Hugh Laurie in Season 1 of House
Like a modern-day Sherlock Holmes in scrubs, the title character of House can solve just about any medical mystery. That's not altogether unrealistic, says Dr. Lisa Sanders, the show's technical adviser. Sanders, an internist and the author of Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis, talked to TIME about House's flesh-and-blood counterparts, how we can teach more doctors to be like them and how patients can help.
So are there really doctors like House, who seem to be able to diagnose just about anything?
There are. If you go to any community of doctors, they will be able to list three or four doctors who seem to know everything. We all know who they are. Different doctors will name different people, but you'll come up with a very short list.
How do they get that way? Are they just smarter than everybody else?
That always helps. But they're not just IQ-smart. It's a puzzle-solving facility. The most important quality in these doctors is that they just know so much. One of the doctors that I go to when I'm stumped has a screen saver on his computer that says, "Have you kept up with the literature today?" These are people who are constantly learning and adding to an already sizable knowledge base. And they have seen a lot. That's very important, because a disease on the page is so different from the disease in a person.
On that note, you're somewhat critical of the limits placed on medical residents' workweeks. You say they don't really get enough time with patients.
I don't know that I'm against the limitation on residents' work hours. I do think it's very likely that residents will make fewer mistakes if they're not tired. But the way residents now learn medicine was developed by Sir William Osler at the beginning of the 20th century. It was great back then. Doctors lived in the hospital; that's why they're called residents. Patients also resided in the hospital sometimes for weeks at a time. So everybody got a chance to see interesting patients, interesting pathology. That's not the way it is now. We have to figure out ways to make up for the fact that patients buzz through the hospital, mostly staying three days or less, and residents spend less than 80 hours a week in the hospital. Eighty hours a week sounds like a lot, but while the hours have shrunk, the workload hasn't. So residents spend less time with the patients.
Do you have thoughts on how to fix the education system?
None that would make me very popular. I think that generalists' residencies need to be made longer so that you can spend more time in the hospital. The government's not going to like that, because it's another year of training they have to pay for. Residents are certainly not going to like it because it makes their already extended training even longer.
One of the recurring themes in the book is the fact that too few doctors sit down and hear out the patient's story. Why is that?
It's hard to listen to a story that's not told well. That's a terrible thing to say, but we all feel this. You know, when we're at the dinner table and Uncle Dave is telling a long, windy story, what you're really thinking is, "Where is this going? What is the bottom line?" That kind of impatience is not just limited to the dinner table; that's often how doctors feel. When you didn't have any other [diagnostic] tools except that story, you just buckled down and listened. But now that we have other [high-tech] tools, we feel like, "O.K., I'm out of here."
It seems like you're trying to get people to think of doctors in a less clinical, more human way, and to recognize that there are emotions on both sides contributing to the successes and failures.
Absolutely. I think one of the great things about House is that often in solving the problem, it's something in his real life that triggers a thought about his patient. I think fundamentally what doctors and patients both have to remember is that the diagnosis process is a collaboration between two experts: the doctor, who is an expert on the body and disease in general, and the patient, who is the expert on this body and this disease and these symptoms. There's no way for a doctor to know what the patient is feeling without asking.
You talk a lot about the death of the physical exam too. You attribute that, in part, to another very human response: doctors feeling awkward about touching another person in an intimate way. That's not something we hear about very often.
I don't know that this has ever been studied in a systematic way, but it is, I think, very natural to feel uncomfortable touching people that you barely know. There are a lot of rules in our society about touching — who gets to touch, and where, and how. Even when you're in the crowd that's allowed to touch, you still have all these feelings [of discomfort]. More and more women are getting mammograms, but fewer and fewer women are getting the physical exam of their breasts, which should be done every year. I can't help but think that [discomfort at] touching other people's private parts is at play here.
How else do you explain doctors' tendency to rely too much on high-tech testing?
Just as patients feel better when they're getting scans and blood tests and all these things, I think the doctor has the same response. When you see that a patient is doing badly, a kind of low-level fear comes over a doctor, an anxiety that they're going to miss something. We feel that the tests are better than anything else we can do. And I just don't know that that's the case.
How can patients help themselves get the best diagnosis?
The most important thing that the patient can do is tell their story. Doctors often interrupt patients. There have been several studies done that show that on average, doctors let patients talk for 20 seconds before interrupting. Some doctors interrupted after only three seconds. Once interrupted, patients are often reluctant to go back to their story. After you answer the doctor's question, say, "Let me just go back and tell you what happened." I also think patients need to be empowered to ask doctors to explain things in language they can understand. The patient is, after all, the owner-operator of his or her body. We wouldn't go to a mechanic who just talked over our heads all the time. Why should we do that with a doctor?