Death of the metrasexual (Thank God!!)

[Bill Glasheen]

"House" is garbage, sorry!

it's obvious that almost all of the major cases are complete bs

I can't say that I recognize all that you witnessed, because I only saw three episodes. However you need to realize a few things.

First, not all health care providers are alike. While many whine about not getting paid enough and dread what they do, there are always some who go the extra mile. Yes, SOME doctors will go to homes and otherwise intervene off hours. My spouse for example freely gives our home phone number away, and people call at all hours of the day and night. Needless to say, she is very popular with her patients.

Second... It would be worthwhile reading a classic article by Kerr L White published almost half a century ago in NEJM. * In this article he first produced his classic diagram which describes "the ecology of medical care."



Most doctors treat patients who reside in the greater cube. That tiny little cube in the foreground is the patients who find their way to academic medical centers. In medicine, doctors sometimes refer to cases as "horses vs. zebras", with the zebras being the unusual. In House, Gregory House deals with unicorns. At least on this program, his team specializes in diagnosing the unusual amongst the unusual. They must first eliminate all the usual suspects before finally stumbling on a diagnosis that nobody else saw. That's what they do.

What you see on that program is unusual because Greg House's shop is supposed to be unusual. That's part of the whole big picture here, combined with a generous amount of cinematic license (think Karate Kid I). House represents the unusual personality and lifestyle of the talented superspecialist. He is who he is. And I'm not making this up, FWIW. Part of what I do professionally is to evaluate the economic efficiency and process quality of physicians. Now and then, you need to create a special category for a rare breed of superspecialist. They are birds of a different feather, and need to be considered only amongst others in their rare peer group.

House celebrates the unusual the way you would celebrate Einstein and his uncommon path to achievement. And it does it in a way that captures the imagination of the average television viewer. That counts for something.

- Bill

* White, K. L., T. F. Williams, and B. G. Greenberg. 1961. "The Ecology of Medical Care." The New England Journal of Medicine 265 (7): 885-92

[Jake Steinmann]

I didn't realize a show could be a show could be more garbage than Grey's Anatomy!

Both of my parents and my uncle worked in the ER* at one point or another, and they really liked the show ER for its realism. Maybe it was better early on; I don't watch much TV and only saw a few bits of it. I'm guessing it got more soap opera-ey as it went on.

Really? My father has been an ER doc for years, and he thought the TV show was just ludicrous. As he put it "there's nothing but people running around screaming 'STAT' constantly".

ER stories are the best. I've learned how to keep eating while listening to people talk about traumatic wounds, drug abuse, death, and other fun subjects.

[Bill Glasheen]

and other fun subjects

Like ones involving gerbils..

I always loved having ER docs in the class. They have a very different view of "reality."

- Bill

[Mary S]

1. Hugh Laurie is a British actor whose roots are in comedy (see Black Adder)

2. Tv medical shows are NOT reality

3. ER doctors and staff do NOT know everything; nor can they solve problem in .5 to 1 hour weekly. (Honest!)

4. Keep the 'stache Bill, looks good on ya.

[Jake Steinmann]

and other fun subjects

Like ones involving gerbils..

Yeah, there were some of those.

Quite an education, having a father in that line of work. And a stepmother who worked in the same hospital (Nurse practitioner).

[IJ]

Bill, its certainly true that some places see weirdness. The Mayo is the source of dozens of case series on obscure diseases for this reason. They're NOT coming from Olmstead county, Minnesota.

BUT, House is not treating referrals. The nonsense walks in off the street. It's not even a consult services for regular docs who are confused. And a lot of what he sees isn't that out of the ordinary. What's unusual is his characteristic style (which I'm willing to accept the same way I accept there is a Force in Star Wars), AND horrifically bad medical judgement... leaping to absurd conclusions... giving dangerous therapies without knowing the person needs them... just silliness.

When I saw him obtain an exploratory laparotomy for abdominal pain, then review the tape (tape!?!) of the surgery, and notice something that all the attendees missed when it was right in front of them (bowel having a high frequency seizure, which is impossible) and leaping to the conclusion only two things could be causing it, and one of those things was early onset Alzheimer's disease (!!!??) without other manifestations, I knew I couldn't watch any more House unless I had a burning desire to be more irritated than amused.

The other kicker was ordering dangerous chemotherapy for the possibility of amyloidosis, which is a disease that is easily diagnosed with a biopsy of affected tissue.

[Glenn]

Those errors would reflect on whoever their medical consultant is I would think.

I enjoy House, but mainly for Laurie's performance. I have no medical training but there is a lot about the show that I would question. They seem to do a lot of jumping into things without full info and take a lot of risks with patients. Their malpractice insurance would have to be astronomical. The other thing is the hospital accepting, and even covering up, certain aspects of House's character like prescription drug abuse, tolerating it because he is so good. Reality would be a lot different, either he would be out of there very fast or the hospital would have one heck of a liability issue on its hands.

Still the show is entertaining for us non-medical types.

[Bill Glasheen]

The other thing is the hospital accepting, and even covering up, certain aspects of House's character like prescription drug abuse, tolerating it because he is so good.

It's *way* more common than you'd think, Glenn - particularly with people suffering from chronic pain. That's why a new specialty in pain management has arisen. And with the episode I saw (too much painkiller use leading to an inability to urinate), he was confronted for his inappropriate self medication. And the culmination of the show was his pissing the bed while solving a case in his vivid dreams.

Edgar Allan Poe achieved a few great things in a similar fashion. He was one of my favorite authors when a high school student. And while he was kicked out of UVa for bad behavior (gambling, lots of etc.), his room on The West Range has been preserved for the benefit of tourists.



- Bill

[Bill Glasheen]

I knew I couldn't watch any more House unless I had a burning desire to be more irritated than amused.

Have you ever taught Uechi Ryu to kids, Ian? If you did, would you teach it in as authentic a fashion as possible? Would you teach and communicate the same way you do with college kids?

Ever taught martial arts to a roomful of 5-year-olds?

Bobby Campbell was a world class sparring champion. And yet at the time, Bobby could get into kids' heads like nobody. And he would be the first to tell you that you need to package the stuff differently.

Is it possible for a person with your considerable intelligence and experience to put yourself in the shoes of Joe Sixpack or Suzy Couch Potato and figure out how to capture their imaginations with medicine? Would you feel too soiled for the experience? Or could you at least acknowledge that it takes a special way to communicate to lay people (or kids in karate)?

Just a few thoughts.

While I love kids and wish I had more of my own, I KNOW I suk at teaching them karate. I KNOW I ideally need someone with childhood ed training, interest, and experience to package and deliver the goods. And I understand that expectations need to be managed.

Maybe you could be a medical consultant for the show, Ian. Why not offer your services for a good chunk of change?

- Bill

[Glenn]

It's *way* more common than you'd think, Glenn

Great, something else to try not to think about if I'm ever in a hospital!

he was confronted for his inappropriate self medication.

He's confronted in most of the episodes I've seen, but it ends up swept under the rug. In one series of episodes where he was being investigated by a disgruntled former patient who happened to be a police detective, people were covering up for him left and right. And when it went to trial because he forged another doctor's signature and stole prescription drugs from the hospital pharmacy, his boss lied on the stand to get him off. I sure hope these are more a reflecion of entertaining TV than hospital reality!

One part that I do believe is accurate is his portrayal of an addict who refuses to change. At one point he pretended to go to rehab and then flaunted to his colleagues/boss how he got around the system. After that and the trial where he could have gone to jail, everything went back to status quo and House was portrayed as having learned nothing...he was back to abusing as normal, and everyone around him were saps. That series of episodes has been my least favorite, but I understand why the writers chose to take that detour.

[Bill Glasheen]

Question: How can you tell when an addict is lieing?

Answer: When their lips move.

Why is drug abuse so prevalent among physicians?

Answer below.

Treating physician substance abuse
By Christopher Guadagnino, Ph.D.

the statistics that are usually kicked around is that anywhere between 10-15 percent of physicians are addicted to either alcohol or drugs.

- Bill

[IJ]

Physicians abuse a lot of drugs and alcohol because they're stressed, they have access (ahem, anesthesia ) and because they're... people. People use a lot of drugs. Most MD addicts / abusers are functional, like most of the addicts and abusers out there. But many fall big time, and if you're interested in one such story, check out Abraham Verghese's "The Tennis Partner," about a meth addicted colleague. Not a pretty outcome.

As for "getting people enthused about medicine," to what end? For their entertainment and miseducation House may be fine. But as I mentioned before, the show fills people with wildly misleading expectations of medicine. Even ER, which is a rather sober show by comparison (at least in its early days, actual medicine happened, rather than straight up BS), causes real problems because it leads people to believe that good things come from CPR. The survival rate on TV for cardiac arrest in hospital is about 60%, according to one review. In the real world, atmost 5-15% survive and of these, those "good" outcomes are pretty hard to find. And yet, you can't change someone's deeply held beliefs quickly enough to help them make a rational code status choice, and lots will be coded and either die then in horrid fashion (and at great expense, I might add, for those of you who care that Medicare will be bankrupt in ~17 years) or after lingering in the ICU in medical death limbo. Or the transplant refusers... or the people who won't let their basically dead relative go because they think we're just after their organs, or because someone woke up on TV.

House is worse because it's almost freeform psychosis. And, it is the perfect example of the independent hero model of medicine (see also Jack Bauer, of CTU) which leads everyone to believe that medicine is an individual skill rather than a group commitment to safety and judgement with the understanding that the complexity of modern medicine exceeds the capacity of the unaided human mind. This is a destructive way to view medicine because independent heros do about as well in real life as did the gunsmiths before interchangeable parts, but worse, because they don't accept / facilitate coverage and can't do a good job 24/7.

I'm just not sure what the positive outcome of House enthusiasm would be, Bill...

[Bill Glasheen]

I'm just not sure what the positive outcome of House enthusiasm would be,

You'll have to take that up with the judges of the Golden Globes and the Emmy's, Dr. Ian.

House is worse because it's almost freeform psychosis. And, it is the perfect example of the independent hero model of medicine (see also Jack Bauer, of CTU) which leads everyone to believe that medicine is an individual skill rather than a group commitment to safety and judgement with the understanding that the complexity of modern medicine exceeds the capacity of the unaided human mind. This is a destructive way to view medicine because independent heros do about as well in real life as did the gunsmiths before interchangeable parts, but worse, because they don't accept / facilitate coverage and can't do a good job 24/7.

I'm scratching my head on this one, Ian, because I didn't see that in 3 episodes.

One thing that comes to mind is attitude that people can get when they live too long in large cities, and fail to travel. They develop a "village" mindset which they are convinced is the way the world must work or we are doomed - especially the disenfranchised. Meanwhile in much of the rest of the country (yes, there is life outside Boston, New York, and LA...) there are libertarian-minded people who - yes - celebrate independence. While academic medical centers wallow in peer-review, physicians who practice ouside academia and in smaller cities truly believe they do things better. And if there is one thing that health services research has taught us, it's that there isn't ONE perfect way to set up and practice medicine. The literature abounds with myriad models and ways of doing things that get equal outcomes. Add patient preference and satisfaction to that (Wow, what a concept!!) and the concept gets even more interesting. Wennberg small area analysis aside, not all variation in practice is bad.

Furthermore... The information revolution I am a part of in medicine makes it possible for us to codify what you academic geeks propose in your specialty societies. So independent or independent-minded physicians get to consider guidelines, and then interpret and execute based upon the context. Bill Gates and Microsoft Office did away with the secretary as we know it. The digital revolution complete with Blackberries, telemedicine and the electronic health record will do much the same to this "need" for group practice in rural medicine. Newsflash - the military is just about there right now. Commercial and government health care will be next - if some European countries don't beat us there.

I would LOVE to have you sitting beside me at a table during my days at BCBS of VA, Ian. I could tell you stories about meeting with physician groups around the state... Go walk into Lynchburg with Moses' tablets, and they'll cart you out on a rail. And when we do the analyses, surprise - they actually get good outcomes and do things cheaper.

Medicine, my friend, is a regional phenomenon. What works in LA won't work in Boise won't work in Boston won't work in Sheboygan.

Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.

- Sackett, D.L. et al. (1996) Evidence based medicine: what it is and what it isn't. BMJ 312 (7023), 13 January, 71-72.


- Bill

[Gene DeMambro]

Glenn,

As the operations manager of a hospital pharmacy I can tell you unequivically that theft/diversion of drugs of abuse is not tolerated at all. If such conduct is discovered, the person in question would be out the door immediately, if not sooner, with appropriate notification to the authorities. Any person in any professional standing who even attempts to cover it up would also be facing serious charges for profound derelection of duty.

As for health care professionals being addicts and getting their junk outside of work, I can't speak for that. I can say that most state licensing boards have programs where someone with a substance abuse problem can self-report to their licensing board, seek help, be monitored and keep their license and their livelihood.

I dont' watch "House" at all. But if a hospital knowingly allows a drug-addicted MD to practice and covers it up numerous time after time, their would be some serious Hell to pay by all involved.

Cheers,
Gene

[AAAhmed46]

When you guys go to watch a martial arts or action movie, do you expect to see super good applications of techniques?

If not, then do you enjoy the movie?


Some movies have realistic fight scenes yeah, but alot of times, it's bullshit.

But you still enjoy watching the movie right?


I ALWAYS watch hospital dramas with the same attitude.

Who cares if it's fake, it's entertainment.