Thursday, September 12, 2013

House M.D. : 95% vs 5%

In one of the episodes of House M.D.
Inspector: Okay. The rules exist because 95% of the time, for 95% of the people, they’re the right thing to do.
Question: And the other 5%?
Inspector: Have to live by the same rules. Because everybody thinks they’re in that 5%.

In recent days medical tragedies hit the news with regular frequency. What has happened to medical training?

Being brought up in the older medical tradition I have found it engaging to watch the ever so popular House M.D.

It was a relief to hear from my classmates that they too like watching it.

It would not surprise anyone to find that House M.D. has made it to Medical Humanities, a BMJ Journal:
Medical paternalism in House M.D.
M R Wicclair Medical Humanities 2008
Deborah Kirklin in the editorial of the same issue commented:

"Fear and pity are not emotions that Dr Gregory House, star of the popular television series 'House M.D.', acknowledges or accommodates in either his professional or private life. He is arrogant, rude and considers all patients lying idiots. He will do anything, illegal or otherwise, to ensure that his patients—passive objects of his expert attentions—get the investigations and treatments he knows they need. As Wicclair argues, House disregards his patients’ autonomy whenever he deems it necessary So why, given the apparently widely-shared patient expectation that their wishes be respected, do audiences around the world seem so enamoured of House? Wicclair’s answer raises interesting questions about the extent to which patients trust the motivations of their doctors. Perhaps, he suggests, for the many viewers drawn to this arch paternalist, there is something refreshing about a doctor willing to risk all—job, reputation and legal suits—in order to fulfil his duty of care to his patients: the duty to take care that his actions or inactions do not harm his patients. Because, for good or for bad (your call), once you’re House’s patient there is nothing he won’t do, no inaction he will tolerate, if he believes that by failing to act he will harm you.”

First do no harm.

Wicclair stated:“Paternalism is clearly against the norms of mainstream medical ethics. Informed consent—the principle that, except in emergency situations, medical interventions require the voluntary and informed consent of patients or their surrogates—is a core ethical principle in healthcare. A corollary of informed consent is that patients who are able to decide for themselves have a right to refuse treatment recommendations. Another core principle is that when patients lack decision-making capacity, surrogates should make decisions in line with the wishes and values of the patient. Both of these principles reflect a strong opposition to paternalism in contemporary medical ethics.”
Contemporary medical ethics! Except perhaps in Anorexia Nervosa where the Mental Health Act could be used to force feed in a number of countries. The fact that such force feeding did not seem to reduce mortality is a different matter as some deaths are not by direct starvation.
Wicclair asked:
“Yet House repeatedly acts paternalistically without giving it a second (or even first) thought. Is he right, and is the antipaternalism of mainstream medical ethics wrong; or is House mistaken and is a strong moral presumption against medical paternalism justified?"
To prevent House M.D. from becoming God they have to make him out to be rude and full of personal problems and he even rides a motorbike.
Wicclair offered a way out:
“In the world of House M.D., choices typically are life-or-death choices: if a patient doesn’t receive a certain medical intervention, the patient will die.
“However, in the real world, choices are not always so stark. ……If, after careful consideration, a competent patient decides against having the procedure, it would be unwarranted for a physician to insist that the patient needs it.”

You can read it
here (may require subscription).
Yet my personal view is this, you may be rich, famous or even well educated, but you may not know all that you needed to know to make that judgment.
As Dr Crippen pointed out there are just three medical procedures that can be dramatically live-saving. You might also want to read Dr Grumble’s personal account here.

At the Hudson Plane Crash earlier this year a quick thinking ferry captain
Brittany Catanzaro came quickly to the rescue of passengers in near freezing water. She was not a doctor.

In Hong Kong a man died outside a medical centre because a nurse receptionist was following guidelines,
Guideline V to be precise.
Kevin M.D. was charitable about Canadian Health Care when he looked at the tragic death of Natasha Richardson. A number of papers only picked up the fact she turned away the earlier ambulance, but then this happened:
"After picking her up from the hotel, there was a 40-minute drive to the community hospital, the Centre Hospitalier Laurentien. She did have a CT scan there, and the decision was made within 2 hours to transport her to a tertiary care center, another hour away in Montreal."
And still no burr holes after the CT scan?
Dr. Crippen said that the brave physician would have drilled the burr holes without the benefit of a CT scan:"It would be a career making or career breaking decision. Few American doctors are brave. Defensive medicine is the order of the day. You cannot have a migraine in the USA without someone ordering an MRI scan."
Has modern medical training managed the unthinkable of producing a new generation of doctors and other medical staff forgetting that they should use their brain? Or have they all been “guidelined” out? Has the 5% finally become the 95% too?
Grand Rounds 5.27: Code Blog 5:29 Getting Closer To Myself
A simple bump on the head can kill you,Natasha Richardson’s Brain Injury
The wussification of the American medical profession.

Related: House M.D.: Modern Tyranny
Links: Covert Rationing Blog Better Health

Where were you when we needed you, Dr House M.D.?
House M.D. must have the last words:
Question: "Isn’t treating patients why we became doctors?"
House: "No, treating illnesses is why we became doctors."


Anonymous said...

I'm not sure what the point of this post is. To rail against the medical profession for having guidelines?

Those last examples seem to be the 5% rather than the 95%, and in Anorexia Nervosa the patient is not considered in a sound state of mind, because they are obviously killing themselves. And it would be sick to then say 'let them die, they'll probably commit suicide anyway'

People like house because he appeals to their inner arsehole. And it's an excellent characterisation.

Cockroach Catcher said...

The medical profession have always have what you may perceive as guidlines --- that was our medical training. The "guidelines" I talked about are most of the time written by a group of selected doctors, selected often for political affiliations and became a means for controlling health care spending. Those kinds of "guidelines" take away initiative and allow those that follow the to hide behind them. Then there are protocols. See what happened at Mid Staffordshire.

The Cockroach Catcher.

Anonymous said...

I have to agree with CC. I have a zebra and it's amazing how many MD's don't use their brains in dealing with my medical issues. They just can't figure out there are no guidelines.

medaholic said...

Medicine is constantly changing and as patient autonomy becomes a higher priority, more doctors will practice defensive medicine.

In 20 years time, who knows where things will be.

Anonymous said...

Take under consideration one simple thing. House was wrong in a very episode you have quoted. Not because he took a guess - he took one under false assumption. He made logical fallacy arguing that "always resistant" have more diagnostic meaning than "rarely resistant" in situation when patient does not respond to some drugs. It's fallacy beacause it doesn't take under consideration that disease which is rarely resistance may be much more common than alternative, ergo: it could be more statistically probable that patient has it, not alternative. It all happend because of House arrogance. And that's why medicine need regulations.