House, M.D. physician technical advisor interview

by Ryan DuBosar

“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: 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. [This made it onto the show in Episode 7 (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.

Ryan DuBosar is an ACP Internist Senior Editor.

Originally published in ACP Hospitalist.

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  • Dermatologist Los Angeles

    Great interview. It is always great to hear how others got to where they are now!

  • Frank Drackman

    “House M.D” IS so unrealistic,
    I mean a NEUROLOGIST who actually makes a diagnosis and makes someone better????
    Next thing there’ll be an Internist who was born in this country…

    Frank, M.D.

  • doctor sabelotodo

    great article and thank you dr. sanders for addressing the inaccuracies and other problems..i watched a few episodes but the grotesque inaccuracies (pt with simultaneous acute and chronic adverse effects to colchicine) and inappropriate behavior (the blonde guy doing an unattended breast exam while jamming hie hand under the pts bra for 2 seconds and telling her she needs a mammogram) totally turned me off!!!

  • cnm3789

    Yes, it’s true that it’s completely unrealistic and the portrayal of nurses as either absent, handmaidens or bimbos (or all three) really irritates me. But is there a care provider who hasn’t silently said to a patient some of the things that House says out loud?

  • amanzimtoti

    Great article, thanx! The lack of nurses and fact that the main characters do all the investigations and sometimes even operations themselves, are majorly amusing to our household. What I find annoying though, besides that he is so rude, is that he and his team treat empirically without any clinical evidence as a rule rather than as an exception. That’s bizarre. My algorithm for House is: 2 or 3 incorrect diagnoses and failed treatment; complications always occurring in the middle of an exam or procedure or as a drip/IV is being put up; liver transplant (or other operation) – interrupted by a new diagnosis; treatment once again fails; new symptom and final diagnosis.

    @doctor sabelotodo: over here, male doctors basically always do breast and gynae exams unattended. In fact, that’s the norm. I therefore find your statement very interesting. Is it because of the risk of litigation? Or is it inappropriate for a woman to be alone with a male doctor because of cultural norms?

    • doctor sabelotodo

      from california, USA..male MD..i always have a female present in the room with me during a breast or pelvic exam..the reasons..that is what i was protect me and the patient..and to afford the patient some degree of dignity..the “breast exam” on HOUSE was inappropriate on many levels

  • Tad

    Say what you will about the medical inaccuracies (no doubt a form of dramatic license), House is illuminating for the general public as to how physicians construct a diagnosis. I had no idea, for example, that doctors routinely break into patients’ homes. Since watching House, I’ve started moving my stash of weed and porn off-site every time I feel a little light-headed.

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