Put down the stethoscope; listen to your patient

Yesterday, I posted on Dr Laura Esserman  the breast cancer researcher and surgeon who is committed to equalizing the doctor-patient relationship.  My hope is that, like Dr Esserman, our doctors are moving away from the old paternalistic style of dealing with patients. Today’s post though, concerns the other side of that coin. Dr Muiris Houston, writing in today’s Irish Times, uses Dr Gregory House, of the TV series House, as an example of just such medical paternalism.

In an era where patient choice and involvement is paramount, Dr House is a throwback to the old school that believed patients and their preferences should never get in the way of a doctor who knows best.

Writing in the journal Medical Humanities , Dr Mark Wicclair of the University of Pittsburgh looks in some detail at medical paternalism as represented by House.

As the head of a Department of Medical Diagnostics, something you won’t find in a modern hospital, Dr House specialises in searching for causes of medical mysteries. In the words of Dr Wicclair: “Patients don’t always get what they want (that is, their preference and choices are disregarded), but they get what Dr House believes they need (that is, tests, medical procedures and medications that enable him to successfully diagnose and treat their medical conditions).”

DNR, an episode from season one, finds Dr House going against the “do not resuscitate” wishes of a musician. He is paralysed and has been diagnosed with amyotrophic lateral sclerosis (ALS), an incurable, progressive disease. When the patient experiences respiratory arrest, the doctor intubates him in order to start mechanical ventilation.

A subsequent MRI scan – performed against the musician’s wishes – shows he has a blood clot in his brain. He is cured following surgery and the diagnosis of ALS rejected. As he walks out of the hospital, he meets Dr House and says: “Thanks for sticking with the case.”

The episode appears to prove that “doctor knows best” and that medical paternalism has prevented an unnecessary death. It’s a theme repeated throughout the series, which sees Dr House and some of his colleagues treating, testing and resuscitating patients against their wishes.

And the victims (sorry, patients) are usually grateful to the medics for disregarding their wishes. Describing patients as “idiots”, House’s bedside manner is atrocious. Early in the pilot programme, the following exchange takes place between Dr House, Dr Foreman and Dr Cameron.

Dr Foreman: “Shouldn’t we be speaking to the patient before we start diagnosing?”

Dr House: “Is she a doctor?”

Dr Foreman: “No, but. . .”

Dr House: “Everybody lies.”

Dr Cameron: “Dr House doesn’t like dealing with patients.”

Dr Foreman “Isn’t treating patients why we became doctors?”

Dr House: “No, treating illnesses is why we became doctors. Treating patients is what makes most doctors miserable.”

Dr Foreman: “So you’re trying to eliminate humanity from the practice of medicine?”

House: “If we don’t talk to them, they can’t lie to us and we can’t lie to them. Humanity is over-rated.”

Luckily, a lot of effort is put in by modern medical educators to emphasise the importance of humanity and the need for high quality communication skills.

A new book – The Green Bookshop (Radcliffe Publishing) – recommends reading opportunities for doctors interested in honing their skills. In “Communication Skills That Heal” the author describes how easy it is to say things to patients that would serve to wound, rather than heal.

He advises doctors to put details of patients’ “interests and relationships” in the case notes, so that they become “whole” human beings. And he suggests using “how are you?” as the opening question in a consultation, rather than “how is your [specific illness]”?

The importance of listening as part of work in primary care is the subject of another offering based on interviews with experienced GPs.

The message is that listening is an essential part of the service a doctor offers to patients: unfortunately, this work is undervalued by experts, although I suspect it is much appreciated by patients.

At one level, House is good entertainment. But its main protagonist would have been struck off long before the conclusion of the first series.

 © 2009 The Irish Times

Related Post: Equalizing the relationship between doctor and patient