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Monday 21st May 2018

A TV show, and a book, lunge at the heart of clinical practice

17th May 2007

23052006_usahealth1.jpg“Keep a watch also on the faults of the patients, which often make them lie about the taking of things prescribed.� Hippocrates

I have always loathed television, except the news. It’s a heap of sound and fury, signifying nothing and robbing humanity of its ability to simply be - to sit quietly and tune in to that non-network favorite, The Still Small Voice Within.

Except for House, the Fox TV series starring Hugh Laurie and chronicling the world of its eponymous hero - a diagnostician from New Jersey with a bum leg, a painkiller addiction, and a uniquely wide-ranging misanthropy.

House possesses a Cassandra-like ability to hone in on exactly why his patients are presenting with unexplained hallucinations, tremors, or, as in a recent episode, menses at age six. Laurie’s character lives by the maxim that all patients lie, either by omission or design. Those who don’t lie are incapable of communication, because they are autistic, aphasic, or unable to speak English.

“Why does everyone lie to me?� he asks. “Everyone lies.� “Why doesn’t anyone tell me the truth?� “All patients lie.� “The truth begins in lies.� And so on.

In almost every episode, Gregory House MD relies on his superhuman intuition to see through deceptions, identify pathologies, and in most instances cure his patients. It isn’t an fMRI, CAT scat, or any other advanced equipment that does the job; it’s the way he uses it. House has the magic mojo that turns such wonders of engineering into a medical magic wand.

Of course, House is right: Patients do lie, and doctors here aren’t specifically trained to delve beyond those lies into the sort of questioning that might lead to a lawsuit. Hippocrates himself warned students that patients often lie about having taken their medications, and that was 2,500 years ago.

I recently spotted an article by the Associated Press, which reported that many doctors use a three-to-one rule when making sense of patients’ reported habits. Triple the number of drinks or cigarettes they say they consume, and you’ll probably arrive at the truth.

Likewise, divide the amount of exercise they say they get by three and you’re probably close. An odd phenomenon, I think, given the tell-all and show-all nature of electronic media these days, in which adults detail the most aberrant sexual exploits and teens post party invitations on the Web for thousands to see.

Off-screen, real doctors in the United States and increasingly in the United Kingdom meanwhile are being trained in “narrative medicine.� This new field, launched in the 1990s by the professor of medicine and literary scholar Rita Charon, aims—and I am sketching very broadly here - to teach young doctors how to listen to their patients’ stories, to decode narratives and deduce from verbal and nonverbal cues what might actually be ailing a given patient - and what might comfort, console, or cure. www.nlm.nih.gov/changingthefaceofmedicine/physicians/biography_58.html

Already teaching medicine, Dr. Charon enrolled in literature courses with the aim of understanding the stories she had heard from patients. A few courses became a master’s degree and then a doctorate.

“I couldn’t bear to stop my studies in literature, not only because I was powerfully drawn to the study of literature but also because it made the medicine make more sense,� she writes. “I realized that the narrative skills I was learning in my English studies made me a better doctor.�

From what I have read, Dr. Charon doesn’t directly address the issue of patients lying. Or perhaps she does, since she urges clinicians to study literature - fictions- in their quest to understand real people presenting with real symptoms.

What then should we make of this odd juxtaposition—the cult television programme about a brilliant doctor who believes all patients lie, and this new medical training that focuses uniquely on the words patients speak about themselves?

I suspect that - deep down - we all want both Dr. Charon and Dr. House to treat us: The unhurried clinician to whom we can confess anything, and the gruff misanthrope who divines illness through brilliant, nonverbal flashes of insight, without our having to say anything at all. Neither judges us. The former is too compassionate, and the latter simply couldn’t care less.

In an era of diminishing personal contact and rampant narcissism, we all still hunger for the clinician who knows the truth about us, thinks hard about us, and never judges.

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