affect clinical practice, and the uncertainty inherent in any medical decision.

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