House: Great Diagnostician?
One of the premises of House as a TV show is that Dr. House is a diagnostic genius. As a character, House's drug-seeking behavior and terrible bedside manner is forgiveable only because he is able to traverse through obscure symptoms and come up with a unifying diagnosis. As one of my attending physicians told me, there are two ways of approaching an arbitrary set of symptoms: Occam's razor and Hickam's dictum. For medical purposes, Occam's razor states that a patient with two complaints (ie. headache and fever) is much more likely to have one disease entity that is causing both complaints as opposed to two different disease entities. Hickam's dictum, on the other hand, says that a patient with two complaints is more likely to have different causes for each symptom as opposed to one unifying disease process.
Historically, physicians whose names are revered today are those who applied Occam's razor to identify new diseases. There's Charcot's triad for cholangitis, Cushing's triad for increased intracranial pressure, Wernicke's triad of thiamine deficiency, and so on. An exceptional physician is someone who is able to decide when to apply Occam's razor and when to apply Hickam's dictum. There is actually an example of a misapplication of Occam's razor which is still mentioned in textbooks, known as Saint's triad, named after C.F.M. Saint, a South African surgeon (not to be confused with Dr. Sanjay Saint, who published a New England Journal of Medicine article about Saint's triad). The legend goes that Dr. C.F.M. Saint saw a number of patients with diverticulosis, gallstones, and a hiatal hernia, and decided that there must be an underlying disease that explains all 3 of those symptoms. He did something that doctors love to do and attached his name to this series. As it turns out, diverticulosis, gallstones, and hiatial hernias are all fairly common medical conditions, and they're much more likely to occur due to their own etiologies than to a shared etiology.
One of the reasons that House appears to be such an exceptional diagnostician is that he is able to correctly apply Occam's razor and Hickam's dictum to the nth degree to diagnose even the most obscure of diseases.But consider how House comes up with his solutions. A patient comes in with a vague complaint. This complaint leads to another complaint, which then leads to a seizure, allergic reaction, or organ failure resulting in the patient requiring intubation. Is this really top-notch care? To ask this question in a different way, what would take place in an "ordinary" top tier hospital?
Order of steps in on an ordinary medicine service:
1. Patient is seen in ER and sent up to the Medicine floor
2. Patient is evaluated by resident (and possibly a medical student)
3. Resident presents the patient's history, physical exam, and labs to the attending physician
4. Attending physician repeats pertinent aspects of history and physical exam and suggests changes to the resident's plan
In this case, substitute the word "resident" for "fellow" because Foreman, Chase, and Cameron are done with their residencies and are now working on their fellowships. As evident on House's team, things work a bit differently.
Order of steps (on House's team):
1. Patient is transferred to House's team from who knows where
2. One of the fellows (Chase/Cameron/Foreman) takes a history
3. One of the others does a physical exam
4. House comes up with a differential diagnosis consisting of 10 things and orders every single test needed to sort out which of the possibilities is actually present
House's differential diagnosis is typically fairly extensive, and in this regard, I think that House is admirably intelligent. It takes experience to be able to name common causes of a spectrum of symptoms, but many of the things that House spouts off (and even a lot of what Cameron says on the show nowadays) reflect a lot of time spent with textbooks (or UpToDate). My primary critique of House's techniques is the same one that was pointed out by Vogler in season 1. Every patient with an isolated symptom doesn't need a complete work-up. Financially (and in some sense medically), it doesn't make sense to work a patient up for an autoimmune disorder until a more likely cause has been ruled out. I think physicians have an inner longing to be able to just order every possible test all at once, but this can be irresponsible, depending on the medical setting. A simple example of this is the difference between telling your family medicine doctor that you're having a headache and telling an ER physician the same. In the first case, you're likely to be treated for migraines, whereas in the second case, you're likely headed to the CT scanner for a head CT.
I think that the fact that House orders an MRI on just about every patient is acceptable only in the context of the fact that his patients are pre-selected to be complicated.
Though House's diagnostic acumen is flaunted in his inpatient cases, I think his real skill is more evident in general medicine clinic, where he diagnoses patients correctly without imprudently asking for unnecessary tests. This is especially impressive given the fact that House is boarded in 2 subspecialties and somewhat far-removed from primary care. There is a joke in medicine that goes something like this:
What makes a good diagnostician is the ability to maintain perspective despite maintaining a wide knowledge base. Sometimes, a cough is hereditary angioedema caused by C1 esterase inhibitor deficiency. Other times, a cough is just a cough.An internist, a pathologist, and a family physician go duck hunting. They see an animal that resembles a duck. The internist says, "Let me run some tests to prove that it's not a goose or a rabbit and only then will I proceed to shoot it." The pathologist says, "I'll kill it now and then figure out what it is." The family physician says, "I'm not quite sure what it is, and I don't really care. I have a gun and I'm killing it."
posted by k-deep at 9:48 PM
6 Comments:
haha love your house posts
Wonderfully described. As a new House fan since this spring I've been crunching to catch up with what's happening.
The plethora of test ordered from the meeting room on the first round has left my jaw dangling at times. It wasn't until House had to pay for family DNA tests that I saw any care go towards total cost of stay.
Has anyone compiled a frequency distribution on the tests ordered by House?
You make the comment that he orders an MRI on just about every patient. I wonder just how many MRI's have been ordered, or screenings for heavy metals, or genetic screenings, etc.
Why don't you add the inexperienced Resident or intern to your Duck Hunting Expedition.
He says, "Whoops". I didn't know any better and I accidentally killed it.
All your analyses are very interesting and fun to read.
Let's step back for a moment and reposition our perspective. House is not a medical drama; it is a mystery drama.
The character of Greg House is based on Sherlock Holmes (House/Home -- get it?) The way you'd solve a murder is very different than the way you'd diagnose a disease, and that is why it seems House does completely unrealistic things.
I love your commentary on the medical stuff, but criticizing his overall methods is just pointless. :P
House's patients don't come out of nowhere. They're patients whom other doctors where unable to treat, because their onset of symptoms isn't specific. So it is assumed that they already went through the "ordinary hospital" sequence you've described. So when House gets a case, a cough's usually more than a cough.
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