“House, M.D.” is the least realistic medical drama on television. That doesn't bother Lisa Sanders, ACP Member, one of the show's technical advisors.
The lead character, Gregory House, MD, verbally abuses patients, goes overboard ordering tests and above all, he's “a jerk,” Dr. Sanders said. But after all, it's television, and the former CBS news producer turned med student turned Yale professor understands the difference between reality and good drama. Besides, as one of the show's writers said after listening to Dr. Sanders' lengthy lecture on proper medical procedures, “You're right. But my way is funnier.”
Before joining “House” as one of three technical advisors, Dr. Sanders worked in television news for 12 years, then enrolled in Yale School of Medicine. After graduating in 1997, she turned her experiences about the difficulties of diagnosing patients into a New York Times column (“Diagnosis”), into situations for “House, M.D.” and, most recently, into a book, “Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis.”
Q: What prompted you to make the switch from medical news reporting to medicine itself?
A: I loved the activity of making television—it's always tremendously fun and very exciting—but I never thought the content was terribly interesting. The rigors of television dull it down. And frankly, television is a terrible medium for getting across ideas or data. It's a very good medium for emotions and for things that you can see with your own eyes.
Q: What appealed to you about internal medicine?
A: It's that mystery story at the heart of every doctor-patient encounter. When I went to medical school I really thought that I was going to be interested in the biochemistry, pathophysiology and the molecular stuff that was very hot for most of the time that I was covering medicine. But once I got to the wards and saw this process of figuring things out, I was totally hooked.
Before “House,” and before my column, this was not a piece of medicine that anyone ever talked about. Even though I'd spent several years covering medicine, I didn't know about this story. I thought diagnosis was math.
Q: Did the column develop into your work on “House”?
A: The character was based on Sherlock Holmes. This Sherlock Holmes character would work on the kinds of situations that were presented in my column. Sometimes they pick the case up from my column and then they embellish it so that it's hardly recognizable.
Q: Why do internists take such an interest in sorting through complex medical mysteries to make a diagnosis?
A: Internal medicine appeals to people who like complexity, and just as importantly, to people who are comfortable with uncertainty. When I was in pre-med and even medical school, I would work through problems and then turn to the back of the book to find out if I got the answer right. With patients you can't really turn to the back of the book. You have to make your diagnosis and treat or not treat based on your diagnosis. And you have to wait and see whether you're right or not.
Some people think that complexity is boring. They like direct problems that you can go in and fix. Those are surgeons. It takes a certain type of brain to think that figuring out something complicated is cool and fun and interesting. And those people need to be internists. There's no place else in medicine that does this.
Q: What diagnostic pitfalls are depicted on the show?
A: The most common problem for diagnosis is inadequate history. House explains it by saying, “Everybody lies.” My response, both to the writers and to the television set while I'm watching it, is of course everybody lies to you, because you're a jerk. I love the character, but as a physician, I'm amazed when people tell me that they wish that House was their doctor.
Making a diagnosis, in fact all of medicine, is a collaborative process. That requires a certain trusting relationship. And I think that House as a character has difficulty establishing those types of trusting relationships. People are actually afraid to tell him the truth because they know intuitively that he's just going to make fun of them. And often enough, they're right.
I just did an analysis of the first three seasons of “House” and how the final diagnosis was made. The overwhelming majority of times, a better clinical exam, both the history and the physical, provided the final clue. It was almost never some test they hadn't done.
Q: How does your experience make its way into the show?
A: One of my favorite things didn't happen to me, but as soon as it happened they came running to me because they know that I work for “House” and thought it would make a great episode. An elderly gentleman had developed an ileus. They pounded him with laxatives and enemas and eventually he developed terrible abdominal pain. Scans found air under his diaphragm, a sign that he had perforated his colon. So they took him to the OR, and the chief resident was doing the surgery supervised by the attending physician. The resident carefully made an incision and then used a Bovie to cauterize tiny vessels that were bleeding. BOOM! This tall skinny flame shot out of this guy's stomach so high that it burned the plastic on the lights overhead. The resident tried to stop it by putting her hand over it. The attending knocked her out of the way and completed the incision so that the gas just diffused into the air harmlessly. [Editor's Note: This made it onto the show as Episode 7 of Season 5: “The Itch”.]
As technical advisor I have two jobs. One job is to come up with story ideas, and then the other job is to point out problems and suggest solutions. But they don't always take my advice. In fact, if you had to tally up my batting average, I would say that they take maybe half of my advice on a good day.
Q: How do some of these medical mysteries translate to a TV audience?
A: Real life is a lot duller than anything you see on television. Whatever it is in reality has to be tarted up. You hear when you talk to a policeman about cop shows or a lawyer about lawyer shows or doctors about doctor shows, they all say the same thing: “It's like that, only duller.”
There are many, many inaccuracies that go way beyond the diagnoses that they develop. If you ever walk into a hospital that has as few nurses as the hospital that they're in, you should run screaming. If doctors try to draw your blood, scream. You don't want a doctor to draw your blood. [The “House” doctors] transport their own patients. They run their own MRI machines. They never ask a radiologist to read their scans. They never ask a microbiologist to help them understand their cultures. They do everything; they know everything.
There are some things that are true about “House.” First, it's a whole idea that a diagnosis is a process and a difficult process. People would like to think that their doctor is a genius and the first diagnosis that came out of their lips would be the correct one. But that would conflict with their actual experience if they were ever sick. So showing it as the complicated process that it can be is a good thing.
The other thing that I think is important about “House,” and true, is that diagnostic errors are part of the process. We wish that the very first thing that came out of our mouths were true. But we teach our residents and we try ourselves to develop possible diagnoses, and if we're lucky and good and are having a good day, then there's a very good chance that one of those is going to be the right answer. But the rest of those are all wrong.