Map of life expectancy at birth from Global Education Project.

Monday, May 23, 2005

House of Pain

Criticism of commercial television is not normally mah thang, not least because I can't afford the death of so many neurons from watching it. But I was inspired by a review in the British Medical Journal and a Fresh Air interview with the creators to check out Fox TV's hit medical drama House, M.D., and I find I have a professional responsibility to comment.

Dr. House is a senior internist (apparently) at an academic medical center whose defining character traits are relentless arrogance, condescension, insult and psychological sadism directed without fear or favor at colleagues, superiors, residents, medical students, patients, nurses and innocent bystanders. Nobody ever complains, talks back, or even appears to be hurt by this behavior because they all know full well that they are all incompetent idiots while Dr. House is the Greatest Medical Genius Who Ever Lived. Every single patient who comes into this hospital is misdiagnosed, often because they have a bizarre or rare condition that only Dr. House has ever heard of, but always because, as Dr. House puts it, "Patients always lie." Only House's vicious put downs and oozing contempt can torture the truth out of them.

Okay. The writers are indeed holding a kind of funhouse mirror up to nature. Many physicians and observers of the medical institution have described what has been called the "culture of abuse" in medical education. Preceptors and medical school professors do indeed often treat students and residents with scorn and contempt, and many a resident has had as a role model an Aesculapian attending who treats patients like specimens of diseased vermin.

It is also true that physicians should not trust everything that patients tell them. Patients commonly underreport their behaviors that physicians will presumably disapprove, such as tobacco use, alcohol abuse, junk food abuse, etc.; overreport their adherence to prescription drug regimens and other medical advice; and may be either misleadingly stoical about symptoms (perhaps because they would rather not hear bad news), or overly worried or hypochondriacal, for various reasons.

However, it is not conducive to accurate diagnosis or the effective practice of medicine to glorify sociopathic behavior by physicians or to morally condemn patients as "liars." Communication and ongoing relationships between doctors and patients are complex social processes in which powerful influences from within the culture of medicine and from the life world of patients can conspire to thwart accurate understanding, in both directions. The solution is to be found in more compassion, understanding, and sensitivity, and less judgment, not the other way around.

Furthermore, diagnostic puzzles and medical detective stories indeed make up a good part of the case study literature, and some prominent medical journals features such stories regularly. They are fun, and sometimes more broadly instructive, but not actually very common or at all typical of a day at the doctor's office. When they do arise, physicians confer with their colleagues. Dr. House never calls a consult or refers anyone to a specialist. Why should he? He knows everything, from neurology to hematology to psychiatry, and nobody else even knows that the knee bone is connected to the thigh bone.

This show is, I must say, an accurate portrayal of one cultural archetype of the heroic doctor, as a kind of artificial intelligence. But it doesn't work for me.

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