“Risks and Rewards” beautifully leads a character to question – Is Shaun a risk worthy of the rewards?

This is a part of a weekly series where I watch a new episode of ABC’s “The Good Doctor” (as it comes out in the UK – so I’m a little behind the US sorry!) and review it for it’s realism in portraying autism and medicine. This week’s episode is titled “Risk and Reward” – Season 2, Episode 15. There will be spoilers from the very start. The cover image is not owned by me and is the property of ABC, all rights reserved.

This weeks episode talks about a subject that it very close to my heart as Shaun’s (Freddie Highmore) future as a surgeon is debated and Dr Han (Daniel Dae Kim) pushes him into pathology (I say push – I mean it. There was no discussion with Shaun and overall it was hugely unprofessional. But I believe that part was unrealistic for dramatic effect so hey ho). As I was a doctor for a while, this specific topic has a lot of elements behind it where I chose a different path to Shaun and so this episode strikes me quite closely.

But I’m going to make you work a bit before we get to that part – let’s talk through the premise for the episode. There are a few arcs interplaying. The first is the case of the parents who just had a neonate born through Caesarian section with an exomphalos (bowels outside of the body due to weakness in the abdominal wall where the umbilical cord connected) and congenital heart defects after the Mother took paroxetine during pregnancy. The second was a really good bit of accurate medical representation regarding screening and shared decision making (which most people would probably find dull, but was actually really well done and I thoroughly applaud the writers for this part). The third was around Dr Glassman (Richard Schiff) at chemotherapy and ultimately in him developing relationships with cancer patients while trying to assess the benefits of joining a support group or not.

The title of the episode is “Risk and Rewards” and the episode epitomises that well, overall being very well written. The neonatology case is one that is complex (not out of the realms of the imagination – the only thing unrealistic is that all of these doctors would be involved in this case. But see last weeks review for my thoughts on that) and doesn’t necessarily have clear answers. You have to balance risks and benefits. The preventative medicine case is an interesting one and is one that shows that sometimes statistics don’t mean anything, a decision is based on your feelings and beliefs for life. The case of Dr Glassman has someone who has a predilection for going through things alone, due to past experiences, and having him face to, not only his current reality (an ongoing arc for Aaron) but with research and the potential benefits from the situation. His case is one where the benefits just make total sense, but he has to get his thought process over a lot of different barriers to appreciate that. The episode is about decision making, ultimately leading to the wider narrative of Dr Han’s evaluation of Shaun throughout the episode leading to him making a decision for Shaun. While the last part was dramatised, this is a really well made episode and the writing team should be really proud of themselves.

Taking the neonatal case. Firstly, there would not be an on call neonatal cardiac surgeon unless you are in a hugely hugely specialist hospital, but even then. You are more likely to just have a neonatal surgeon on call. It’s a bit odd to have someone so specialist on call, unless you are a tertiary paediatric centre. Seeing as though we only ever see (now four) surgeons at attending or above level then this seems unlikely. Also, to stress the point, the surgeons would probably not be able to insert an endotracheal tube into a neonate – this is a really technically demanding skill and requires a lot of practice to get it right. There are also some strange continuity errors (Shaun has gloves that he seems to chuck on the floor at some point, which is really bad practice and makes for quite the health and safety risk).

One of the things discussed in the case is the use of SSRIs (selective serotonin re-uptake inhibitors – the main form of antidepressants we use) in pregnancy. It is highlighted that SSRIs have been linked to birth defects. This is a field that is currently gaining more investigation and information around it, so is fair to approach, though the show does not discuss the complexities of mental health during pregnancy and so provides an unbalanced argument around this.

Firstly, the evidence is not consistent. Some studies report that there is no significant increased risk of birth defects, some report that there is a small increase. We are still talking about rare events and not everyone taking these medications during the early stages of pregnancy around going to have problems. It should also be noted that due to how development of the foetus takes place, the risks are at their greatest during the first trimester and then go down a lot after that (the specific development points are not those as affected by the medication). Would this make me want to recommend people stopping SSRIs? Not necessarily.

The choice to use SSRIs in pregnancy is one of risks versus rewards. Ultimately, what we have learnt over the years is that poor mental health is bad. Another thing we have learnt is that mental health doesn’t necessarily get better during pregnancy and that being pregnant doesn’t protect you from mental illness. In some cases it can lead to things getting worse. Therefore, you now have a person with a mental illness that could get worse during pregnancy, which could add a potential risk for the mother and for the baby. This then makes it into a balancing act. Is it worse to have a small additional chance to the general population of having a child with a birth defect that (at least in this case) was treatable, or is it worse to have a mother whose mental health becomes worse and may behave in a way that is unsafe for all parties involved.

There is not necessarily a clear cut answer. In some mental health conditions, you should stay on medication during the pregnancy in some way if possible (ex. Schizophrenia, bipolar affective disorder). Luckily, antipsychotic medications that can be used in the treatment of both of these are thought to be mostly safe during pregnancy (unfortunately for the people with bipolar affective disorder, lithium and a lot of the anti-epileptic drugs that may be used are associated more significantly with birth defects and so they may need to change medications). However, for people with depression this is a bit more murky. How has their depression presented in the past? How are they feeling now? What were they like at their worst? How much have the SSRIs helped? There are  a lot of questions you need to ask. If someone was suicidal before, has been on SSRIs and tried coming off them, which lead to them feeling suicidal again – then the risk of suicide could be seen as much more significant than the risk of a small increase in the chance of birth defects. If the person has only been on SSRIs for a few months due to a problem that they have been having that is now sorted, then the risk of birth defects may be more significant and so they may want to stop the SSRI.

There is not set answer for this and this is the patient’s decision. However, what I want to make evident is that it is not a straight forward decision. Taking SSRIs does not mean that your baby will definitely have a birth defect. Avoiding taking SSRIs does mean that your baby could still have a birth defect. Sadly we can’t always know and sometimes life just sucks. But throughout this you need to make an assessment of risk and reward. Where the benefits are, and what the potential cost is.

This episode discussed this well in regards to the baby. Should the doctors take the decision making away from the parents? This is a paternalistic approach to medicine, but is a fair discussion in regards to children. The ethical principles surrounding medical decision making is more interesting regarding children. In England, in this situation there are a few outcomes. If the surgeons were coming with a potential treatment that they felt was the best option and one parent consented, even if the other didn’t the doctors could take that as consent and give the treatment. If the surgeons did not think that a potential treatment was the best option, then they shouldn’t be offering it because it is against their good medical practice and they have a duty to not perform the procedure if it is going to cause harm. If both parents disagree with a proposed course of action, you can then involve the courts to act as a ‘super parent’ and agree with the doctors, thus ruling over the parents. But mostly, the parents have the decision making. This becomes more complicated as a child gets older where they can fulfil the rules of Gilick competence and make their own decisions (if they fulfil the criteria for that specific decision) but we are talking about a baby so they won’t fulfil that for this scenario. So in this country that isn’t how this would go, but for America this could be different. Either way, I felt the ethics of this were discussed in a good and interesting manner.

The second arc was brilliant and I am really impressed with. Preventative medicine is a complicated area, there are some places where it can be really appropriate (ex. use of statins for preventing cardiovascular disease in people who have previously had cardiovascular disease) and others were it is inappropriate (ex. full body scans to check for any random abnormalities, leading to the finding of incidentalomas). This episode discusses the risk of the inappropriate ones, but puts all of it over to the patient to decide and is a beautiful example of shared decision making. If I was redoing my community based medicine block then I would highlight how wonderful this episode is for presenting this, as it does it so well.

Full body scans are just a horrible idea. We all have random things that aren’t going to be perfect in line with textbooks. When doing any imaging you can often find little anatomical differences and other things that just don’t matter. But once you have seen it, you may need to do something about it. At least in the UK (it may be different in America due to how money works in the health system), we are careful about what tests we order. There is a financial element to that, but mostly it is because you have to ask yourself the question ‘if I find something on this test, do I have to do something about it’. A good example is d-dimer. This is a marker for lots of things, but is used for looking for deep vein thrombosis (blood clots in the veins of the leg). When someone has a DVT, d-dimer is raised. But as d-dimer can be raised in a lot of scenarios (pretty much for just small things, d-dimer can be raised if you exercised this morning), it can otherwise be a bit pointless. Therefore, you should only really order a d-dimer test if you are suspecting DVT and the results you should take with a pinch of salt (not literally). If you order a d-dimer and are not suspecting a DVT, then it may come back raised and then you need to do something about it, even if you think they don’t have a DVT.

One hospital I was at had d-dimer as a routine test for whenever a patient entered the hospital. It was a stupid idea for this reason. A lot of people would come back having a raised d-dimer leading to all sorts of unnecessary follow up as they came in for reasons that were not in anyway relating to DVTs.

The point from this is that you need to be careful when organising tests. In the case of the patient in this episode, their full body scan shows a tumour that the doctors think is benign, but can’t be certain of. This is a bit more cloudy, but with those statistics, it was probably benign. Ultimately this leads to a procedure where they remove it, but the patient is left with a limp due to their nerve root needing to be resected to reach the tumour. For the patient, this was a risk that they were willing to accept for the potential that they wouldn’t have cancer.

Whatever you think of this decision, that doesn’t matter, and that is where I am so impressed with this episode. Mental capacity is the ability for a person to listen to information, process it, weigh it up against other factors, make a decision and communicate that decision to others. The patient in this scenario has mental capacity and makes a decision that people may not think is worth the risk. But the thing is that they make that decision of their own free will. There is no saying that the decision is right or wrong, the decision was his to make. He had the information, he made a decision with it, and he lives with the consequences. This is how medicine works. Doctors should not be making your decisions for you – that is not their job. The role of a doctor is, in part, to give you all of the information (from their specialist understanding through training for many years) in a way that you will understand so that you can make your own decisions. This episode does this beautifully. The beauty of it in this arc emphasises how unfair the decision of Dr Han’s is against Shaun later in the episode, which is brilliant story writing.

Dr Glassman’s arc is nice. I like how the story is played out. It is very much a minor note, but adds nice definition to Dr Glassman’s character. He is someone who wants to be left alone, but more and more in this season is learning that he probably shouldn’t. From the start of it to where he was talking to his hallucination of his daughter and hiding everything from others, to this point where he is now engaging with random people, there is a good amount of development. This is a good progression for his character and is very human. I worked on Oncology as a doctor, and this sort of experience is something that is quite believable. They also discuss a fair number of random tidbits that can help (ex. Peppermint oil), which is fair to mention. Cancer patients often become ‘specialist patients’ where they have a lot of information about their disease that they can use to help others. This is a really good thing and can provide catharsis for the person giving the information, while providing beneficial information to the person receiving it.

Finally, we get to Shaun and Dr Han and that whole situation. You’ve worked enough – I can give you a bit of my insight now. Do I think that Dr Han was unfair in making the decision for Shaun? Yes. Do I think that Dr Han was completely wrong? That is more difficult to answer, as we end up discussing risk and reward.

I mentioned in a previous answer that Shaun is a bit of an unrealistic character. He is an autistic character who, as commonly done by people creating autistic characters, has every single trait of the disorder while also being incredibly brilliant. Does Shaun fit the bill for savant syndrome? Probably not, and if he did then I would be more worried about him being a doctor. The reason for this is due to the duties of a doctor.

A doctor is a position of great responsibility. Doctors are generally a very respected part of the population with people generally trusting them (until recently they were the most trusted occupation). When you think about doctors, and in particular good doctors, a lot of traits should turn up. Things like honesty, respect, empathic, understanding, confidential, trustworthy.

The General Medical Council puts the traits of a good doctor as this:

  • Knowledge, skills and performance – all in all, a doctor should be good academically and able to do the job. They should be reflective and willing to learn more (and always striving to it). They should know where their limits are and work within these. Ultimately, their first concern must be their patients.
  • Safety and quality – A doctor must take swift action if they think that a patient is in danger (if their safety, dignity or comfort is being compromised). They must protect and promote the health of everyone, even those who are not their patients.
  • Communication, partnership and teamwork – A doctor must treat patients as individuals and respect their dignity – treating them with empathy but also keeping their right for confidentiality. They should work in a partnership with their patients: giving them the information they need to make a decision in a way they can understand; respecting the patients’ rights to make their own decisions; supporting patients in caring for themselves; and listening to and responding to their concerns and preferences. A doctor should do this while working in a team in a way that best serves this goal.
  • Maintaining trust – A doctor must be honest and act with integrity. They must never discriminate against anyone (in particular patients and colleagues) and must never abuse the trust given to them by their profession.

The General Medical Council is an organisation in the UK that seeks to protect patients from people that would abuse those principles and so puts together information and guidance to doctors as professionals. Issues come that doctors have to balance their professional guidance with ethical and legal guidelines, with the practicalities of modern day service and with their personal sense of right and wrong. It is not always clear cut as to where the priorities lie, but if you can bring it back to best serving patients then you end up in the right place.

Let’s look at Shaun through this. Shaun has brilliant knowledge, skills and his performance is great. He is distracted by sensory environments, but on an academic level he is fantastic and a credit to his profession. He knows his limitations pretty well and, up until this point, him and the team have been working around that pretty well. Problems occur, but they muddle through and are supportive of each other. Does he take swift action against problems with patient safety? Yes? However, when he is exposed to huge amounts of sensory information this makes this tricky. When he is overloaded, he sometimes hasn’t acted swiftly against problems with patient safety in a way that someone who is neurotypical may have been able to. However, he quickly makes his point known and has owned up in the past when he makes a mistake, which is really important for trust. He promotes health for everyone he interacts with.

Where it gets trickier is when we look at communication, partnership and teamwork. Shaun has been working really hard at this, but he struggles to communicate things in a way that is appropriate for the patient. He at times says certain things that are harmful for the patient, and in saying those things can cause patients to lose trust in their medical professionals, which negatively impacts the medical profession as a whole. He has made progress in respecting patient’s rights to make their own decisions, which is great. But he can struggle in listening to and responding to their concerns and preferences. One of the difficulties around this as well is his awareness of him doing this. He is not aware of the mistakes he is making, and on reflection about it he is still not sure about the situation. While reflection is an important part to academic skills, the skills of communication are equally important and reflection plays a huge key towards this. However, Shaun is honest to a fault, which can in some cases be brilliant for patient relationships and in other cases be a real issue. He isn’t discriminative against others from what we have seen so far.

So by these criteria, Shaun is brilliant in some aspects and worrying in others. The problem is that in order to maintain the high level of respect for the medical professional, you need to be good at all of them. This is a problem for Shaun as he is faced with a world that he doesn’t completely understand.

For me, I don’t feel Shaun would have made it out of medical school without this being addressed in some way. If not addressed then, it would have been addressed when he was an intent (junior doctor by our standards). Shaun has two major complicating factors to his ability to be ‘The Good Doctor’:

  • Shaun has a tendency to experience sensory overload, which can affect his decision making and ability to respond to patients. This means that he may not always be able to help with patient safety while performing his professional duties.
  • Shaun has limitations in his communication skills, namely in identifying the concerns of others and reciprocating that by directing his language in the best way to support them. In this way he could upset the trust relationship of the medical professionals working on the case and could lead to harm to the patient.

However, Shaun brings a lot of positive factors to his patients too. He is brilliant, and provides fantastic solutions to patients. While this is brilliant and worth celebrating, doctors are held to a high standard. A doctor who can do all of the duties on an average level, is not as much of a risk as a doctor who can do two brilliantly but then two poorly. We need doctors held to a high standard as otherwise we can’t trust them and then everyone is left in a tricky situation. We need to be able to trust doctors, and Shaun produces a risk to that.

Shaun has really good skills as a doctor. And when I say good, I mean really good. He thinks of things that others don’t and provides interesting perspective. This is even seen on a communication level when working with people in diverse groups where he provides some quite helpful elements for their care. Most importantly, Shaun has a passion for helping people in this way and for using his knowledge of healthcare to help others.

This brings us to me. I don’t think I am the same as Shaun in this situation and I think that in part is why I am not a doctor anymore. My communication skills have always been pretty good, because I was taught to overanalyse everything and read non-verbal cues. My ability to read non-verbal communication has always been one of my strong points that I used as a support worker to connect with the people I worked with. This ability for analysis though is exhausting. I am constantly aware that I could make a mistake at any point if I am not at the top of my game every second, and this is terrifying. I know my tendencies in communication, and I know that I don’t understand everything and so I could screw up. If I screw up, then I could cause someone harm. This provided me with an issue when I had all of these duties given to me. I love a rule set, and this is a hefty rule set. I want to follow rules. However, in order to do that it took a lot out of me.

Where I am the same as Shaun is regards to our capacity for sensory overload. If anything I’ve probably got it to a worse degree than Shaun does, but that is a debatable element due to us not being able to actively compare. For me, hospital lights were the worst thing (so I really felt for Shaun during the quarantine episodes). But the fact is that hospitals are layers upon layers of complex sensory information. The lights, the number of people all running around, the huge levels of emotion everywhere, the sounds, people touching you, odd smells, odd feels of equipment, people you don’t know being everywhere. There is always something new to analyse. When faced with this, it takes away a large amount of your ability to think about a situation. When you are a doctor you need to be able to think. You need to be at your best so you can provide your best to your patients.

When I was faced with this information, I didn’t collapse on the floor and curl up into a ball – as that would show others what was happening and could affect trust. Instead I would start to shut down internally to protect myself. This occurred to the point where I dissociated from the situation and put myself on autopilot to survive (as that was what it felt like). I would be good at running notes over, writing exactly what someone had said (as far as I could hear it) and doing what I needed to do to fulfil other’s requirements. However, if someone would have asked me to think independently in that situation then I wouldn’t be able to. My head was thinking so much to control my own thoughts and stop me from doing something awful that I would never want to happen. This worked fine for me. No one knew that there was a problem most of the time. Some people were able to tell, but that was never anyone who has a health professional. If it was them, then they never showed me that they did know. Probably if they did, then they were focussing on keeping themselves stable and ok, which is understandable.

The problem for me was where the constant assault of sensory information built up on a daily basis and I didn’t get to rest up enough to recover from it. I worked less than full time, but still didn’t have enough to recover from this. This led to a few things, but an important one way me thinking whether I was fulfilling what a ‘good doctor’ was. I was being brilliant in lots of ways, but was I being a good doctor? I went through those guidelines again and again and reflected on what I was providing.

This is where I find Shaun a little unbelievable. He is not concerned with all of this. He has no shown any doubt in his ability to provide these standards. While I’m sure this is possible, I’m not sure if it is compatible with being a doctor. Being able to reflect on your abilities at all times means that you need to be able to reflect on these factors. Being a good doctor, to an extent means thinking about this. Nothing I have seen has shown Shaun thinking about that at all, which I find at the least worrying, but at worst unbelievable.

For me, during medical education I had to think about realities. If I was to become a doctor then I would have to choose my speciality. I had a real passion for psychiatry, and in particularly learning disability psychiatry, combining a lot of my past experiences and knowledge together. However, the realities of this were likely to be a problem for me and getting to the point where I could be flexible around my requirements was going to be an extremely big challenge. The other option was to head towards pathology (where you can study specimens from patients to determine the diagnosis) or radiology (where you can interpret scans to determine the diagnosis), as given as Shaun. Both were interesting, and realistically pathology would have worked and so I was in half mind toward heading to that. It would be more comfortable for me, easier to make adjustments around (as a lot of the adjustments needed otherwise are not possible in a general hospital setting) and practically more sensible.

Shaun appears fixed on being a surgeon though, and I can understand that. You have to do what you love in this world, as otherwise what is the point really? But working out your practicalities, working out how you can be your best and so provide the best to people is important too.

Dr Han was a douche in the episode. He had music on in the operating theatre, knew it was off-putting for Shaun, and carried on anyway. That is a stance of someone with privilege that diminished the effectiveness of his team as a whole, and is not being a good doctor for the team. But it is also a part of his function and how he achieved the best results as a whole. In his position, he can do that. It sucks, but it leads to positive results for the patient and follows the duties, to an extent. Him making the choice for Shaun is douchey, but might be offering a way for Shaun to consider something else that may be more comfortable and make it ok. For me, I would have had to get through a load of general work before I could take this path, which ultimately was not going to be achievable for me while maintaining my health. For Shaun he has the option. But that is where things get complicated and will make it interesting to see how it develops.

Is Shaun a “Good Doctor”? – that is for you to decide. I do not have the answer for this. I want Shaun to be brilliant and I think that there is a definite way to use Shaun just as brilliantly to achieve this. But I don’t know if healthcare systems are ready to do that and are as inclusive of neurodiversity by design to achieve it.

Rating for medical accuracy: A

Rating for autism representation: B

References:

ABC Studios. The Good Doctor. Season 2, Episode 15 “Risks and Rewards”.

General Medical Council. (2014). Good Medical Practice.

Schwartz, R. (2019). The Good Doctor recap: Will the new chief end Shaun’s surgical career. (URL: https://tvline.com/2019/02/18/the-good-doctor-recap-season-2-episode-15-daniel-dae-kim-new-chief/) Last accessed: 27th February 2019. – For the cover image

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