The New Health Dialogue

It’s the end of an era in modern medicine. House is no more.

The Fox show House ended last week. It was entertaining, but as far as health policy is concerned, we’re not sorry to see it go. The main character (Dr. Gregory House, played by Hugh Laurie) exemplifies the kind of “cowboy doctor” too many patients have come to expect. The cowboy doctor rides in on a lab result and offers a brilliant diagnosis, saves the patient’s life, and rides off into the sunset, never to be heard from again. It’s the dominant image of heroic doctors in television. Even Hawkeye Pierce, the caring Army surgeon in M*A*S*H whose demeanor is the polar opposite of House, saw his patients in one-off interactions before sending them home or back to the front.

For most of us, though, that’s an entirely unrealistic portrait of medicine. Our interaction with doctors is usually about trying to stay healthy and avoid problems, or managing long-term, chronic diseases like diabetes, heart disease, obesity, cancer. We need doctors who will listen to us, who can explain things clearly, and who we’re comfortable telling our concerns. Chronic disease management makes for lousy TV, but in recent years it has become the dominant kind of problem doctors and patients face day to day.

That's not our only quibble with Dr. House. In addition to being a cowboy, he's not much of a diagnostician. Through the magic of scripted TV he somehow manages to stumble on the treatment that saves the patient, almost by accident. He practices what I call “spaghetti on the wall”  medicine—as in, “throw the spaghetti on the wall and see if it sticks.”  He diagnoses his patients' rare illnesses by throwing treatments at patients and seeing what happens—often causing significant harm in the process. That's just bad medicine, and it isn’t something that doctors should do lightly. To us, House isn't a hero, he's a hazard, a catastrophe waiting to happen. Blinded by his own pain, he's indifferent to the suffering he causes through his reckless, unscientific, non-evidence based treatment decisions.

But there’s one point in House’s favor: he works with a team—and that team actually talks to each other. Unfortunately, that’s as unrealistic as the rest of the show. There are only a few hospitals and medical practices (Virginia Mason, in Seattle, comes to mind, and the Mayo Clinic in Rochester, Minnesota) where communication among providers is very good. In most places, the ball gets dropped between the hospital and primary care doctor and home, or even between different specialists in the same hospital.

Maybe one day TV will produce a more realistic version of medicine, but beware: it won't be the clean-cut single interactions we saw in House, or any of the other medical dramas out there. It'll be messy, and it'll be ambiguous: something a lot more like The Wire than Marcus Welby, M.D.