A clever little article in JAMA, written by Gurpreet Dhaliwal, suggests that diagnosticians should admire not House, MD, but rather NPR’s Car Talk mechanics, Click and Clack:
Car Talk, like most forms of technology and media, offers advantages and conveniences that supplement those trainee-patient-teacher interactions. First, podcasting makes the lessons of reasoning available anytime, anywhere to the student. Second, in a given afternoon in clinic or admitting cycle on the wards, we are pleased to have the student see one or two undifferentiated cases where their own thinking and that of their teachers can be put to the test. Car Talk presents six or more problem-solving encounters in one hour each week. Finally, the disentanglement from medical facts allows the student of reasoning to observe the process rather than obsess over the content (consider if this were a medical call-in show Body Talk: “My husband makes this terrible noise . . . â€). (source)
I once showed an episode of House, MD to my Introduction to the Natural Sciences class as an illustration of the scientific method (we discussed how it both was and wasn’t a fair representation of science — mostly it wasn’t. Nor, incidentally, was the Sherlock Holmes story we read). Obviously, the irascible, manipulative, drug-seeking Dr. House is not a model I wanted my pre-med students to emulate. But the thing about House that charms and fascinates (and that I wanted my students to notice) is his delight in intellectual curiosity. He takes childlike pleasure in figuring things out; it’s the one aspect of his life which is self-sustaining, in which he needs neither a drug nor a crutch. And that curiosity is at least one characteristic of Dr. House that we should hope physicians do cultivate — because curiosity is essential to keep investigators (in science, law enforcement, or medicine) motivated in the face of puzzlement and frequent failure.
So there’s one reason to admire Dr. House — even if only one. But there’s also a big problem with using Click and Clack as a model for diagnosis. It’s a problem we have totally failed to grapple with as a society: the skyrocketing cost of diagnosis and treatment. Click and Clack can be honest with a caller that their twenty-year-old car, nearing 250K miles, is simply not worth further diagnosis/treatment. It’s often easier and cheaper to simply replace the car, and it’s to their credit that they say so. But a physician obviously can’t make the same financial tradeoff for a patient.
House, M.D. has the opposite problem: Dr. House avoids the issue by ignoring cost completely. Practicing in a fully equipped teaching hospital, with special dispensation for his professional eccentricities, House routinely tests for obscure, vanishingly unlikely conditions using invasive, expensive assays. (In some early episodes, House butted heads with a hospital chairman who was concerned with cost overruns. However, the chairman was capricious and overbearing, using money as leverage rather than grappling with genuine cost-benefit analyses for the good of patients.)
Ignoring money and probability makes good tv — a patient’s quotidian symptoms are more interesting really produced by brain-eating Ecuadorian parasitic fly larvae, or something equally unlikely, and it’s even better if House discovers the parasite using a maverick test that has a 50/50 chance of breaking the hospital’s multi-million dollar MRI! But all this is grossly (pun intended) unrealistic, and not obviously so. People can readily appreciate that Dr. House is obnoxious and misanthropic and has no bedside manner. It’s not like you have to tell medical students he’s a bad model (and if you do, maybe they shouldn’t be medical students). But most people don’t really think about how expensive all those tests are, or the skyrocketing costs of medical care in general — until they are forced to.
Real patients and doctors (and medical administrators) do have to grapple with cost, including assessing how important accurate diagnosis is in the larger context (will it change the treatment plan? will it require invasive, dangerous tests?). This process isn’t as simple as determining whether the cost of repair outweighs Bluebook value. So while we’re on the whole topic of medical education, it would be nice to have something that modeled for doctors and patients how to discuss, with sensitivity and honesty, how to end invasive, bankruptcy-inducing treatments with little hope of success, or how to weigh a slightly improved duration of life vs. severely impaired quality of life. Unfortunately, if there were such a television show, it would probably be called “Death Panel!” and be pulled off the air amid much outrage. Sigh.
In the meantime, perhaps medical students should be assigned reading by Atul Gawande. Gawande’s influential 2009 New Yorker article on health care costs observed that
nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.
To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed. (source)
Health care, like other goods, is unfairly and inefficiently distributed. Recognizing that problem doesn’t mean you must embrace any particular political solution — it just means you understand that cost plays a significant role in medical care, even when neither doctor nor patient brings it up. Click and Clack aren’t afraid to discuss cost, often quite bluntly. Dr. House isn’t concerned with cost at all. But there should be a middle ground — both for policymakers and for individual patients making choices for their families. I have yet to see a successful model for that.