The Script Doctor

13 Departs House, Leaving Lessons About Genetic Testing

noreply@blogger.com (Andrew Holtz, MPH) — Mon, 17 Oct 2011 22:40:00 +0000

One of the central features of the Olivia Wilde's character "Thirteen" was her struggle with the memory of what a terrible genetic disorder did to her mother... and her tremulous approach to confronting the answers that genetic testing might reveal to her. As Wilde makes her final regular appearance on House, it's a good time to look back at a bit of that history.

While it seems that Dr. House has never met a test he didn’t like . . . or a fact he didn’t want to
know. That drive to know everything pointed him on a collision course with Thirteen. In Season Four, it was revealed that Thirteen’s mother had Huntington’s disease. The disease has devastating physical and emotional effects. Those affected often develop symptoms and die in middle age.

In “You Don’t Want to Know” (4-08), Thirteen chooses not be tested. House can’t fathom why she doesn’t want to know whether or not she is probably going to die from the same terrible disease that took her mother. He is so obsessed with knowing everything that he takes a cup that Thirteen was drinking from and has the DNA in her saliva tested. When Thirteen gets an envelope that apparently contains genetic test results, she confronts House about violating her privacy and tosses the unopened envelope into a trash bin. At least House resists looking for himself. Still, it’s obvious that he simply cannot figure out why Thirteen does not want to know her likely future.

Over the course of Wilde's seasons on House, her personal struggle with genetic testing and Huntington's disease showed viewers a little bit of what family stalked by this and other genetic abnormalities face in the real world.

Read the full discussion in “House, M.D. vs. Reality”

"Stranger Danger" & Obesity

noreply@blogger.com (Andrew Holtz, MPH) — Fri, 07 Oct 2011 17:00:00 +0000

It happens, but very rarely.

A U.S. Department of Justice report* estimates that about 115 children a year are abducted by a stranger and taken far away or overnight or held for ransom or killed. It's a calamity for each family. But by comparison more than 1,500 children under age 15 are killed and almost 600,000 are injured in car crashes in the US each year according to CDC statistics.

Yet parents are scolded and shamed (or worse) if they let their kids play in the neighborhood without a minder shadowing their every move. And parents load their kids into the car and drive them to school (remember the leading cause of death of children in the US is car crashes) because they are afraid to let them walk there or even wait for the school bus without a parent posse on hand.

The "stranger danger" hype on TV has real consequences.

How does it relate to obesity? Think about it. Free outdoor play is discouraged. Walking or bicycling to school forbidden. Kids are kept inside or in the car. While fear of abduction by strangers is not the only reason that children today aren't as active as earlier generations, it certainly plays a role... and the toll of rising childhood obesity may be shorter lives.

So should we really spend so much time worrying about strangers? Or maybe a little more time worrying about the effects of the familiar TV set.

Read the full discussion in “House, M.D. vs. Reality”

*Note: The Second National Incidence Studies of Missing, Abducted, Runaway, and Thrownaway Children (NISMART–2) is currently being updated with research that will go into NISMART-3.

Scary TV Makes the Real World Look Scarier

noreply@blogger.com (Andrew Holtz, MPH) — Thu, 06 Oct 2011 17:00:00 +0000

A half-century ago, communication researcher George Gerbner developed the "Mean World Index." Survey questions measure how trusting or fearful people are. What’s interesting is that fear of crime, for example, appears to correlate more closely with the level of crime on TV than it does to actual rates of crime reported by law enforcement agencies...

It appears to be an international phenomenon. For example, a survey in Belgium asked people whether they or anyone they knew had been mugged or their house burgled, how frightened they were of crime, and their amount, frequency, and type of TV viewing:

This study included measures of direct and indirect experience of crime. There was no significant relationship between experience of crime and either watching crime on television or (more surprisingly) being afraid of crime. It appears, then, that in a sample of the general population mediated experience (i.e. watching television) is a better predictor of fear of crime than actual experience of crime. - From J. Van den Bulck, “The Relationship Between Television Fiction and Fear of Crime,” European Journal of Communication 19 (2004): 239–248

The same thing may also be true about our health care beliefs; that is, they may well correspond more closely to the health care we see on TV (in entertainment and news programs) than to health care in the real world.

Read the full discussion in “House, M.D. vs. Reality”

Influence of TV Medical Shows Adds Up

noreply@blogger.com (Andrew Holtz, MPH) — Wed, 05 Oct 2011 17:00:00 +0000

The influence of fictional TV shows is a drip, drip, drip effect.

“It’s not a conscious process, where you become frightened because you say, ‘In ER they didn’t manage to save that person’s life, so that will also happen to me.’ Instead, it’s totally unconscious. But there are studies which clearly document this process, which we call ‘cultivation.’... In other words, you think that the way life is portrayed on television is equal to your surrounding life.” - communications researcher Amir Hetsroni, PhD.

He says the effect is small. For most people, most of the time, it may not make a measureable difference in attitudes or beliefs about the risks of going to the hospital. But Hetsroni notes that even if very few viewers change their health care decisions because of the effect of TV shows, it all adds up. There are more than 300 million people in the United States, almost all watching TV at least sometimes. So even if more than ninety-nine out of a hundred aren’t affected, the number who are could still reach into the millions.

Read the full discussion in “House, M.D. vs. Reality”

How Cheery Marcus Welby MD Became Surly Greg House

noreply@blogger.com (Andrew Holtz, MPH) — Tue, 04 Oct 2011 17:00:00 +0000

Whatever you thought of last night's season 8 premiere of "House", you have to admit that it's hard to imagine the medical TV icon of an earlier generation, Marcus Welby, M.D., ever finding himself behind bars. The evolution from TV physicians who were almost always really nice guys to the rough and biting Dr. House is just part of a TV industry response to changing technology, according to communications researcher Amir Hetsroni, PhD.

He documented a turn for the worse in TV patient outcomes, concluding that TV patients are nine times as likely to die in the hospital as are patients in real-world hospitals in the United States.

“I was quite surprised, honestly, to come across the finding that hospitals in medical dramas are very, very scary places. I was raised on more traditional medical dramas in the 1970s in which most of the diseases were cured in thirty or forty minutes. And the biggest diseases were something like a problem with your tonsils,” he says. “All of a sudden, when we come to the modern medical dramas, like ER and Chicago Hope, we come to a very nihilistic surrounding, where actually the survival rate is much, much lower than the survival rate in real hospitals. It’s a very scary place.”

He thinks the turn toward a darker, grittier portrayal of life—and more frequently death—in medical shows was part of a larger course change by the major broadcast television networks as they tried to adapt to the growth of cable television.

HBO and other cable-only networks not only did not have to abide by the constraints of regulations that set standards for acceptable speech and other content on broadcast programs, they weren’t trying to please the mainstream. Instead of devising programs acceptable to almost everyone, cable channels consciously sought out viewers willing to pay extra in order to watch the kind of programs not available on free, over-the-air TV.

Read the full discussion in “House, M.D. vs. Reality”

Don't Expect a Happy Ending on House (or other TV shows)

noreply@blogger.com (Andrew Holtz, MPH) — Mon, 03 Oct 2011 17:00:00 +0000

Season 8 of House premieres tonight in the United States.

While the show is often loads of fun, the fates of patients on this and other TV medical dramas is often not the kind of "happily ever after" we tend to believe define Hollywood Endings. In sharp contrast to the common belief that things work out better in fiction than in reality, a recent survey of hospital patients on TV shows found quite the opposite.

TV Patients 9 Times as Likely to Die

That's what communication researcher Amir Hetsroni, Ph.D., discovered when he compared the fates of hospitalized patients on TV to the death rates reported for real US hospitals.

The finding that TV patients are far more likely to die than real patients is the opposite of what most people believe. After all, a “Hollywood ending” is supposed to mean that the characters surmount monumental challenges, that they succeed against all odds, and that everyone lives happily ever after. Even communication researchers have long accepted that view.

“This is what you are raised on when you study communication at a university, for instance, that TV is a very, very ‘Goody Two Shoes’ place, a very, very nice world where nothing bad happens, nothing that cannot be resolved within a 45-minute episode. And currently the situation is pretty different,” Hetsroni says.

So be thankful you aren't likely to wake up on a ward in the Princeton-Plainsboro Teaching Hospital or Seattle Grace Hospital!

Read the full discussion in “House, M.D. vs. Reality”

What You Think You Know May Be a Fantasy

noreply@blogger.com (Andrew Holtz, MPH) — Fri, 30 Sep 2011 17:00:00 +0000

How often do you hang out in a hospital or doctor’s office? Not often, unless that’s where you work, right? What if I pointed out that you probably see the inside of a clinic or hospital ward or even an operating room almost every day?

Of course, you see it on TV, not with your own eyes. This sort of media experience is not firsthand experience, but it still has an effect on how you view the real world around you.

Amir Hetsroni, Ph.D., sees firsthand how TV shows fill gaps in our personal experience. He does research and teaches classes on communication. At the beginning of a term he will often quiz his new students.

“I ask, ‘How many of you have ever been in an operating room, not as an anesthetized patient?’ In a class of thirty or forty students maybe one raises his or her hand, usually not even one. And then I ask the following question, ‘How many of you think you can describe to me what an operating room looks like?’ All of a sudden half of the students are able to describe it, sometimes more than half. How do they know about it? They’ve never been there. It’s from television. It’s unconscious. They don’t even know that’s where they’re getting the information.”

Medical dramas make us feel like we know something about a world, the world of medicine, with which most of us have little direct experience. Beyond learning the basic layout of an operating room - that the anesthesiologist usually works near the patient’s head, for example - viewers absorb other recurring themes from TV hospitals. And the images that sink into our brains influence what we believe about health care in the real world.

Read the full discussion in “House, M.D. vs. Reality”

House Orders: Patients Must Live

noreply@blogger.com (Andrew Holtz, MPH) — Thu, 29 Sep 2011 17:00:00 +0000

Living longer is good... for most people... most of the time. But maximum survival is not always what people want. There are many cases of patients choosing to forgo treatment... or even commit suicide... rather than endure the unendurable.

But Dr. House almost never accepts the wishes of patients when those wishes don't put postponing death above all other considerations. It works on the show, because it almost always works out for the best on the show, but the logic is not as compelling in the real world, where it is not always easy to be sure which choice will lead to the best outcome for the patient.

“In the program, it looks like the doctor knows best. And that’s one of the things that one has to fight in medicine, is the idea that doctors do know best. They may know medicine best, but they may not know what’s best for patients, because patients have all sorts of priorities and preferences and values. And it is not necessarily maximum length of life or maximum health.” - Bioethicist Mark Wicclair, PhD.

Read the full discussion in “House, M.D. vs. Reality”

House is Gray-Blind

noreply@blogger.com (Andrew Holtz, MPH) — Wed, 28 Sep 2011 17:00:00 +0000

House almost always sees decisions as black-or-white, live-or-die. He overlooks the (less dramatic) middle road or third option. I interviewed bioethicist Dr. Mark Wicclair for “House, M.D. vs. Reality” and he offered an example of how the contrasts and choices House sees frequently miss the shades of gray that real doctors and patients have to deal with:

“House says that if the patient doesn’t agree to be on a respirator, he’s going to die in a very painful, suffering way by choking to death. That’s a no-no in the real world. If a patient decides not to be put on a ventilator, then she is given sedation and palliative care so that she doesn’t suffer. It’s a third way. You can go on a ventilator, you can not go on a ventilator and choke to death, or we can make you comfortable. But House always presents things in a way that paints one of the options as being very rosy and the other as being completely bleak. In the real world it’s often not quite that way: both options aren’t great and there’s maybe two or three others that aren’t that great either, so you are choosing among a variety of options none of which is a clear winner. That’s more the real-world situation.”

Read the full discussion in “House, M.D. vs. Reality”

Dreams of Being Dr. House

noreply@blogger.com (Andrew Holtz, MPH) — Tue, 27 Sep 2011 17:00:00 +0000

As I noted recently, many people who work in health care are irked by the portrayals of their profession on TV in shows such as House and Grey's Anatomy. But the shows can be a guilty pleasure for them, though perhaps in a different way than for people whose only view of an operating room is the light on the ceiling as the anesthesia meds kick in.

House gets away with all sorts of things real doctors can’t, and he exudes a confidence and certainty few real doctors would dare to.

“In terms of medical professionals and students, I think it’s really kind of a fantasy world for them, where they see somebody talking back to patients and family members, treating them quite brusquely, and they get away with it. I think that’s one of the reasons [medical] students enjoy it so much, besides the fact that it’s just good entertainment, I think every medical student has had a situation where they would have just loved to tell a family where to go, like House does, so it’s a bit of a fantasy for them.” - Mark Wicclair, PhD, professor of philosophy and an adjunct professor of community medicine at West Virginia University in Morgantown.

Read the full discussion in “House, M.D. vs. Reality”

Dr. House: Bioethics Instructor

noreply@blogger.com (Andrew Holtz, MPH) — Mon, 26 Sep 2011 17:00:00 +0000

In my last couple of posts, I've quoted Dr. Howard Trachtman about how TV shows like House distort how patients in the real world look at doctors and health care in general. I came across Dr. Trachtman because of a commentary he wrote for a special issue of the American Journal of Bioethics that focused on the TV viewing habits of medical and nursing students.

Trachtman asked readers to understand that he wasn’t arguing against shows like “House,” but just asking that the entertaining fictions be kept in the proper perspective.

"I fear that I have come across as a stuffed shirt, an almost dead white male. I am not arguing for canceling medical dramas from television.I hope people watch them and enjoy them as much they like. I am only advocating basing the teaching of bioethics to health professionals in training on vehicles that will stand the test of time and which focus on physician education rather than the Nielsen ratings." - From H. Trachtman, “The Medium Is Not the Message,” American Journal of Bioethics 8, no. 12 (December 2008): 9–11.

In conversation, he notes that the article was intended to be part of a point-counterpoint exchange, and that actually he thinks House and other shows can be used effectively in educating medical and nursing students about bioethics and other areas of medicine.

“Good teachers can use anything. You can always flip anything and make it into a valuable teaching tool,” he says. “There is so little time and so much to learn, so anything that they can use that would make students assimilate more information in a quick way, well, all the power to them.”

A survey of student TV viewing included in the journal reported that attitudes about medical TV shows tend to be more negative among more senior students, suggesting that the more a person knows about the real world of health care, the more troubled that person may be about the dramatic license taken by TV writers. Older students simply know better. By contrast, the average viewer has little or no direct experience that could counterbalance
the media images.

Read the full discussion in “House, M.D. vs. Reality”

Bending Reality for TV Bends Reality... Really

noreply@blogger.com (Andrew Holtz, MPH) — Sat, 24 Sep 2011 17:00:00 +0000

Yesterday I wrote about the warped perceptions that come from TV medical shows dramatically (as in, for dramatic effect) collapsing the time course of disease, diagnosis and treatment.

Obsession with the bizarre has a similar effect. Certainly, people would not watch House and other medical shows in such numbers if all the cases were boringly routine. The point of entertainment shows is to be more colorful and exciting than real life, but some health experts worry about viewers being distracted from the real issues society faces as we try to improve health care. They say people should understand that the greatest improvements in health come from small changes in dealing with common things that affect a lot of people, not the bizarre, though exciting, cases that House takes week after week; cases that are far more rare than lightning striking a person.

“The TV shows are about the lightning strikes. They are interesting. And they are fun. And they are engaging. And they are exciting. And they make us all feel better.” - Dr. Howard Trachtman.

But the steady diet of “lightning strike” cases, may lead viewers to overestimate just how much they need to worry about being struck by lightning, in the medical sense. And so the desire to have a health care system of heroic doctors available to rescue them from freak occurrences may trump their interest in supporting basic, routine care.

Read the full discussion in “House, M.D. vs. Reality”

Time Travel is a Weekly Occurrence on House

noreply@blogger.com (Andrew Holtz, MPH) — Fri, 23 Sep 2011 17:00:00 +0000

It's not just House. All medical TV shows, indeed all TV shows, engage in time travel.

I'm not talking about sci-fi plots involving meeting your grandparents when they were young, but the way a lab test involving cell cultures that takes weeks in the real world can produce results during the lunch break on TV. And of course, in order to keep emotions running high, patients wildly swing between full health and near death in minutes or hours of TV time.

Sometimes things do happen fast in real hospitals. The high-speed dance of a trauma team swooping in on a car crash survivor is wonderful to behold. But things almost always transpire at a much slower pace and with much less certainty. Doctors almost never know the full effects of their decisions right away, and when the results are known, they are almost always in-between; that is, neither a clear victory nor an absolute defeat, unlike on TV.

One doctor I interviewed for “House, M.D. vs. Reality” put it this way:

“It’s always predicated on a clear-cut black-or-white outcome. Most of the time, for myself in pediatric nephrology [kidney disease in children], it’s rare for children to die in my subspecialty. I win, I lose. It’s all in very subtle gradations,” Dr. Howard Trachtman told me. Yet every now and then, things do happen quickly. Dr. Trachtman recounts one such case in which a patient declines rapidly and deeply. "The slope of her illness is so steep. It almost does remind me a little bit of a TV show. But that is so exceptional. They make it the rule. I find it to be the exception. Most of my encounters with patients are very, very evolutionary in nature. And most of what I do is a mixed blessing.”

The speed and certainty of TV medicine raises the expectations of patients to unrealistic heights. As a surgeon told me recently, "Patients think we should have all the answers within 45 minutes. I actually have told many [patients] that this isn't TV."

Read the full discussion in “House, M.D. vs. Reality”

House Teaches Ethics to Med Students. House?!

noreply@blogger.com (Andrew Holtz, MPH) — Thu, 22 Sep 2011 17:00:00 +0000

Mark Wicclair, Ph.D. teach bioethics to medical students. He has this to say about House:

"I really love the show."

Really. Wicclair, a professor of philosophy and an adjunct professor of community medicine at West Virginia University in Morgantown who also works at the University of Pittsburgh’s Center of Bioethics and Health Law, says he sees value in examining the world of health care according to House.

"Is it worrisome that medical students appear to enjoy watching a series that features such an unethical physician?...
It would be if one assumed that they look at House as a positive role model. However, this may be an unwarranted assumption." - From M. R. Wicclair, “The Pedagogical Value of House, M.D.—Can a Fictional Unethical Physician Be Used to Teach Ethics?” American Journal of Bioethics 8, no. 12 (December 2008): 16–17.

House can serve as the anti-ideal, Wicclair says. By violating one ethical rule after another, by assaulting patients, by bending their wishes to suit his will, by gaming the system, and on and on... House often demonstrates, in a powerfully emotional way, just why the rules exist.

There have been a number of studies and other evaluations of the ethics demonstrated on House and other shows. Just last month, researchers in Australia published the results of a study of medical students and what they learn from House, Scrubs, Grey's Anatomy and other medical shows.

From a patient's perspective it is comforting to know that as medical students gain experience, they grow increasingly skeptical of the means and methods of Dr. House.

Read the full discussion in “House, M.D. vs. Reality”

Some of the articles I used in my writing:

Czarny, M., E. Bodensiek, R. R. Faden, M. T. Nolan, and J. Sugarman. “Medical and Nursing Students’ Television Viewing Habits: Potential Implications for Bioethics.” American Journal of Bioethics 8, no. 12 (December 2008): 1–8. Abstract available at http://www.bioethics.net/journal/j_articles.php?aid=1709&display=abstract, accessed on February 8, 2010.

Czarny, M. J., R. R. Faden, and J. Sugarman J. “Bioethics and Professionalism in Popular Television Medical Dramas.” Journal of Medical Ethics 36 (2010): 203–206. Abstract available online at http://jme.bmj.com/content/36/4/203.abstract, accessed on April 1, 2010.

Trachtman, H. “The Medium Is Not the Message.” American Journal of Bioethics 8, no. 12 (December 2008): 9–11.

Wicclair, M. R. “The Pedagogical Value of House, M.D.—Can a Fictional Unethical Physician Be Used to Teach Ethics?” American Journal of Bioethics 8, no. 12(December 2008): 16–17.

Wicclair, M. R. “Medical Paternalism in House M.D.” Medical Humanities 34(2008): 93–99;

No One is That Good

noreply@blogger.com (Andrew Holtz, MPH) — Wed, 21 Sep 2011 17:00:00 +0000

Dr. Greg House gets away with a lot mostly because he is so dang good. So what if there are ethical or even legal lapses in how he diagnoses and treats patients. After all it's the cure that's the goal, right?

“It all works out marvelously well. Generally, House finds out what the condition is, diagnoses it, comes up with the treatment, and at the end of the show patients are very grateful. You know, that’s not the way the world really works. If physicians were to act that way in the real world, chances are that they wouldn’t find the proper diagnosis, or even if they did, the treatment would have some horrible side effect and the patient would get sick and wouldn’t be terribly grateful.” - Mark Wicclair, Ph.D., professor of philosophy, adjunct professor of community medicine, West Virginia University in Morgantown.

Unfortunately, when the methods of TV docs are examined, they are seen to bear the same relation to real clinical care as the supernatural beauty of the stars, aided by make-up, kind photography, lighting and editing, has to the looks of the average doctor or nurse after working overnight call in a Level III Trauma Center.

Read the full discussion in “House, M.D. vs. Reality”

Now How Will We Know What Dr. House Has Done?

noreply@blogger.com (Andrew Holtz, MPH) — Tue, 20 Sep 2011 13:00:00 +0000

From previews of the upcoming season of House, we know that he's in trouble again.

Curious Expeditions

While doctors in the real world don't match up to Dr. House in many ways both good and bad, sometimes they mess up. But it's often very hard for patients to find out if their doctor has a skeleton in the closet... and not the one used to learn about the bones in our bodies.

If you live in New Jersey, where "House" is set, a good place to start is the Web
site of the New Jersey State Board of Medical Examiners. Other states release information on health care provider discipline to varying degrees. One catch is that a doctor, nurse or other provider who gets into trouble in one state can pull up stakes and move on down the road.

The federal government does maintain a National Practitioner Data Base. It is primarily intended for use by hospitals or others who need to check the background of a provider applying for a job. Some data, without doctor names, has been made available to the public.

Public Use File Closed

Oops, let me update that last line. Just recently the federal government blocked access to the public database. It seems that some people didn't like the fact that journalists were using the information to reveal breakdowns in the oversight of health care providers. On Sept. 15, 2011, three major journalism groups sent a letter of protest to the Obama Administration. The announcement by the Association of Health Care Journalists of its protest includes a link to a site where you can download a copy of the data that was removed from the HHS web site. The archive is hosted by the Investigative Reporters & Editors group.

Read more about disciplining doctors in “House, M.D. vs. Reality”

A couple of references:

Weber, T., and C. Ornstein. “Dangerous Caregivers Missing from Federal Database.” ProPublica.org, February 15, 2010. Available online at www.propublica.org/feature/federal-health-professional-disciplinary-database-remarkably-incomplete.

Wolfe, S., and A. Levine. “Hospitals Drop the Ball on Physician Oversight: Report on Under-Reporting to the National Practitioner Data Bank.” Public Citizen, May27, 2009. Available online at www.citizen.org/Page.aspx?pid=585.

More references related to topics in "House, M.D. vs. Reality" available here.

What Do Doctors Think of House?

noreply@blogger.com (Andrew Holtz, MPH) — Mon, 19 Sep 2011 17:00:00 +0000

As rule, I don't watch a lot of the medical dramas on TV. It is often too hard to suspend my disbelief and just enjoy the show.

Plenty of doctors, nurses and other health care professionals share that attitude. Some even reject the shows... strongly.

“I can’t stand to watch House. It just makes me crazy. I want to teach him doctor-patient communication and respect for persons and autonomy. I want his colleagues to deal with an impaired provider,” says one physician I interviewed while writing “House, M.D. vs. Reality”

But there are also plenty of House fans among the ranks of medical professionals. Some enjoy a cathartic release watching House say and do things they know they can’t . . . and shouldn’t.

“I know House is an ass. And I like that he’s an ass most of the time because it’s amusing. I know that in real life, I can’t be an ass when it comes to dealing with patients” is how one put it in a blog post.

And then there are physicians who just love House.

“I think he’s terrific,” says a doctor who admits that watching the show is a guilty pleasure that many colleagues don’t understand. This doctor admires the way House’s mind operates. “He’s actually figured out the concept of objectivity, in making a good decision, so I actually like him.”

Read the full discussion in “House, M.D. vs. Reality”

As Seen on House vs. the Reality of Premature Autopsy

noreply@blogger.com (Andrew Holtz, MPH) — Sun, 18 Sep 2011 17:00:00 +0000

How often do people wake up in a morgue? Very, very rarely, but it does happen.

In the episode of House titled "Brave Heart", Foreman and House screamed when a patient they believed was dead suddenly woke with a yell as they began an autopsy. Although coroners quibble with several details of the scene, they admit that people have been sent to the morgue when they weren't actually dead.

Fears of premature burial haunted Edgar Allan Poe.

It may be asserted, without hesitation, that no event is so terribly
well adapted to inspire the supremeness of bodily and of mental distress,
as is burial before death. The unendurable oppression of the
lungs—the stifl ing fumes from the damp earth—the clinging to the
death garments—the rigid embrace of the narrow house—the blackness
of the absolute Night—the silence like a sea that overwhelms—
the unseen but palpable presence of the Conqueror Worm.
From “The Premature Burial” by Edgar Allan Poe, 1850

Over a century ago, this sort of life and death mistake was more common than it is today. A more typical contemporary scenario for a premature declaration of death is a multiple-victim car crash or other hectic casualty scene, where paramedics and others may miss faint signs of life as they focus on patients who are obviously alive.

Read the full discussion in “House, M.D. vs. Reality”

As Seen on House vs. the Reality of Biological Liars

noreply@blogger.com (Andrew Holtz, MPH) — Sat, 17 Sep 2011 17:00:00 +0000

In the episode Known Unknowns, Foreman explains a young woman's repeated lies.

“She can’t control it. A bleed in her brain is affecting her thalamus, causing her to lie.”

A better description of her behavior is confabulation, the mixing of reality and fantasy, in this case to fill in gaps in memory. Bruce L. Miller, M.D., professor of neurology at the University of California at San Francisco explains it this way.

“Confabulation is making up things when you don’t know what the right answer is.”

Miller says that some patients with problems that disrupt memory may fill in the gaps with invented stories.

“We see that with a lot of neurologic diseases. We see it with a lot
of memory disorders. Alzheimer’s patients can confabulate. The classic
example where we see it is something called Korsakoff’s syndrome,
which is alcohol-related injury to the thalamus where there is a memory
disorder. These patients make up stories around what they don’t
remember."

Read the full discussion in “House, M.D. vs. Reality”

As Seen on House vs. the Reality of "Death Cats"

noreply@blogger.com (Andrew Holtz, MPH) — Fri, 16 Sep 2011 17:00:00 +0000

A nurse freaks out because a cat curled up next to her. She tells House that the cat is predicting her imminent death in the episode titled Here Kitty. The nurse has seen the cat repeatedly seek out the beds of certain patients in the nursing home. Those patients then soon die.

The episode may have been inspired by an article in the New England Journal of Medicine in which a physician who works with elderly patients told of A Day in the Life of Oscar the Cat. The article included this section:

“A nurse walks into the room to check on her patient. She pauses

to note Oscar’s presence. Concerned, she hurriedly leaves the room and
returns to her desk. She grabs Mrs. K.’s chart off the medical-records
rack and begins to make phone calls.”

The phone calls were to alert family members that their loved one might die very soon. The article about Oscar the Cat was written by Providence, Rhode Island, geriatrician David M. Dosa, M.D. who says Oscar has been remarkably accurate.

“He really doesn’t miss. What’s interesting about Oscar is that he is not

particularly friendly most of the time. He really doesn’t hang out with patients

or other people on the unit. He keeps to himself and does his cat thing. But

when somebody is near the end, he seemingly becomes comfortable with

people and spends a lot of time holding these vigils."

But Dr. Dosa disagree with House's ultimate explanation. While House suspects the heat of fevers attracts the cat, Dr. Dosa leans toward the cat's sense of smell detecting signs that humans and our machines can't pick up.

Read the full discussion in “House, M.D. vs. Reality”

As Seen on House vs. the Reality of Scrotal Pain as a Seizure Symptom

noreply@blogger.com (Andrew Holtz, MPH) — Thu, 15 Sep 2011 17:00:00 +0000

When House was almost stumped by a case of seemingly untreatable pain in the episode titled Painless, his "Aha!" moment involves watching a plumber scratch his groin. House surmises that they are making a mistake by trying to mask the pain instead of treating the source, which he believes is an unusual form of epilepsy.

There are a few cases that sound similar in the medical literature. For instance, a research letter to the Journal of Neurology, Neurosurgery & Psychiatry includes this description:

“The boy who was playing cheerfully, suddenly started screaming
and clutched his scrotum with his hands,” the letter reported. “The
entire attack lasted about 2½ minutes and this was followed by slow
return of the right testis to its normal position within the scrotum.”

Ten days after admission to the hospital an EEG “showed random epileptic activity over the left central area.” And so the author of the letter advised readers that “scrotal pain associated with testicular jerking is an unusual form of seizure.”

Read the full discussion in “House, M.D. vs. Reality”

Pfizer Offers Goodies to Journalists

noreply@blogger.com (Andrew Holtz, MPH) — Wed, 14 Sep 2011 21:08:00 +0000

(Click on 'Read more' to see update.)

Normally I would salivate over a workshop titled "Let Me Be Clear: Science Journalism in the Age of the Genome and Twitter". OK, yes, I admit to being a nerd about both science and journalism.

When I received an e-mail about this event, I clicked through right away to learn more.

As I read phrases such as "an interactive conversation about media, health research, science and public understanding of these issues" and "Leaders in science, health communications, journalism and social media" I sighed "Ooh, Baby! Gimme more!"

But then my building excitement and anticipation was doused by a real buzz kill in the middle of the sponsor logos...

Pfizer?! Sponsoring a gathering of the very journalists who are supposed to be independently examining the company's products and pitches? In truth, I was not completely blind-sided: Pfizer also tosses money to the National Press Foundation to pay for workshops on cancer and Alzheimer's aimed at journalists. (Gary Schwitzer & I wrote about one of those all-expenses-paid journalism workshops last fall.)

UPDATE 9/16: New blog post from Gary Schwitzer.

Italian journalist argues against pharma-sponsored press events.

Pharmaceutical companies are adapting some of their marketing efforts in response to growing concerns about how gifts and "educational" meetings for physicians alter their clinical decision-making and prescribing practices. A growing number of health care and medical education institutions are restricting or banning such goodies given out to the docs who are supposed to act in the interests of patients, not industry. Medical journals have substantially toughened disclosure requirements for authors. Changing standards and emerging regulations are shining more light on these ties between companies and doctors. (See the excellent reporting by ProPublica, "Dollars for Doctors".)

Ah, but there are no regulations or reporting requirements when it comes to attempts to co-opt journalists. Seems to me there's a natural opportunity there for companies to shape the messages reaching both consumers and policymakers.

Meeting organizers often respond that the corporate sponsors don't dictate the program or panelists. But these events tend to cluster around diseases that the sponsors just happen to have products for. I'm sure that the sponsors are smart enough to realize that the media spotlight will spill over onto their drugs and devices. There is no need for them to be heavy-handed in order to shift the media agenda and ultimately get a marketing boost.

And on a broader level, these kinds of events and the stories that result tend to focus on diseases and medical interventions. I don't see a similar level of attention to public health, how transportation and urban planning policies affect physical activity, how agricultural policies influence the foods we eat, how zoning and industrial policies affect disparities in neighborhood health, and so on. There aren't any commercial products that are likely to get more sales based on enhancing public attention to these topics... so the media agenda is subtly redirected in a way that is consistent with commercial interests.

The Association of Health Care Journalists fundraising policy bars sponsorship or even advertising from companies that sell products or provide services in the health care field, though academic medical centers may be event sponsors. Pfizer would not be welcome at an AHCJ meeting.

As dear to my heart as the topic of journalism about science and medicine may be, I would not feel comfortable attending an event with the sort of corporate ties the "Let Me Be Clear" meeting displays.

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Disclosure: Several years ago I accepted some money from ResearchAmerica for helping to organize a meeting between medical researchers and journalists. There were no named corporate sponsors involved in that meeting.

As Seen on House vs. the Reality of Using Worms as Medical Treatment

noreply@blogger.com (Andrew Holtz, MPH) — Wed, 14 Sep 2011 17:00:00 +0000

Can infestation with parasitic worms reduce inflammatory bowel disease symptoms?

In the episode "Teamwork" they cured a patient of his parasitic worm infestation, only to discover he got sicker. Eventually they decided the worms were helping to blunt autoimmune attacks that were eating away at his gut. So they re-infected him with worms.

It may not be standard practice in the United States, but helminthic therapy as it's called is being examined in medical trials.

Some researchers hypothesize that our bodies, including our immune systems, evolved over the eons to coexist with parasites and that by altering the ancient relationship we have caused new problems. “Diseases like inflammatory bowel disease used to affect 1 in 10,000 people; it’s now becoming 1 in every 200 to 250 people. Something’s causing it, and it’s environmental,” Joel Weinstock, M.D., is quoted as saying on a Web page about his research at Tufts-New England Medical Center in Boston, Massachusetts.

To browse clinical trials that are testing the effects of parasitic worms on human health, go to www.clinicaltrials.govand enter “helminth” in the search window. Note: some of the trials listed will be those that give people worm eggs, while others will be experimental treatments meant to kill parasitic worms.

Read the full discussion in “House, M.D. vs. Reality”

Cholesterol, Statins, Disease & Journalism

noreply@blogger.com (Andrew Holtz, MPH) — Wed, 14 Sep 2011 13:00:00 +0000

A couple of questions posted to the listserv of the Association of Health Care Journalists got me thinking.

One asked about side effects of statins. That post was followed by a question about the science linking cholesterol (which statins can lower) and heart disease. The topics raise a number of important points that journalists should keep in mind. I posted some thoughts that are relevant also to the readers, viewers and listeners of the stories we journalists tell.

Great discussions on statins and cholesterol. There are a lot of fundamental questions about both topics that deserve more insightful and nuanced reporting. I think some points are worth emphasizing or clarifying.

As one post noted, most people with high cholesterol will die of something other than a heart attack or related cardiovascular ailment. (Meanwhile, most people who have heart attacks were not identified as high risk in advance.) Keep in mind that this fact neither supports nor undercuts the evidence associating cholesterol with heart disease or the use of statins to reduce risk. It does underscore the importance of distinguishing anecdotes from evidence... and clarifying the difference between what choices and perspectives an individual might have given the gray areas in knowledge... and what policies may gain support on a population basis.

In other words, there is really no conflict between a population-based policy of trying to lower cholesterol levels (based on the consistent correlation of cholesterol levels and heart disease rates) and an individual's choice to not swallow a statin (based on the fact that you have to treat many people in order to change the outcome of one, so most people do not actually receive a measureable personal benefit). I remember being in a group of docs in a workshop discussing how to get a man at high risk of a heart attack to take a statin. In the scenario, the number needed to treat was 8, meaning that for every 8 people treated there probably would be one less heart attack in a given time period... but the other 7 would not have any different outcome (heart attack or not) than if they had not been treated. The population basis rationale for prescribing a statin to that individual makes sense, for every 100 such people treated you'd expect to see about a dozen fewer heart attacks... but it doesn't mean that he as an individual will be necessarily better off, in fact the odds are 7 to 1 against changing the ultimate outcome for that specific individual.

It's also important not to confuse the questions about cholesterol and those about statins. Some people suspect that the effect of statins seen in clinical trials may be related to suppressing inflammation in arteries, reducing the risk of plaque ruptures, or other mechanisms beyond reducing cholesterol.

Always be clear about whether the topic is primary prevention (risk factors) or secondary prevention (preventing a second heart attack, etc.). Almost all of the trials that show giving someone a statin reduces the odds of bad stuff happening have been done in people who have already had a heart attack or are otherwise considered to have heart disease (as opposed to being at risk for developing heart disease). There are relatively few big trials that included people who seem healthy, but have high cholesterol or other risk factors. There is a lot of debate about where to set the parameters for recommending statins to people who haven't had a heart attack or other event, but much less argument about treating people who have already had something bad happen.

I'm wary of those who have bad things to say about statin pills, but recommend foods (or supplements) containing similar substances that are supposed to lower cholesterol or offer other benefits. I'd want to hear a good explanation for how the food would be better than the pill... and what the evidence is. Maybe there is something in some foods that is lost when you distill one ingredient into a pill. We've certainly seen many examples of how people who eat diets high in certain vitamins do well, but then supplements with those same vitamins fail in trials. And if the food is said to be less likely to cause side effects... is that just because the dose of the active ingredient is lower... which suggests any benefit would be less as well?

And be careful to check whether the evidence offered is from experimental trials or just observational studies. Diet studies are notorious for tripping over confounding factors and other flaws... that is, people who eat a more 'healthful' diet often do a lot of other things that are associated with good health. They also may have more education, higher incomes, live in better neighborhoods, and have other characteristics associated with health and longevity. I am very skeptical of diet studies that don't measure socioeconomic status, education and other personal characteristics.

I'll close this tome with a reminder to always ask about relative risk, absolute risk and number needed to treat. It's particularly important in the matter of using statins for primary prevention. Reducing the risk of a heart attack by a third sounds wonderful. But that statistic means nothing without knowing the absolute risk. The effect on 100 individuals with a 20% risk of a heart attack in a decade would be about six or seven fewer heart attacks. But in a group with a 3% risk of a heart attack you would be treating 100 people in order to maybe prevent one heart attack. What's more, the risk of side effects is probably about the same in both groups, so the risk-benefit ratio may be dramatically different.

Sorry to go on at such length. We need more solid coverage of cholesterol, statins, and so on... but like most of the topics on the health beat, there are important details that have to be considered in the editorial process, even if you can't include everything in the final story.

Cheers,
Andrew

Contagion (2011) - Outbreak (1995)

noreply@blogger.com (Andrew Holtz, MPH) — Tue, 13 Sep 2011 23:06:00 +0000

As soon as I saw the trailer for Contagion, I was reminded of the 1995 epidemic disaster movie Outbreak, starring Dustin Hoffman, Morgan Freeman, Donald Sutherland, Renee Russo, et al.

In a CNN report, I contrasted the Hollywood nightmare with the reality of the Ebola virus, pointing out that the faster a virus kills, the less likely it is to cause widespread disease... simply because there isn't time for the virus to jump to a lot of other people. It's the slow and stealthy viruses, like HIV, that can really rack up a death toll.

But here's the bottom line...

In 1995 when I was a CNN Medical Correspondent covering how Hollywood depicts infectious disease threats, that's what I did... report about the movie... not appear as a reporter in the movie.

My how things change.