Season 6 Recap: 6×13 39 Differences

Another thoroughly enjoyable episode that hit all the right beats and was overall wholesome and cohesive with just the right amount of character development. If the season continues like this, I’m happy.

The Technicalities

Written by David Hoselton & Tristan Thai
Directed by Cayman Grant
Original airdate 13 Feb 2023

Patient Cases

Patient #1 – Ricky Pavlovic

Treating physicians:
Shaun Murphy, Asher Wolke, Daniel Perez

Diagnosis:
Nail impalement through the foot, concomitant naegleria fowleri infection with resulting brain oedema

Case notes:

• Ricky is initially seen in the ER by Asher and Danny for removing a large nail that has fully penetrated the foot
• Ricky is apprehensive and afraid of the procedure of removing it, his parents are also on edge and in disagreement over how to raise their child
• After removing the nail, they find that Ricky’s body temperature rises unusually fast, so he is given further tests
• An MRI of his foot doesn’t reveal any signs of infection, but Asher and Danny discover two tick bites on his back
• They suspect he may have complications with neural involvement, so they suggest a lumbar puncture to check Ricky’s CSF (cerebrospinal fluid)
• The CSF spurts out of the needle, which indicates elevated intracranial pressure, they administer anti-seizure drugs and glucocorticoids to reduce the brain swelling and prevent seizures
• CSF sampling results confirm a rare infection with naegleria fowleri, a brain-eating amoeba
• They induce medical coma and place a port to feed antibiotics right into Ricky’s brain that they hope will reduce the swelling and help fight the infection
• Ricky starts seizing due to increased brain swelling, they get him to the OR to open up his skull and relieve some of the pressure
• Rick’s brain swelling is severe and Ricky is now in status epilepticus (dangerously prolonged seizure activity), Shaun orders more anti-seizure medication and an additional external ventricular drain
• As a rather extreme but effective option, Shaun proposes to remove the damaged area of the brain that the seizures are originating from since Ricky is maxed out on anti-seizure meds
• The region of the brain they propose to remove is responsible for speech and memory, it’s possible that the procedure could affect his ability in these areas, but most likely not long-term
• The parents agree to the surgery when Shaun and Asher pitch it to them
• When Ricky wakes up, neither his memory nor his speech seems to be affected and the brain surgery saved his life without significant aftereffects

Fun fact: The actor who plays Ricky (Beckham Skodje) portrayed the five-year-old version of Norman Bates on Bates Motel, the series that Freddie Highmore starred in before he accepted the role of Shaun on The Good Doctor.

Patient #2 – Brecka

Treating physicians:
Audrey Lim, Jordan Allen

Diagnosis:
Cystic fibrosis in its end stages requiring a double lung transplant

Case notes:

• Brecka is one of Lim’s long time patients, she has known her since she was eight
• Brecka has cystic fibrosis in its final stages and is in dire need of a double lung transplant
• Donor lungs have just become available and Brecka is at St. Bonaventure for the transplantation, but both lungs show signs of pneumonia when they arrive
• Jordan suggests ex-vivo lung perfusion so that the lungs can heal themselves
• Jordan and Lim hook the lungs up to blood and air supply and antibiotics – the P/F ratio needs to be at last 400 mmHg in order for the lungs to become viable for transplantation
• The team and Brecka wait, and around the critical six hour mark, the lungs only hit 278 mmHg
• Lim and Jordan inform Brecka and her mother that the lungs are currently not viable and the outlook is not good, Brecka will be lucky if she has another week
• Lim and Jordan keep monitoring the lungs, and the P/F ratio rises, but only very slowly
• Brecka goes into full respiratory failure and her mother says that Brecka didn’t want to be intubated – they’re ready to let her go
• At the last minute, the lungs hit 402 mmHg and Lim calls Jordan to get Brecka into the OR
• When Brecka wakes up from the surgery, they extubate her so she can try breathing on her own
• Brecka takes her first breaths with her new lungs and they seem to work perfectly

Interesting side note here as well: The actress who played Brecka is a double-lung transplant cystic fibrosis patient herself, her name is Elspeth Arbow. CBC published an article about how she was being cast for the role and what it meant to her, it’s a really good and emotional read.

Patient #3 – Mr. Riggs

Treating physicians:
Morgan Reznick, Alex Park

Diagnosis:
Hemochromatosis

Case notes:

• Riggs is one of Morgan’s clinical trial patients and is there for one of the study visits to monitor side effects (and possibly other study assessments)
• When she and Park examine him, he presents with fatigue, joint pain, impaired mental acuity, tachycardia and mild liver failure
• Morgan is concerned about these side effects since they’re unexpected and more severe than what would be indicated
• Park suspects Riggs could have a pre-existing condition, but Morgan states that should have been caught in the screening process
• Blood tests reveal Riggs had a pre-existing condition after all: hemochromatosis (a disorder in which the body builds up too much iron in the skin, heart, liver, pancreas, pituitary gland, and joints)
• Morgan presumes that Riggs lied about the condition so that he could participate in the study and be paid the $3,500 compensation
• Park tells Riggs about the diagnosis who asserts that he has never had these symptoms before
• Park notices that Riggs has a “20 Gallon Club” blood donor pin on his jacket, and Riggs confirms that he gives blood very regularly – that is until he joined the study about two months ago and hasn’t been allowed to give blood since
• Riggs’ regular blood donations prohibited iron build-up in his body, which explains why he didn’t have symptoms of hemochromatosis until now, which also means he didn’t lie and it has nothing to do with the study drug or the study protocol

The Shaun & Lea Family Journey

Shaun is in full planning mode for the future of their son, now also apparently known as The Peanut. (Awww.) He has already put him on the wait list for prekindergarten at McClelland Hall, the snobby private school in Menlo Park.

Shaun’s take is that, with the genetic makeup of his parents, their son is likely to be very intelligent and should be attending Stanford University. Lea would rather Shaun start thinking about a college fund for the Peanut. She’d also prefer waiting until he’s old enough to consider his educational path or his preference for academics.

With the nursery door closed, Lea wonders if Glassman is still asleep, but Shaun said he already left. Shaun is a little taken aback when Lea mentions Glassman has been so sad about losing the house, because how can she tell? Shaun didn’t take Glassman’s taciturnity as something worrisome and felt it was a nice change.

Lea surmises Glassman is throwing himself into his work, but what he’s actually doing is buying amateur excavation gear in form of steel-capped shoes, gloves, a heavy-duty flashlight and a shovel. I think we can all guess what he’s doing with that.

Meanwhile at St. Bonaventure, doubts about parenting are starting to surface for Shaun when he watches and listens to the parents of his teenage patient. They can’t agree on very fundamental ideas how to raise their son, and Asher and Danny sow more seeds of uncertainty when they share their own views and experiences about parenting.

And then Shaun goes to do what he does best: He makes a list. By the time Lea comes out of her big meeting, he’s jotted down 37 potential differences that he and Lea might have about child-raising. And he wants to discuss them all with her right away. Lea, however, has just been given the task to run beta-tests in the next 24 hours on new electronic medical records software that Andrews wants to implement.

While Lea and Shaun are busy with their paid work, Glassman is doing more manual labour among the debris of his burnt down house. He’s trying to unearth physical memories that may still be buried underneath all the rubble. There really isn’t much to show for that’s still intact, but he finds a flask with glittery nail polish that somehow survived the fire that he thoughtfully pockets.

Supervising his residents, Shaun is mildly reassured by Asher and Danny who tell him that he and Lea will be fine because they’re not that different, and they love each other, which is all that matters – at least according to Hallmark Channel. The reassurance doesn’t last that long, because Shaun inquires with his patient’s mother if she loves her husband, and she tells him that she does. It was the little things that she and her husband could never agree on, and she’s not sure that love is enough anymore.

With Lea stressed and somewhat unapproachable, Shaun takes his latest conundrum to Glassman to try and get some advice there. Much to Shaun’s credit, he actually takes a moment to gauge Glassman’s emotional state of mind—as much as that’s possible for Shaun, but I’d like to think that the seed that Lea planted about Glassman being sad gave Shaun some pause to not immediately go like a bull at the gate with his own need for guidance.

Shaun checks with Glassman if he loved Ilana and if he loved Debbie, and why that wasn’t enough to make their relationship work. And that’s the thing. You can’t know if love is going to be enough. Which Shaun clearly isn’t happy with. “I do not like worrying about this.”

Glassman reminds him that he and Lea managed to get over their latest bump in the road when Lea was unsure about motherhood during their babymoon, but that doesn’t seem all that reassuring to Shaun because differences over child-raising seem to be so much bigger than what they struggled with before. It gets worse when Glassman talks about how having children will shift everything, including marriage. Because change is inherently bad, and Shaun very much doesn’t want any shifts. Except Glassman suggests that maybe the shift might be for the better.

I think Glassman can see that it doesn’t exactly help Shaun, that he’s still worried, so he shares some of his own memories of how he and Ilana thought they could fit both their blossoming careers around their daughter, and how that changed in an instant when they brought Maddie home from the hospital.

Glassman isn’t the one who Shaun should be talking to, however. He really needs to run all this by his wife. Which he tried and got rebutted, so there’s nothing other than patience that will help Shaun right now. And even though Shaun says he can be very patient, that isn’t always the case.

In this event, Shaun’s hyperfixation gets in the way of his patience, so when he gets home pretty late at night he makes another attempt at discussing their now 39 differences (since he thought of two more) despite Lea being visibly busy and having told him before she has a deadline to work against.

Not surprisingly, this isn’t a great time to broach the subject, which Lea clearly tells Shaun, but he keeps pushing. What Dr. Glassman told him about their dynamics shifting must be running circles in his mind now, adding the ruminating worry instilled by his patient’s parents that he and Lea will not be able to work out their differences.

When he tells Lea that he isn’t sure that love will be enough to glue them together in the long run, it catches Lea off-guard. That’s a really big thing to drop on her late at night with her being super stressed already. Props to her that she’s not actually exploding in Shaun’s face and instead calmly tells him that they’ll have to table that conversation until after she’s done with her IT project.

It’s his patient’s parents the next day that give Shaun the nudge in the right direction. Ricky’s father says, “Sometimes you have to trust that things will work out,” and his wife links her pinkie finger with her husband in hopes that their son will make it through the needed emergency brain surgery and the night. Maybe love will be enough after all?

Glassman is still digging through the rubble, and this time it’s Lea who is dropping by to see how he’s doing. He insists he’s fine, and he’s less than enthused about the hot dog flavoured crisps and the chocolate wafers she’s brought in lieu of an actual meal due to serious lack of cooking skills.

There are so many memories buried here, and he talks about the one time when Maddie insisted she paint his nails (hence the pocketed nail polish), and the other time Maddie wanted to go as a ham for Halloween, and then when she was scared of ghosts and insisted to sleep in her parents’ bed for two weeks. Glassman surely isn’t as “fine” as he indicated to Lea.

And as sweet as it is that Lea stopped by, Glassman remarks that rather than talking to him, she should be talking to her husband. Lea knows that, but she admits that this is easier. Oh yes, the old avoidance tactic, but I can’t say I blame her. Shaun can be a handful when he’s sunk his teeth into something.

Their moment of truth comes when Lea (presumably) texts Shaun to join her and Glassman at the debris site so they can finally talk about their 39 item list. Shaun does just that and sits down next to Lea, reaching his hand over to link his pinkie finger with Lea’s. He starts with, “Number 39, dietary restrictions.”

It’s the Peanut who cuts that particular conversation short for a moment when he makes himself known, Lea feeling him kick for the first time. Shaun immediately reaches his hand over and gets really excited. Lea gets Glassman’s hand in there as well, and they all share the exhilarating moment. She looks at Glassman and says, “Think of all the new memories, waiting to be made.”

There’s a small smile on his face and he’s finally ready to leave the remnants of his old life behind to go home with his family that’s right there. As they get up to leave, Shaun returns to his list and to item 39, which was the Peanut not consuming any dairy products before six months other than breast milk. Easy peasy, Lea is fine with that. Next?

Lim’s Journey

Lim’s case is that of a young woman with cystic fibrosis by the name of Brecka whom she’s been treating since she was eight years old. She’s in the end stages of the disease and urgently needs a double lung transplant, which thankfully is just around the corner with a donor lung that’s on the way.

The case is very personal to Lim since she’s known Brecka for so long and Brecka has also been documenting her journey in videos and on her website (called More Than 65 Roses). It becomes even more personal then Lim and Jordan discover that the donor lungs both show signs of pneumonia. Lim knows that it could be a death sentence for Brecka if she doesn’t get those donor lungs, so she is willing to fight for those lungs.

It may be possible to hook the lungs up to blood and air supply and feed them with antibiotics so that they can recover from the infection and heal themselves enough to be viable for transplantation. Lim is ready to fight tooth and nail for it.

It’s heartbreaking when Lim has to give Brecka the news that they had to put her back on the donor list since the lungs aren’t improving the way they were hoping. It’s likely that Brecka might not make it if they don’t find a new donor within the next few days.

Lim tries incredibly hard to keep those lungs (which she’s named Pneumie) going by changing up the antibiotic regimen and staying there all night, not ready to give up hope. Brecka crashes and gets to the point where she’s in full respiratory failure and they will have to intubate, but her mother says they don’t want that, she’s ready to let Brecka go. And just then, the hard work and patience pays off and lungs reach viability, so Brecka is prepped for the surgery that will save her life.

It’s a very moving moment when Brecka makes it out of post-OP and takes the first breath with her new lungs. Her new life can begin, and it’s thanks to Lim who saved her life anew.

Morgan’s Journey

Morgan is enjoying her new job a little too much, it seems. Fancy new office with a fancy coffee machine and all the perks of now being the head of a department. The pastel coloured office supply accessories on her brand new desk are on par with everything else, too.

I’d like to think that the binder on her desk is a paper copy of the ICH Good Clinical Practice guideline, but hard to tell. Props to the prop department for putting a few medication bottles and packages there that actually look like real study medication.

Morgan’s first study is a big one – 800 patients. Yes, in clinical trial terms, that’s a lot! And it sounds like she’s still in the hiring process for study nurses and sub-investigators, so right now she’s a little short-staffed and Alex helps out.

They make their way through the study patients to do the necessary assessments and check for adverse events (i.e. side effects and negative reactions to the study drug). Their last patient is the one who actually has more than a mild reaction, he’s fatigued and has joint pain and signs of jaundice.

This worries Morgan since it could mean that the study drug is causing more severe adverse events (AEs), to the point where it could lead to the trial having to be stopped for safety reasons. Alex tries to reassure her and tells her to wait for the blood panel results, it’s possible that the patient had a pre-existing condition that is now causing these symptoms. Which also worries Morgan, because that should have been caught in the screening process. So is her staff incompetent and overlooked this? Or is the study protocol badly written?

What Morgan refers to when she mention screening process is an actual thing. Every clinical study has inclusion and exclusion criteria that determine if a patient is fit to enrol in the study. These criteria are checked before the patient signs the Informed Consent Form that officially starts the study participation. Very often a reason for exclusion are certain pre-existing conditions, like heart or liver conditions, drug abuse, cancer, intolerance to ingredients of the study drug, suicidal ideation, etc.

What’s not necessarily realistic here is that they seem to be running the blood test at the local hospital lab. Usually big studies use a central laboratory where all blood tests are being run in a standardised way. It would have been more realistic if they’d sent the sample off to the central lab, but of course if there are immediate safety concerns, study sites can also run blood tests locally.

The lab results that come back reveal that the patient did actually have a pre-existing condition that should have excluded him from participation. Morgan presumes he lied about it so he could enrol and receive the $3,500 compensation. And at any rate, it means that the people who are screening study patients are incompetent.

Alex remarks that Morgan has an unnecessarily negative outlook on life if she immediately suspects the worst of everyone. Is that really the world view she wants to impart on her future child? She justifies it with, “I’d rather be pleasantly surprised than bitterly disappointed.” And, you know, I totally get it. I tend to do that too, because I don’t handle disappointment well. Not sure that has to automatically be a bad thing…

It’s Alex who ultimately solves the mystery of their study patient. He’s been a lifelong blood donor, which eliminated his symptoms – until he joined the trial and had to stop giving blood regularly. So it turns out that nothing actually went awry with the trial. The screening process and the protocol is sound, no one was incompetent, the patient didn’t lie and the AE is unrelated to the study drug. All’s well that ends well.

Things to Further Dissect

Carry-Over From Last Week

I missed to mention this last week, but I wanted to briefly touch on it now, because it’s kinda curious and not sure if it was intentional or just another continuity blunder. At the beginning of 365 Degrees, when Glassman was talking about not wanting to impose on Shaun and Lea while his house was tented, he called Shaun and Lea “friends”.

Which seems odd in the context of there now having been multiple mentions and acknowledgements that Glassman is actually Shaun’s father more than anything else. In fact, Lea has called him that more than once, in his presence, and he’s definitely conveyed to Shaun as well that this is how he also sees himself.

So why is he suddenly afraid to actually call himself that in front of Shaun and Lea? Perhaps this was supposed to be another journey to follow along during the episode, to have Glassman realise that Shaun and Lea are family and not just friends, but it seems strange since he’s already been through that journey in the past and I thought it was like… been there, done that.

That said, there was definitely a story there in terms of parental figure acceptance, or maybe parental figure affirmation. Not just because Lea and Jordan were talking about Grandpa Glassy, but also because Shaun pretty much immediately compared Lea having accidentally seen Glassman naked in the shower to Shaun seeing Lea’s mom naked.

Moving on to this most recent episode, 39 Differences continued Glassman’s journey of acceptance of being an extended part of the Murphylallo family, in addition to Shaun and Lea trying to figure out how having a child would impact their marriage.

Memory Lane

In the wake of the house fire, we see Glassman trying to come to terms with the fact that a large portion of his life now lies in shambles, and with it any physically tangible item that is tied to all the memories he made over the course of several decades. Not just did he lose his daughter all those years ago, he has now also lost any physical connection he may have still had to Maddie. There are no more photos, no more children’s toys, no more visual cues she was tethered to.

In some ways, it probably feels like Maddie is being erased from Glassman’s life altogether, with nothing palpable left to hold on to. Is it any wonder he’s now spending his days trying to dig through the debris somewhat futilely in hopes of picking up the not quite disintegrated pieces of his past?

We learned bits and pieces about Maddie across the seasons, but lately it’s been a theme that Maddie is more and more front of mind for Glassman, perhaps with now having a grandkid on the way. It had been made very clear before that he still carries guilt for not having tried hard enough to get Maddie out of a spiral that eventually killed her, that he failed as a father to his own daughter, some of which he probably channelled into trying to do better with Shaun.

I think on some level, Shaun and Lea’s son will also be a cathartic journey for Glassman to see a child growing up whose life he can be a part of, that he can love in a way that he never could with Maddie, and as Lea so aptly put it, make a whole bunch of new memories that will be worth living for. This episode was all about packing up those old memories to put them in storage and make room for new ones that will be just as fulfilling and worthwhile: Time to close the old chapter and start the new one that’s waiting to be written.

The last scene in the episode was so very beautifully done since not only gave it Shaun and Lea room to resolve their 39 differences but also to bring things around for Glassman and make him realise that he has a figurative home with Shaun and Lea, that he plays an active part in a new family that’s soon to be expanding.

Shaun Insights

Another interesting thing about this story arc was also that not only did we learn about Glassman’s sentimental attachment to his past and how deeply the loss of Maddie still hurts, we were also reminded how Shaun’s processing of emotional aspects is very different from that of most neurotypicals.

If you think back to that scene in the morning when Shaun and Lea get ready for work and Shaun mentions Glassman already left, Lea comments that Glassman seems really sad, and Shaun asks her how she knows that. She, in turn, asks Shaun if he didn’t notice how quiet Glassman has been, and Shaun says he did but that he actually enjoyed the quiet, showing us once more that he has a disconnect in associating certain behaviours or non-verbal cues with emotional states of mind.

It was left a little ambiguous whether Shaun actually ponders or internalises this and whether that was part of his motivation to check in with Glassman at the debris site. My personal take is that his going to see Glassman was actually more self-motivated in that Shaun was seeking out Glassman to get advice for his own issues with Lea, which then led to the conversation about how disagreements related to parenting feel so much bigger than the usual disagreements.

Kudos to Shaun, though, that he didn’t immediately start the conversation with that but that he actually first listened and tried to gauge Glassman’s state of mind before he graduated to what bothered him personally. I think that’s as close as we’re gonna get in terms of Shaun being empathetic to emotional plights of people he’s close to, and actually a pretty significant thing for Shaun to first listen to Glassman before bugging him about his own 39 Differences Conundrum.

If we dissect this further, there’s all of this to consider:

1. Glassman sent Shaun a text that he was fine the day he started digging around in the rubble instead of going to work. We don’t really know if Shaun had texted him before, which may have prompted that response, or whether Glassman sent Shaun the text unprovoked just to reassure him after not showing up for work.
2. Glassman had told Shaun in the text message that he was “fine”. Shaun is all about verbal communication. If someone tells him they’re fine, Shaun believes that this person truly is fine, despite what they may be trying to communicate non-verbally. He chose to try and gauge Glassman’s state of mind after Lea’s hint that Glassman might actually not be fine rather than go by Glassman’s verbal assertion that nothing was amiss.
3. Shaun, by design, is often inherently selfish. This isn’t malicious or even intentional, it’s part of how many people with ASD think or perceive. Shaun not putting his own personal challenge above Glassman’s emotional state was a pretty big deal.
4. Shaun isn’t a man of introductions or easing people into conversations. He is often talking about what’s on his mind before he’s even crossed the doorframe. So going in and first sitting back to let Glassman dictate the conversation was an equally big deal. It may not have seemed like it on the surface, but if you know how to read Shaun between the lines, this actually spoke very loudly about how much he cares about Glassman.

There are more subtle hints in these scenes that tell us how much Shaun is attached to Glassman. Shaun’s first go-to about the losses of the fire is Glassman’s large LED TV. On the surface, you could surmise Shaun only cared about having access to a large size TV, but there must be more layers than that. First of all, Glassman mentions that the TV was old and had a pixel line down one side. Shaun, with his visual acuity and attention to detail would have known that – it even sounds like the kind of thing that would bother him quite a bit.

So below the surface, I’d like to think it was never about the actual physical television set, it was about the fact that it provided a reason for Shaun to come over to watch something on it together with Glassy, maybe the latest football game or some old movie or TV show they mutually enjoyed. It was basically Shaun’s roundabout way of saying: I will miss having a reason to come visit you so we can have a good time together.

Conversely, when Shaun gets home after visiting Glassy at the debris site, Lea asks Shaun how Glassman is. Shaun’s first reaction is to describe visual and physical attributes rather than answer the question of the emotional state of mind. Lea probably chose not to dig further because she had a work deadline to meet and might have wanted to avoid longer back and forth with Shaun, because she’d know that there might have to be a good amount of prompting to get Shaun to talk about anything emotional. Shaun’s lack of information about Glassman’s emotional state may have also prompted her own visit to see Glassman the next day to find out herself.

There may have been people who, after the ending of the previous episode, assumed Shaun might be more distraught about Glassman losing all his belongings, but I didn’t actually think that Shaun was out of character here. He’s always been the type of person not to dwell on the past and the person to focus on moving forward, to focus on fixing what is fixable. The burnt house and the loss of everything in it isn’t fixable, and Shaun knows there is nothing anyone can do to change that.

You also need to consider that Shaun doesn’t really have a close attachment to that house beyond it being the place where his dad has lived for most of his life. Shaun’s most important memories tied to Glassman are from their time in Wyoming. We don’t even know if Shaun has ever been to that house before he himself moved to San Jose for his residency.

Which brings us to another question: What’s next for Glassman? Seeing how the burnt down house was the perfect metaphor for the emotional baggage of Glassman’s past, a perfect evolution of that metaphor would be not to buy a new house but to rebuild. It would be wonderfully poetic if he cleaned up the rubble of his past and used the foundations of the old house to build a new one.

If we wanted to spin this further, they may even consider building it in a way that could be a home to two family units, Grampa Glassy and the Murphylallos – in a way that they have their own separate spaces but are still close to each other, with the added bonus of Glassman not having a massive house all to himself and building according to his needs with his chosen family doing the same. It’s certainly possible they won’t go that route, but I would personally really love that idea.

The Peanut

I think it’s super cute that Shaun and Lea are calling the baby Peanut. When I was writing my Shaun and Lea offspring fanfics, that nickname was also on my shortlist, but I ended up using Cricket. I’m kinda glad the two versions of the little Shea rascal are diverging that way as to not muddy the waters.

And of course it’s very Shaun to already be trying to plan every single one of Peanut’s big milestones. There’s definitely going to be a rude awakening for Shaun when he will realise just how much of actual parenting you can’t plan in advance. Right now he thinks he’s in safe waters, he’s got it all figured out, with the hospital smocks and the menthol cream and the noise-cancelling earbuds. Let’s see how he fares after the first few sleepless nights and a cranky, equally sleep-deprived wife to deal with at the same time.

With the introduction of the patient case with the teenage boy and the parents who were in constant disagreement about parenting choices, this was the perfect catalyst for Shaun and Lea to address some of the important aspects of how to parent the Peanut. It’s perhaps a bit surprising that they haven’t tackled all these big things until now, seeing how Lea must be at least six months pregnant by this point.

The theme of Shaun doubting that he can be a good father has been touched on so many times in different ways, and more recently it was actually Lea who was having doubts and Shaun being the one assuring her that they’d work it out as a team. At the time, Shaun thought their love for each other would be enough to make it through the hard and the tricky times, but seeing Ricky’s parents is now making him doubt that reassurance. And that spirals him into a whole new maelstrom of insecurity and unease.

Shaun being Shaun, he goes into “we need to talk about this and fix it” mode, but unfortunate timing has it that Lea is too stressed with the important work deadline and isn’t in the right headspace to get into the big ticket item conversations.

I really liked that they were depicting some of the everyday struggles of being in a mixed-neurological relationship, and the scene in the bedroom where Shaun is trying to get Lea to talk about it but she tells him it’ll have to wait was a great example of this. I still admire Lea’s patience with Shaun, and it’s a testament to how well they’re in tune, even when Lea is stressed. Her eyerolls at Shaun sitting and waiting were top notch, and her reaction to him was, in my opinion, incredibly reserved and considerate.

Melissa Reiner talked about this briefly in her episode insights, she mentioned how Lea was setting clear and important boundaries for Shaun when she told him that she couldn’t go over his 39 items list or talk about their marriage dynamics right at that time, also giving him a strong verbal indication that it was not appropriate to raise these big issues when she was already stressed with work.

Of course Shaun wasn’t happy that he was being rebutted, and Lea wasn’t happy about the whole situation either, since she knew Shaun had this innate need to tick off all the items on that list and alleviate his own worries, and that it wouldn’t be an easy conversation and would likely involve some arguing back and forth on their respective ideas of parenting their son. She even voices that when she goes to Glassman and tells him it’s easier to talk to him than to Shaun.

It was also a beautiful notion, that in the end it was right in the middle of the rubble of Glassman’s house where all the threads converged and that it was both Glassman and the Peanut who brought resolution to all the underlying friction. Not only did Shaun and Lea find their space to finally talk about the potential parenting disagreements, Glassman was also invited to be a part of all those important decisions and be a part of their growing family.

I get why they didn’t go into much detail beyond #39: Dietary Restrictions on Shaun’s list, but man, I would really love to know what all those other 38 items were! Clearly, education was going to be one of them, but I have a feeling Lea would have ended up with the winning argument that you can’t decide a lot of those things when your child isn’t even born yet and you don’t know their personality and strengths and weaknesses.

I mentioned before that I think there will be few rude awakenings for Shaun in terms of parenting and how much of it is unpredictable and requires instant adaptation and flexibility. I think that will be a recurring struggle for him, although we also know Shaun is great at adapting and learning, and he will definitely be motivated to learn when it involves their child or children. I hope that they address this in one way or another on the show in the future, once the Peanut sees the light of day and starts growing up.

Question: If Shaun already enrolled their son in the snobbish prekindergarten at McClelland Hall, what name did he use to do so? Peanut Murphy?

The Clinical Trial Stuff

I was a little afraid they would mess this up, and they did. A little bit. Nothing that has me screaming at the TV (yet), but there’s a few thing they didn’t get quite right about the clinical trial stuff.

• Park said he would help Morgan out with patient follow-up because he had time. The way they introduced this, Park didn’t know anything about the study itself (after all, he took a brief glance at a document in a folder to ask about it). That’s in violation of GCP – Good Clinical Practice.

All clinical studies have to follow what’s called Good Clinical Practice, a code of conduct that outlines how clinical studies have to be run to protect study participants as best as possible and to ensure there is no bias or fraudulent activity going on. According to GCP, all personnel working on a clinical study have to be well trained on study knowledge and procedures, and this needs to be documented as well.

There’s no way Alex is allowed to just help out without study training because he has the time. It would be a major finding if there was an audit or an inspection and it was detected that untrained personnel was performing patient assessments and tests.

• When Park glanced at the folder, he mentioned Morgan’s first study was looking to recruit 800 patients. It’s not very likely Morgan would be able to enrol 800 patients just at St. Bon’s. Depending on the indication, you’re often hard-pressed to find 800 participants at multiple study centres in multiple countries around the world.

We don’t really know what trials they’re running with this CRO, but even if it’s healthy volunteers like the episode suggested, finding 800 of them in one American city is not very realistic. Granted, I’m not an expert in healthy volunteer studies, but that sounds super unreasonable to me.

If they were really trying to recruit 800 people just from the area, they must have had a massive marketing and promotion machine with a big focus on the compensation money so that the study becomes a lucrative option for participants.

Speaking of payment, several thousand dollars of compensation for participation doesn’t usually happen unless the study is very burdensome or uses medication that has a known or expected risk to result in significant side effects. $3.5k for what they were doing seemed unusually high, but without more knowledge of the study protocol hard to say whether that was unrealistic or not.

• The fact that people in the study were being paid for participation tells me they were running a phase 1 study in healthy volunteers. I don’t know what healthy volunteer study they thought they could run with 800 patients, because these studies are usually where a drug first gets tested in humans. It’s in the best interest of everyone to keep the number of participants small and see what happens in a few people first before you go into a larger population. It’s unusual to see phase 1 studies with more than 20 patients, often it’s below 10.
• Riggs also mentioned he had been in the study for about two months and it’s apparently still running. Phase 1 studies are usually short, often just a few days or a week, although it’s certainly possible there may be 2+ months long phase 1 studies. But it’s another indication that these details don’t add up.

Healthy volunteers get paid for their time and effort in phase 1 studies, and to a degree also for the risk they take when they agree to be treated with a drug that has not been tested in humans before.

When a phase 1 study is successful, you can move into phase 2, then phase 3, and then you look for patients who have the actual disease you want to treat. Those patients don’t get payment beyond maybe travel and study related expense reimbursement. They don’t have to pay for the study medication or any tests they receive as part of the study, and there’s a chance they could be receiving a drug that could help them.

Who does get paid on every study, however, is the hospital or the physician running the study. They are being paid per patient and study visit for the work they do and the time they put in, basically. The amount of payment varies with the complexity and length of the study and the disease area.

So if Morgan was running an 800-patient single-centre healthy volunteer study, what the hell were they testing? Not to mention that healthy volunteer trials are often super involved with many, many blood draws and tests run at regular intervals, often also overnight stays with very strict meal restrictions. Phase 1 units usually have their own facilities with overnight stay offerings and clinic beds. It didn’t look like that was the case here, either.

I’m glad that The Good Doctor didn’t go the route of there being something fishy going on with the study. Pharma companies get enough of a bad rap for being evil and extorting sick people for money, or that clinical studies are all rigged and fraudulent. What we often see on TV related to clinical research is a pretty gross misrepresentation of what it actually is and how it works.

Clinical studies are run in an extremely regulated environment. Sure, there are always ways that data can be manipulated, but there is so much at stake with these trials (usually billions of dollars) that it would not be smart for a pharma company to go and actively jeopardise that, especially those that are well known and have a reputation to lose.

The way that studies are run is very rigidly governed by laws and rules and regulations—some global, many regional or national, but all fairly similar. The large regulatory agencies (like the FDA in the US or the EMA in Europe) have very strict rules that need to be followed in order for a pharma company to submit a drug for approval.

And before a drug gets that approval, it will cost a pharma company literally billions of dollars in developing it before the drug can start making them money. Some drugs never will because they fail during the development process when the company has already spent millions or billions on it. It’s actually a pretty tough business.

It’s also the reason why pharma can’t go and sell all their drugs for peanuts. A large phase 3 clinical trial can cost you 30 to 40 million dollars alone. It’s pretty crazy. All that money needs to be recouped, and there needs to be more money available in order to keep discovering and developing new drugs. Without profit, there can be no new research. Extra points for The Good Doctor that Morgan mentioned the trial she’s working on costs $4,000,000 (which, to be honest, sounds low budget for an 800 patient trial).

What I hope for future episodes is that the writers take enough care not to twist the realities of clinical research into these sensationalist and unsavoury ideas that puts clinical development in a bad light or that depict the day-to-day business of running trials in a way that it has all these negative implications.

As someone with first-hand experience, I will stand up to say that pharma companies aren’t inherently greedy and evil, and there isn’t a general underlying motivation of clinical trials being manipulated and faked just to make money. Those are the absolute exceptions that always end up in the media and shape the overall perception of pharmaceutical companies in the general public. But it’s just like plane crashes. Everyone talks about the one plane that crashed, but no one talks about the how many million flights that didn’t.

That said, if anyone ever approaches you to ask if you would consider participating in a clinical trial, I recommend that you try to stay open-minded about it. Don’t be afraid to ask questions or look up resources online that explain the basics of research. Here’s a few links to get started if you want:

• CISCRP
• EUPATI
• FDA website
• ClinicalTrials.gov
• National Institute of Health (NIH)

Favourite Scenes and Lines

• Shaun already planning out the Peanut’s whole academic career while he’s still in the womb. So very Shaun. It’ll be interesting to see when Shaun learns first-hand just how unplannable parenthood really is.
• Lea startling when Shaun ambushes her as she comes out of her meeting, à la ‘I have this bulleted list of 37 things we need to immediately go through so I can put my mind at ease.’ Really, Shaun?
• Shaun actually being mindful enough to give Glassman some room to indulge in all those memories buried underneath the rubble. I love these subtle moments that tell us just how much Shaun has grown over the years and how much he loves his family.
• Jordan getting cronuts and joining Lim to watch over the lungs. That was sweet and caring.
• Lea setting clear boundaries for Shaun late at night as he keeps hyperfixating on his list. I love how level-headed she stayed with him, although the eye-rolls behind his back were amusing.
• Shaun having an eye for the important details and soaking them up, like when he stopped to take in the parents’ pinkie finger linking.
• Lea and Glassman and the potato chips with the Nutty Buddies. His, “Mmh,” reaction was so priceless. Extra points that he actually ate them.
• That beautiful last scene with the kicking Peanut and the family bonding. Murphylallo-Glassman bonding is always awesome and sweet.

Sorely Missing

Last episode I said I would have loved to see more of Glassman’s immediate reaction to the fire, like the night or the morning after it happened, him processing the whole thing, but I was fairly sure we wouldn’t be seeing any of that. And we didn’t. Which of course I can totally live with, I get that they didn’t want to waste time on something that would be fairly obvious and that they elegantly packaged up in the few lines around Lea remarking how sad Glassman has been.

Another thing that I think we’re all dying to know is what the other 38 differences were on Shaun’s list. I really wish that we could get a close glimpse at all those little grey notebooks of Shaun’s, because I’m sure some prop person or intern wrote them all down in there. Of course I also get why the rest of the conversation about Shaun’s list didn’t make it on screen.

Could be a fun exercise trying to figure out what other differences Shaun thought would be an issue. I’m fairly sure things like exposure to screen media and screen time restrictions would be on there, as well as choice of toys, bedtime rules, recommended playtime activities and sanitary products to use. If you have more suggestions, leave me a comment below!

Oh, and sorely missing are also official episode stills for this episode. Turns out set photographer Jeff Weddell wasn’t booked to shoot stills for this episode, so I guess there aren’t any. What a letdown.

Best Shaun Muffin Face

No Spoilers, please!

Quick reminder that I love feedback but try very hard to actively avoid any kind of spoilers for upcoming episodes. Please don’t mention any spoilers in your comments, which includes information from episode promos, stills and other official promo material. Thanks, guys!

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