I have a bit of a website crush on TV Tattle – it's my one-stop shop for TV news, and has been in my sidebar for as long as I've had a sidebar, plus I've mentioned it as an inspiration for the TV, Eh? site. So I had my TV/webgeek moment today when they linked to my Blogcritics article The Metaphorical Medicine of House.
Anyway, I previously posted the interview with Polite Scott of Polite Dissent used in that article, so now here's the transcript of my pre-Christmas chat with Dr. Sanders. It includes a small spoiler for a future episode about half way through. I've marked it so it should be easy to skip, but strict spoilerphobes might want to stay away until the Superbowl episode has aired, in case of accidental eye grazing.
Tell me how your association with the show began. The story I've heard is that your Diagnosis column was the inspiration to begin with.
I got a call from [executive producer] Paul Attanasio the spring before they went on the air and he said "I'm putting together a show I think you'll be very interested in." I flew out to LA to meet with him, and he told me he was reading one of my columns and said "this is the show we want to do." He might have been saying that to be nice. And it was extremely nice to hear that.
The way your column is laid out seems very similar to how House attacks a case, too, so it does seem like they've kept that template.
Oh, I think so. I was very impressed with House from the beginning for what they were trying to do. The topic of what they're really looking at is how doctors think and it's not really a television friendly topic, to be honest.
What is your role as a medical advisor now? Do you comment on scripts after they're written or do you give input when they're thinking of cases?
When I see things that I think they'll like, I set them aside in a file I have. I talk to the writers; when they're looking around for ideas, they'll call me or the other technical consultants. They always like their stories to at least start in fact. What they love the most is to have a story that's based on something that actually happened. So whenever I can find crazy case reports – and there are many – I set them aside and say "hey, how about this?" I'm in this big community at Yale and so whenever something crazy happens, or Housian, I get flooded with e-mails, "why don't you use this?" I've picked up some very nice concepts and passed them on. They've used some and not used others, but it's fun.
Then I read their scripts afterwards and try to keep them from making medical errors. But I have to say, on that count they're way more sophisticated now. They're in their fourth season and they're far more sophisticated, and they just don't make many errors that they don't recognize as errors. Sometimes if it's a choice between drama or comedy and complete accuracy, accuracy loses. I understand that. But I'm there to be the voice promoting accuracy, so I point it out and they either take it or not.
Do you ever watch and think, why didn't they listen to me?
No, because I understand. It's hard to criticize their sense of drama and character. I think they're very good writers.
We had a very long fight once over something that just happened to intersect with something I care about very deeply. Not a disease, but there's this thing about medicine and language: when you learn medicine you learn a whole vocabulary. Not only do you learn a vocabulary, you learn phonemes with which you can create a word that may never have existed before but everyone will instantly understand. I love that about medicine. I also love that when you hear a word or the name of a disease you also know a lot about it just from hearing the name. And sometimes you know most everything there is to know about some diseases just from their name. I love that about medicine too.
So one script -- this has already aired, and actually it was wonderful and unbelievably funny, but, BUT -- there was a character and they wanted to imply genital contact between two characters and so they had the male character get a rash in his mouth which was promptly diagnosed as bacterial vaginosis. I wrote them an e-mail and I said you can't have bacterial vaginosis in your mouth. First of all, it doesn't grow there. But more importantly, it wouldn't be called bacterial vaginosis if it were in your mouth. The same bug in a different spot has a different name.
So they were like, "That's very nice, but this is way funnier." And you know, it was. What can I say? I fought the battle for linguistic purity and I lost to prurient humour and it was funny.
It's nice you can appreciate that, even if it's not completely accurate.
I do hear from some of the doctors at Yale who lament the inaccuracies. It's true, there are some shows that probably adhere more closely to the way things are, but I think that's because their focus is on a different thing. House is really about figuring stuff out. Because of the nature of television, it has to be about things that happen, but it's really about figuring out what's going on, whereas a program like ER is really about things that happen. You're not really figuring things out, you're trying to manage things that are happening, and that's a completely different perspective. So it's true that House takes liberties with the truth -- you know, bacterial vaginosis -- but I think it's usually in an effort to do a show about thinking. There aren't very many shows about thinking that are out there, in part because it's a very untelegenic activity, a bunch of white guys sitting around scratching themselves looking through the literature.
It's not very visual, is it?
It's not. So one of the things I love about House that I had absolutely no role in except to observe it, is ... well, my column is written the way an admission note is written. We call it an H&P, history and physical, even though it includes much more than a history and physical. All my columns follow that very rigid format. And House also follows that rigid format. So here's the format: you start off with the chief complaint and the history of the present illness. So what happened. And that's exactly how House starts off. They always start off with a tease where you see what happened and it immediately establishes all the stuff that you get in the history of the presenting illness -- how old the person is, what their social class is, what they were doing when the symptoms started, how long they last, what the nature of it is, all the stuff we teach medical students to include in their history of the presenting illness is right there. And then you go on to get the patient's medical history. And that's all woven into the script. What you really do is you say "Do you have any other medical problems, uh huh, uh huh. Diabetes? Uh huh, uh huh." You know, very boring. They don't do that.
No, they break into people's houses.
That's the great thing: House works on a metaphorical level. One of the things we do, one of the great pleasures of being a doctor, is you get to ask all these incredibly nosy, intrusive questions. People can feel extremely violated with intimacy. Of course, it's part of a trusting relationship, you hope, but you probe into the inner recesses of their personal life as if you were breaking into their house. Their propensity to break into houses is a perfect visual representation, a psychological representation, of what we're doing. So I love that, even though I have never broken into any of my patients' houses. I have on occasion made house calls, but I usually ring the doorbell and if they're not home, I come back later.
That's good to hear – what a concept.
But you know, it's not reality on a level base, it's a metaphor for something that's very true about medicine. I think House works on that level a lot. It's more of a metaphor.
They have Wilson doing surgery. Oncologists don't do surgery. A very fundamental split in medicine is you pick medicine or surgery, period. The only thing that crosses the line is OB/GYN. That's the only thing that's sort of in the middle. Everything else, if you're going into medicine, you might lance a boil, you might pick off a wart, but you don't do surgery. And yet Wilson's in there chopping up with the best of them.
He's multitalented.
He's incredibly talented.
I have never touched the controls of an MRI. In fact, if I did, I would certainly be called before the CEO of Yale-New Haven Hospital: "I understand you were touching our $6 billion MRI?" Never in a million years.
House doesn't respect much, but he respects science and he respects rationality, so some people think that even if the show doesn't get everything right, it's leading to an atmosphere of respect. Others think they leave a wrong impression of what medicine is like. It sounds like you fall more into the "it doesn't matter, it's drama, not life" category.
It doesn't matter, it's drama. But I have to say, in my academic setting, I'm a big advocate for evidence-based medicine, and to me, House is what the world would be like if nobody practiced evidence-based medicine. He never checks the evidence unless he has an intuition that it's going to agree with what he's already planned to do. And you know what, people used to practice medicine that way. They would try to think it out.
I can't remember who said this, but somebody said an ounce of history is more important than a pound of logic. And that's true, an ounce of experience, which is what we mean by evidence, experience that has been put together in some kind of scientifically appropriate way, is worth a pound of thinking things through, because what we know about the body is so very limited that you can absolutely do the logical thing and be completely wrong. And actually, this happens to House all the time. In fact, it happens three out of four times. There's always three things that happen before you get to the right answer.
It's so much more predictable in House than life.
Well, fortunately, it's more predictable in life than in House. In fact, most of the time you will get to an ending and the personal will live. I would say patients have a much higher rate of living without complications if they actually went to a real hospital than if they went to House.
There are things I hate about the House character. Some of the things I love in medicine the character of House doesn't value at all. There is nothing more valuable than taking a history. Nothing will give you more important information than taking a history. The older and more seasoned you are, the better you are at getting to what House gets at, the truth that other people were unable to find. And he often does that, comes in and asks one or two questions, and he's been doing it more over recent shows than he did in the early seasons. But you know, history is unbelievably important. The other thing that's really important that they never do is the physical exam.
BEGIN SPOILER
One of the scripts for this season, I don't know if it's aired yet, have you seen the one where the woman is up at the south pole and becomes quite ill?
No, that hasn't aired yet.
So House insists on doing an extremely close physical exam by video camera but he lets her keep her socks on. And of course, whatever it is she has is underneath. The thing is, if you really valued the physical exam, you know House, he would make her take her socks off. But he doesn't really value the physical exam. And in fact you've never seen him examine a patient.
END SPOILER
So there are things about House that rub against my intuitions about what a good doctor is. And certainly I am way nicer to my patients.
That's good to hear, too.
The first season it was on, one of the surgeons came up to me and said "I love House. He gives us surgeons a good name."
House doesn't care about those things. On the other hand, House cares about a lot of things I care about. He cares about thinking. He's not a person who will order a test if he doesn't think they're necessary. Now I personally think they're necessary a whole hell of a lot more frequently than he will, but he recognizes the limitations of testing. So there are lots of great values about him.
Also, House is such a damaged character. He's such an unreliable narrator that his personal affectation of being a total schmuck is belied by the warmth and generosity in his face. Not in the hatched lines of his wonderfully handsome face, but his eyes are marvelously expressive and his mouth is ... I mean, you look at his face and he might be saying the meanest thing ever, and you know that inside there is a deeply caring person. Even if he's not caring about you as an individual, he cares about an idea that happens to be important to you too, which is figuring out what's going on. I think the genius of Hugh Laurie is that he's able to get that duality across.
When I was first talking to Paul Attanasio about the character, he was telling me about the show and he was saying "It's about a doctor who figures out what's going on with very mysterious patients who have unusual diagnoses. The guy's kind of a shmuck, but you know, he tests well, everybody loves him. He's rude and he's obnoxious and he's not very nice to people but everybody loves him, go figure." And in my own mind I thought "Good Lord, I'm not going to be employed for long. I'll be out of Hollywood soon."
I think a lot of people thought that in the beginning.
It would be a different show if Hugh were a different actor. I think he's really an incredible talent and it's because of him and, let me just say, because the writing is extraordinary that I was wrong. It's always moving. Even when I read the scripts, I'm often moved to tears. Just by reading the scripts!
That's unusual – I'd think most doctors would find it difficult to overlook the dramatic license they take but it seems House gets beyond that and many doctors seem to like it.
Some doctors, many doctors, actually like House. It's a dirty secret, I think, but that is the doctor they'd like to be. Not the rudeness, but they'd like to be someone who's completely committed to figuring out what's going on. The biggest difference between every other doctor and House? House has one patient at a time.
It's not that I want to shirk work, but when you're running around and have so many patients who are so sick, the one thing you long for, and have to make room for by not sleeping, is more time to think about what's going on for something that's not obvious. Fortunately, most of the time, most of your patients have common things. That is the definition of common. But not everyone does. Even a regular doctor has cases that defy expectation and have to be figured out. I think the one thing that House represents is how much time we spend trying to figure out the things that don't necessarily make sense or fall into our expectations.
The other thing about House, medicine is all about having an expectation about what a disease looks like, and then when the disease doesn't follow that course, aha, this means there's something else going on here. House is very good at capturing that. It's not something I think a non-physician would pay attention to, but it's something that's very much there. You can tell doctors are involved in the creation of the show. Not me, I didn't put that in there.
House adheres very closely to some things in medicine and I think some of the things it values are also things that doctors value about what they do.
And then of course there are many doctors who are just furious about how it doesn't adhere to medicine as we know it. What can you do, you can't please everybody.
His ethics are a little different from most doctors in real life.
That's one of the things I am least comfortable with.
Do you think he gives a bad impression of the profession?
I think he gives a wrong impression. I think there are very few doctors who set out to kill a patient, even out of mercy, and yet that has happened more than once on House.
I think there are very few doctors who would be willing to force their perspective on a patient. Not only is it against the law, as House has touched on, not only is it assault, but it really goes so deeply against so many of the things we value.
The way House stabs people with syringes when they're not expecting it, it's only because he's such a limited human being that he has to resort to that. The rest of us use our relationship with the patient. The patient wants you to tell them what to do. They want to follow your advice. That's why we have to be so careful about explaining the pros and cons of every side, because they're listening and they're so attuned to trying to figure out what you think they should do.
You wouldn't go to a lawyer who just laid out your options. Obviously your lawyer is an expert and he'd give you an opinion. But he wouldn't just give you one option, and the chances are excellent that you will follow your lawyer's advice.
That's also true of patients. They're dying for you to tell them what to do. Dying to do what you want them to do, because they have faith in you. Otherwise they certainly wouldn't be lying in a hospital bed letting you touch them. I think he does that when it's not necessary. It's never necessary. It just never is necessary.
But what can you say, the guy's a jerk. Doctors shouldn't be impaired when they're taking care of patients, either.
Do you think the show can be effective in bringing up these issues even if you're not on House's side? Do you think the viewer is always on House's side?
I think the viewer is always on House's side, but that's not my concern. I think people have enough real-life experience that they're consistently and accurately able to draw a line between fiction and reality. The specifics of disease, which House often gets wrong, no one cares about that. Period. No one cares about that. But I know that people know that when they're in a hospital, if they don't want something done to them, they say no. I think that's very clear.
Whether they're able to do it is a different thing. I think the authority of doctors is overwhelming sometimes, and people often agree to things they're not sure about because they don't know what else to say. But I think most people know that in a hospital, nobody is going to stab you with a scalpel or a needle just to see what happens. It's not going to happen. I think people understand that.
I think the ways House is outrageous are ways people are familiar with and understand.
Do you hear from patients who are influenced by what they've seen on TV? Do they say "I saw this on House..."
People do say "I saw this on House" but they don't usually think they have it. But on the other hand I do have a whole bunch of colleagues who send me e-mails every time one of their patients walks in with one of my columns as their chief complaint. Because mine are written in a more credible fashion. Really, you'd have to be near death to think you have what any patient of House has.
Was there anything you'd like to add?
I think it's important that there be lots of different perspectives about science on television. Too often, there's only two pictures of the doctor or scientist. One is the benevolent, kind-hearted do-gooder. And that's nice. The other one is evil, cold-blooded villain. I think the great thing about House and other medical shows on television is they show the human side of doctors.
The other thing I like about House is that he often uses observations about real life, sometimes it comes from his own life, sometimes it comes from another case, but it shows that thinking just about the facts is not always the only way to get to an answer. It's often not the best way to get to an answer. So many things have come out of House's life and that is how it works.
There's a great story about Lou Gehrig, who was suffering from ALS and he went undiagnosed for a very long period of time. Nobody could figure out what he had, in part because he was such a healthy substrait that when this debilitating disease hit him, he wasn't as debilitated as other people might have been with the same disease. He went to the Mayo Clinic and when he walked into one doctor's office, the doctor looked at him and said "oh, I know what you have." Didn't touch him, just said I know what you have. Because his own mother had this disease.
Medicine is not this separate category that lives isolated. It's part of a texture of life, and I think one of the great things about House is he shows that interaction between life and medicine.
