House’ Has to Teach About the Importance of Medicine As a Team Effort

PAGE 50 / OCTOBER 25, 2006

What the TV Show ‘House’ Has to Teach about the Importance of Medicine as a Team Effort

By Andrew Holtz reflected a deeper truth: that consent is “The real fiction is not in the medical minutiae of often not truly “informed.” Consent ast fall I got an assignment: forms are generally written for readers Separate medical fact from fic- individual cases. Dr. House lives in a physician’s with at least solid high school, if not tion in the hit TV series “House, utopia of unlimited resources devoted to a single patient college-level, literacy…even though L M.D.” Of course, the show is a surveys show many patients have diffi- drama…and the purpose is to entertain, without distraction. He is never seriously constrained culty understanding even basic terms, not teach. But fans would naturally be such as “tumor.” interested in what kernels of reality, if by pesky administrators or laws and regulations. He Since the TV show includes an any, were to be found in the episodes. re-defines ethical behavior to suit his needs, including expected amount of exaggeration and If you haven’t seen “House,” the time compression, composite patients main character, Dr. Gregory House, is often overruling the decisions patients make about tests needed to serve its dramatic needs. But an infectious disease specialist who as I explored the first two seasons of takes the cases no one else can figure and treatments. In Dr. House’s world, patient autonomy “House,” my questions expanded out. In other words, when he hears is subordinate to his ‘superior’ judgment.” beyond simple comparisons of plots to hoof beats, he always looks for a zebra. case reports, because the real fiction is Despite his diagnostic brilliance, not in the medical minutiae of individ- Dr. House is far from a paragon. In fact, ual cases. he’s a jerk. What’s more, chronic pain young woman suddenly begins sleep- of the actual case reports that describe Dr. House lives in a physician’s from an infarct in his thigh has him ing 18 hours a day. It’s not depression. the ultimate diagnosis of a bizarre case utopia of unlimited resources devoted gulping Vicodin by the handful. The Malaria or some other tropical parasites that is similar to one featured on to a single patient without distraction. show’s producers have said his charac- are considered and rejected because “House” are based on autopsy reports. He is never seriously constrained by ter borrows from Sherlock Holmes. she’s never been out of the country. The cases were solved…but too late to pesky administrators or laws and regu- My resulting book, The Medical Nevertheless, the symptoms are help the patient. lations. He re-defines ethical behavior Science of House, M.D., follows the consistent with African Sleeping Sick- There are layers of truth in the sto- to suit his needs, including often over- chronological structure of the show… ness. Dr. House suggests the parasites rytelling. For instance, one episode ruling the decisions patients make which in turn is based on a compressed were transmitted by sexual contact grappled with the challenge of obtain- about tests and treatments. In Dr. timeline of medical cases, from presen- with someone who had been in Africa. ing informed consent during a medical House’s world, patient autonomy is tation, through lab tests, scans, and He cites a case report from a Portu- crisis. In this case, Dr. House and his subordinate to his “superior” judg- other diagnostic procedures, the guese medical journal. team discovered that the neurological ment. process of differential diagnosis, and Well, indeed, doctors in Lisbon did problems of their teenage patient were Another unreal aspect that clini- then treatment decisions. report on a woman who was diagnosed caused by a measles infection that had cians immediately notice when watch- To say House’s case mix is weird with sleeping sickness. Her partner had been dormant since he was an infant. ing “House” is that a small team of doc- would be a monumental understate- been in Angola and was an asympto- They wanted to implant a device to tors do everything. Need a lab test? A ment. Almost all his patients are young; matic carrier of the parasites that are deliver interferon directly into the ven- physician on House’s team personally rare is the patient older than 40. Almost typically spread by tsetse flies. Howe- tricles of the patient’s brain. draws the blood, operates the cen- all are apparently in robust health until ver, the writers didn’t have to be fluent The condition, subacute sclerosing trifuge and peers through the micro- suddenly struck by a life-threatening in Portuguese to find their inspiration. panencephalitis (SSPE), is quite real, scope. This TV hospital doesn’t seem to crisis. Except for stints in the hospital’s The case was described in a letter to and indeed not that rare in places have any lab techs or pathologists. urgent care clinic—which House des- Lancet in 2004. where measles is still common. The Need a scan? Two or three physi- perately tries to avoid—he leaves to In order to pique Dr. House’s inter- proposed treatment is also an accepted cians roll the patient into the imaging others all the common maladies and est, a diagnosis can never be obvious. option, if not usually the first choice. room and then sit at the controls. chronic conditions. So when tumors are involved, they hide But when one of the doctors pre- Apparently there are no radiologists, Although the primary cases on from scans and other tests. Often the sented his recommendation to the either. Need an injection or overnight House are improbable in the extreme, first hint of cancer is a paraneoplastic patient’s parents, they were befuddled monitoring? A physician usually takes when I dug into the medical literature, I sign. After all, it’s much more interest- and he quickly gave up trying to care of it. Nurses are nearly invisible. almost always found, somewhere in the ing if a case of lung cancer presents first explain the procedure. In actual clinical In the final chapter of “The Medical vast libraries of case reports available as mental confusion in a young non- practice, physicians routinely explain Science of House, M.D.,” an excerpt of today, that at least once, yes, there has smoker, not a chronic cough in an older this procedure (and more complicated which is reprinted here, I set out to been a case resembling the patient on two-pack-a-day puffer. ones) without much difficulty. explain to the shows’ fans and other the show. Of course, with the writers on his But while it may not be difficult to readers that medicine is increasingly a For example, a side, Dr. House defeats maladies that obtain informed consent for this specif- team sport, with many players and real world doctors often cannot. Some ic procedure, the scene on “House” even more rules.

Excerpt from new book: The Medical Science of House, M.D. By Andrew Holtz

Berkley Trade, New York City, Oct. 2006, ISBN replied Dr. Cuddy. “They deal with of a textbook titled Health Care USA: #0425212300, 272 pages cases that other doctors can’t figure Understanding it Organization and s Edward Vogler began his brief out.” Delivery highlighted the daunting com- A tenure as the Chairman of the Vogler is perplexed by Dr. House’s plexity of modern hospitals. Hundreds Board of Princeton-Plainsboro Teaching idiosyncrasies and challenged by his or even thousands of people, many of Hospital, he had a question for Dr. Lisa resistance to Vogler’s efforts to run the Cuddy, Dean of Medicine and hospital hospital like any other business. Reprinted from ‘The Medical Science of House, administrator: “What is a Department But even when you look past Dr. M.D.’ by Andrew Holtz by arrangement with of Diagnostic Medicine?” House’s peculiarities, hospitals are not Berkley, a member of Penguin Group (USA), Inc., Copyright © 2006 by Andrew Holtz. “That’s Dr. House’s department,” like any other businesses. The authors