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Only occasionally are there television shows that give you something serious and enlightening to think about, and that make it fun for you to analyze them from an intellectual, psychological, or educational perspective. The Fox Network television program House is such a show. On the surface the program is the same each week -- patient comes in, is given a treatment that s/he either does not respond to, or that, more frequently, makes him/her even worse. Diagnosis is corrected in light of new information, and new treatment is confidently instituted. Patient still gets worse. Finally, around the 50th+ minute of the hour show, some symptom or new information appears or is finally recognized that allows for the correct diagnosis. Patient is saved (except in the case of the woman with a rabies infection diagnosed who came in too late to be saved, but not too late to help her psychologically come to peace with her life, and in the case of a pregnant woman with a deadly form of cancer). So if all you are watching for is how it is going to turn out, that is pretty much the plot each week, and the show would not be all that interesting.[This is a perspective on the first season. Two episodes so far into the second season, some deeper ethical and philosophy of life issues have been added to, and have replaced some of, the diagnostic efforts. This makes the show even richer when it works well. What is below still applies to the program, but, at least at the beginning of the second season, shares the stage now with more philosophical concerns. -- RG, 9/21/05]
But the show is tremendously interesting because it is about far more than just whether the main patient of the week is saved or not. (There is typically one main patient with a serious problem, and one or more "clinic" patients with minor, often quite amusing, problems or personalities.) It is about all the things that make up the process of diagnosing the patient correctly. It involves human error of many sorts: normal "immaturity" or routine, unthinking practice, on the part of doctors that foster their making careless, but typical or "normal", errors; patients' lying about things they think irrelevant to their condition, or that they think important enough to hide even if it means they might not be correctly diagnosed or cured, or even saved; faulty logic; doctors' jumping to conclusions; doctors' (and viewers) not noticing clues that don't seem like clues; misleading clues, coincidences that lead doctors the wrong way, reliance on previously faulty diagnoses of other doctors, outside psychological factors that distract the doctors, etc. (Watching re-runs or recorded versions of House once you know the correct diagnosis is interesting because you then see all the clues that were before you and the doctors -- clues you didn't even notice the first time, let alone notice as clues.)
The program also is cathartic (often humorously so) in that Dr. Greg House, who on the surface is a sarcastic misanthrope, gets to say the things many of us wish we could say to the kinds of people he says them to, but he is able to get away with saying them (usually) because he backs them up with medical reasons (or fake medical reasons when he wants to use them) and because he is such a pained, "damaged", irrascible, curmudgeon (grumpy 40-something man).
His character also has a consummate understanding of human nature and applied psychology (as opposed to psychobabble), as in the episodes where he rejected applicants for a vacancy, based on reading things about them, and making deductions about their character based on aspects of their appearance (clothing, kind of tattoo) or comments they made. One of the more interesting cases of this was where Dr. House was a defendant in a court case and got the judge not to listen to the plaintiff's attorney by telling the judge, just before the opposing attorney spoke that he noticed a potential sign of impending heart attack the judge was displaying and that if the judge had any history of heart disease in his family, he should see a specialist soon. House figured the odds were good the judge had someone in his family with heart disease. That pre-occupied the judge's attention for the remainder of the hearing.
There was also the time House showed some kid, pretending to be 18, he could tell the boy was only 15 from an X-ray he had taken of his wrist. He threatened to tell Child Services unless the kid gave him some truthful information about the mother, who was seriously ill. The boy told the truth and then said it would violate his privilege as a patient for House to tell Child Services on him. House's response was "Relax; that's not even your X-ray." House had pegged the kid for 15 and had just used the handy X-ray and medical information as a ruse to get the kid to confess.
And the show has even taught me something about psychology and human nature I did not know -- the means of redemption for a character on the show whose actions had seemed irredeemable. One of House's staff, Dr. Chase, who had been a very likeable character until a certain point in the season, had gone behind House's back to report some of his actions to hospital administrators in order to save his own job after he had made a medical error House had caught. Until that time, Chase had been a likeable character, but it seemed to me, this turn of character meant Dr. Chase would have to be fired and the actor playing his part would no longer be on the show. Even House's friend, Dr. Wilson, thought Chase needed to be fired. House handled it differently though, by tormenting Chase to the extent that I felt sorry for him and felt he had somehow earned the right to be liked and trusted again. Part of the reason this worked is that Chase accepted his punishment or mistreatment as being deserved. I would not have thought it possible for his character to be redeemed in my eyes, but the writers found a way to do it -- by making his punishment and suffering be redemptive, and by making his acceptance of that punishment be part of his atonement. In many cases on the show, such as this one, House seems abrasive, if not actually mean, and yet he is doing it to secure an ultimately worthy goal that may not be able to be secured in any other way.
Dr. Greg House is nice ultimately (or deep down inside) and works hard to save his patients and do the right thing. He just doesn't see any point in wasting time being artificially polite to people who are actually harming his patient (like the mother who gave her son some cough medication when she visited him in the hospital, and the medication was the cause of his problem because it was a pharmacy error), and he sees no reason to follow ethical conventions that he knows are wrong and that just serve to benefit practitioners rather than patients. He is essentially both ethical and nice or caring without appearing to be either, because he is not artificially polite, and because he practices real ethics, not just obedience to rules or tradition. Many movies and television show episodes have turned on the difference between real ethics and "professional ethics" but House does it repeatedly and well. Those who would think House mean or cruel only view him at a shallow level, and are likely the same people who think false praise fosters self-esteem or that sensitivity and effectiveness always demand delicacy or sweetness, even when those are false or contrived.
But it seems to me, because I am interested in this aspect of education, that House can be looked at to be generally about three things: (1) acting more responsibly, reflectively, and conscientiously than normally is expected, (2) making intelligent deductions from facts, and (3) always being vigilant and receptive to which facts might be significant ones from which to make deductions -- that is it is about seeing evidence, not just facts.
I will come back to this, but first, I want to describe and then dispel a problem I had for a few weeks until they showed why it was not a problem. What typically happens on many of the episodes was that House, Foreman, Chase, Cameron, and sometimes Wilson will brainstorm about the patients symptoms, which House usually has listed on a whiteboard, looking for all the diseases or conditions that might cause those symptoms. In some cases they get the right disease in the original list, though coincidental factors hide it and make them temporarily rule it out. But typically what happens on the show is that the cause they ultimately come up with is not in their original list. It troubled me that their original list was so incomplete each week, leading them not to do all the distinguishing tests they should have. But they have answered that on one of the episodes, plus I have my own answer for it. On the meningitis outbreak episode, a girl had neck pain that was not caused by meningitis. House had Chase search through all the conditions that presented neck pain. Chase said the list would be two miles long, and essentially pointed out that would be a very time-consuming (time-wasting) inefficient way to try to arrive at an accurate diagnosis.
What I had decided prior to that episode is that it is just too difficult for people to think up all the diseases or conditions that might cause certain symptoms, many of which present themselves in a great many illnesses (as Chase pointed out); so, I argue, that what is necessary for a physician to diagnose a difficult case is a symptom that triggers an association for the physician with a particular cause. It is not necessarily a defining symptom, but it is a psychologically distinguishing symptom that reminds the physician of the disease or condition that has been missing from the list they had been trying to narrow, and which accounts for all the other symptoms as well. Finding that symptom or set of symptoms is the crux of the show and the crux of House's superior diagnostic skill. On House that comes about each week in various ways, all of which have to do with logic and psychology. And that is one of the essential features of the show that makes it so intellectually interesting. All the doctors on the show are knowledgeable and know a tremendous amount of facts. But Dr. Greg House is the one who is able to sort out which facts are evidence from among all the facts presented and all the things about the patient that we see and hear. The show is about recognizing clues from what seem to be merely normal human occurrences, medical history information, or apparent symptoms of diseases or conditions. And that is what the show is teaching. That is what he is teaching his staff and colleagues. It teaches us that clues and evidence do not come to us labeled that way for us to then plug into some computer or knowledgeable human diagnostician. It shows that the art of diagnosis is not just knowing what conditions cause which symptoms, but it is figuring out what ought to count as a symptom or a sign or a clue to a condition in the first place. It is about recognizing clues to diseases and conditions, not just knowing what conditions cause the symptoms you are handed to solve.
It is like the difference between being able to do math calculations that are set up for you and being able to solve word problems where not all the information is relevant and where the significance of the information that is relevant does not tell which formulas to use or which calculations to perform. It is like the difference between being able to program a computer to do a prescribed task you are presented, and seeing on your own, as a programmer working for a company, what kinds of potential computer tasks might benefit the company in the first place. Schools tend to teach students how to solve problems of certain sorts that are given to them; but schools do not generally teach students to seek or to recognize problems that need solving. And it does not teach them how to notice which facts they know might count as evidence that would help solve a problem. House is about finding the relevant features of situations that define a problem or that will help you solve the problem. In one episode he overheard casual conversation between two obstetricians and determined an epidemic was hitting the delivery or nursery areas, long before more babies got sick.
One of the prime examples of his always being attuned to finding clues to medical conditions others don't even suspect was the episode where he had to teach a medical school lecture on diagnostics because the course teacher was out sick. It was the fifth time House had to fill in for the guy, which, because he hates doing it, seemed like a lot of illness for the guy to be claiming, but which seemed normal to everyone else. During the lecture, House got thirsty and found a child-painted "World's Greatest Dad" coffee mug in the guy's drawer that he washed out and filled at the drinking fountain, only to spit the water back into the mug. At the end of the lecture, which was the end of the program, he handed the coffee mug to the dean and said something like "This guy is not the world's greatest dad. He doesn't even rank on the list. What kind of parent gives their child lead-based paint to play with! Throw this mug away and get him some plastic cups, and he won't be sick any more, and I won't have to teach his course for him." He had made a diagnosis from just three facts, without having met the guy and without knowing anything else about him other than that he was sometimes ill and that he had a coffee mug that made water taste funny and looked like it had been painted by his kids.
Sometimes, though seldom, House will talk with patients (all of whom he distrusts to give a truthful description of their history), but when he talks with them, it is as an observor, not a listener. He assumes they are not telling the truth, but what they say and why they say it gives him informational clues about their condition. After many episodes of the show in which he would not talk with patients, he finally talks to one he thinks he can learn something from -- a paranoid delusional woman -- prompting Dr. Wilson to point out in total surprise that House won't believe anyone is telling the truth, except someone who has no concept of reality at all. But House was not interested in the veracity of the conversation; just on what he could deduce from it as signs of her condition. He is always suspicious of test results or previous doctors' diagnoses or treatments. Sometimes he thinks symptoms are meaningful and sometimes he doesn't. Often he finds clues no one else sees in some offhand remark the patient or a family member or friend makes or some act they do that to the viewer and to all the other doctors on the show simply seems normal. He is always seeking clues to the medical condition, but medical tests and previous medical diagnoses are themselves only potential clues for him, not to be taken as conclusive; and medical tests and medical diagnoses are not the only potential clues.
Now House will himself make diagnostic mistakes. On some episodes he initially thinks there is nothing seriously wrong with someone who actually is seriously ill. The difference between him and the doctors that had misdiagnosed his own leg muscle death and muscle infarction as being nothing to worry about is that House is always attuned to noticing symptoms others do not. Even after he has made a diagnosis, if anything at all occurs that might point out that diagnosis is not correct, he notices it. He noticed one young man's seemingly "nervous energy" leg motion after House had walked away from him and told him to go home and rest. He realized that particular motion was a neurological sign of a possibly serious condition.
He tries to teach his young proteges to do the same thing. He chides Cameron for getting too much, and relying too much on, patient history information, most of which is not relevant or helpful, and the abundance or direction of which only makes it more difficult to find what is salient. He derides Foreman for too easily dismissing symptoms that are actually significant. He derides Chase for being too quick to find either an exotic cause or a mundane one without doing more or reasonable tests to verify the ideas and without being willing to entertain other possibilities. He chastises all of them for believing as obvious facts things which may be mistaken, such as previous tests. House is always interested in making sure all the pieces of the puzzle fit each other and fit the bigger picture. He tries to explain every possible anomaly, instead of dismissing it as unimportant.
House also takes into account the side effects of treatment options that might interfere with other diagnostic tests or treatments later. The whole show and the whole series is not just about knowing all the medical facts and procedures, but knowing when and how to use them in the wisest and most reasonable way. It is about reflecting constantly on anything that might be relevant at all to assist in a diagnosis, whether it is the appearance of a symptom or the seemingly innocuous comment of a patient or visitor, or even another patient in clinic that House hates to work in. In one of the first episodes, he says that every treatment, even if it is wrong, will give you more information about the patient, and yet it is easy for the viewer or the staff to miss the clues in the failed treatment -- seeing it only as a mistake.
It is a brilliantly written show in that the dialogue and the actions tie together at the end of each episode (except for the Vogler -- evil temporary hospital chairman of the board -- episodes, which have been uncharacteristically unsatisfying so far) and yet are often also enhanced or explained further in some future episode. House's personality and character make one very curious about how he got that way and why he is that way, and from time to time during the season, we find out more about him, in small, but seemingly sufficient or satisfying doses. The writers have thus been able to develop and explain his character in extremely subtle ways so that it is still an intriguing enigma, but not such a frustrating one that we lose interest in understanding it. They give us neither so much information about him that he becomes trite or predictable, nor so little that he seems cartooonish or unworthy of our concern, understanding, or interest.
One of the appealing aspects of the show for me is playing the game of trying to beat House at any diagnosis. Once in a rare while, I, will see a clue and be ahead of the diagnostic game. When I do, it is almost always a misleading clue they have set me up with in some subtle way so that I won't know they are playing me. During one episode I figured "snakebite" before they did; only for it to turn out at the end not to be a snakebite as we thought, but a dog nip that had caused serious bacterial ("flesh-eating") infection with venom-like symptoms. They had showed the dog earlier in the show, but in a way that made it seem unrelated to the owner's problem. All the other visual clues and the symptoms pointed to snake bite even before they showed the puncture wound. And, to once again illustrate a point repeatedly made on the show, the guy was lying about not knowing what had happened in order to protect his dog from having to be put to sleep as a health menace (it had bitten other people before).
In another episode, a nun comes in with an ostensible allergy to new cleaning agents she used on the pots and pans at the convent. House treats her for an allergic reaction but that treatment brings on a different reaction almost immediately that he has to treat her for, the second treatment culminating moments later in cardiac arrest. He seems not to be helping this woman's rash on her hands. After they save her from the cardiac arrest, her condition seriously deteriorates even when she is placed in a non-allergenic "clean" room. After a few days it appears she will die.
At one point in the episode House goes to the convent to get more information about the nun from the Mother Superior because he has reason to believe the nun is withholding information that might be important. They happen to meet in the kitchen, which is really beautiful and pristine. There is beautiful stone work and there are many large copper pots and pans hanging from the ceiling beautifully arrayed. But the focus of the attention is on the dialogue and House's questioning and badgering of the Mother Superior; the kitchen just seems to be a pretty and natural setting for the conversation. Moreover, House discovers during that conversation that the tea they serve at the convent has a home-grown herb in it, which is what caused the cardiac arrest in combination with one of the treatments he first gave her. At the end, it turns out the nun is allergic to copper, not to the cleaning agent, and furthermore, her moribund condition is being caused by a copper IUD that had been implanted in her uterus long before she had become a nun and the IUD was eventually forgotten about, becoming embedded in growing, surrounding tissue. All the other copper she was exposed to finally triggered a nearly fatal allergic reaction to the metal that she contained within her body. In watching the episode a second time, the copper pots are a clue. They just are not a clue to either us or to House the first time because the pots had already been "accounted for" by reference to their cleaning agent, and because the kitchen conversation produced the information about the tea. So the kitchen scene was in a sense itself seemingly accounted for in terms of any clues it had to offer to the nun's symptoms. It simply had even more evidence to give.
Each week, I not only want to watch the show for its
but I want to solve the case, or at least notice clues, before House
I at least want to be able to think and see things as he does.
week I fail, and yet it is not frustrating; I can't wait till the next
week so I can play the writers again. So reset the game board,
one of these days I am going to win. Maybe.