Portal de Periódicos da CAPES

The Medical Science of House, M.D.

2006; Wolters Kluwer; Volume: 28; Issue: 20 Linguagem: Inglês

10.1097/01.cot.0000295295.97642.ae

1548-4688

Andrew Holtz,

Healthcare Policy and Management

Berkley Trade, New York City, Oct. 2006, ISBN #0425212300, 272 pages As Edward Vogler began his brief tenure as the Chairman of the Board of Princeton-Plainsboro Teaching Hospital, he had a question for Dr. Lisa Cuddy, Dean of Medicine and hospital administrator: “What is a Department of Diagnostic Medicine?” “That's Dr. House's department,” replied Dr. Cuddy. “They deal with cases that other doctors can't figure out.” Vogler is perplexed by Dr. House's idiosyncrasies and challenged by his resistance to Vogler's efforts to run the hospital like any other business. But even when you look past Dr. House's peculiarities, hospitals are not like any other businesses. The authors of a textbook titled Health Care USA: Understanding it Organization and Delivery highlighted the daunting complexity of modern hospitals. Hundreds or even thousands of people, many of whom have advanced degrees and extraordinary expertise, work together in a highly regulated organization providing customized services to people whose lives are at stake. “[W]ith so many different kinds of employees and so many interrelated systems and functions, it is a small wonder that they work at all,” authors Harry Sultz and Kristina Young wrote. Hospitals were not always this way. When the United States was established, Sultz and Young point out, hospitals were little more than pesthouses. In the 18th century, people did not go to a hospital to be cured; people infected with contagious diseases were sent to hospitals in order to protect the rest of the community. People who had the money to hire physicians usually received treatment at home. As medical knowledge and practice has changed, and as society has altered its expectations of health care, hospitals have gone through several transformations. It is really only within the last century or so that people began to see hospitals as institutions that provided valuable health care services. Modern health care insurance got its start in the 1930s with prepayment plans that guaranteed a certain number of days of hospital care. After World War II, the nation went on a hospital building boom. Then as hospital care became increasingly sophisticated and expensive in recent decades, smaller hospitals closed and care of very sick patients became increasingly concentrated in large institutions that could afford the costly tools that physicians like Dr. House employ with such fervor. There are two principal ways to categorize hospitals: one, by the types of health care services they provide, and two, by their ownership structure. There are three basic types of hospital ownership: Not-for-profit—for example, hospitals owned by religious groups or foundations. For-profit—these hospitals may be part of a chain or independent, but they are meant to make money for their owners. Public hospitals—may be owned and operated by a city or county, or a federal agency. The types of services and how hospitals go about providing them are not simple to categorize. In fact, hospitals can be looked at as structures that are built out of an array of programs. For instance, a hospital may have an emergency room, it may have a heart transplant program, and it may provide psychiatric services. But another hospital nearby may have none of these particular services and still be a hospital. Some hospitals are affiliated with medical schools and others are not. Princeton-Plainsboro Teaching Hospital So where does Princeton-Plainsboro Teaching Hospital fit in this hospital spectrum? It does not appear to be a public hospital. After all, Dr. Cuddy hasn't been hauled before a county commission yet. Likewise, there are no symbols of a religious order around the building, so it does not seem to be part of one of the nation's church-affiliated health care systems. Whether the ownership is a for-profit corporation or a not-for-profit foundation, the hospital seems to stand on its own, without any references to a distant hospital chain headquarters. As the name implies, the hospital is also a training ground for new physicians. However, Dr. House seems to have only occasional contact with students…and he treats them with the same disdain he has for his clinic duties. Indeed, in the first season medical students figured prominently in only two episodes. In “Three Stories” [Season 1, Episode 21], Dr. House lectures an auditorium class, but Dr. Cuddy has to bribe him with time off from clinic duty in order to fill in for an ill professor. And then, as if to emphasize his disdain for teaching, Dr. House jumps back and forth between the stores of three patients with severe leg pain. He even goes as far as changing key details as he goes along, seemingly in order to torment the students.FigureWhen is a hospital not a hospital? What hospital building stands in for the fictional “Princeton-Plainsboro Teaching Hospital” in the aerial views sprinkled throughout “House, MD”? Well, none really. The building pictured on the series is actually Princeton University's Frist Campus Center. It is named after the family of Senate Majority Leader Bill Frist (R-TN). Sen. Frist, who is also a physician, is a Princeton alumnus. Older alumni of Princeton who have not visited the campus recently might not recognize the building at first. The angle usually shown on “House, MD” emphasizes a modern expansion that was grafted onto the old Palmer Physical Laboratory building, which was built almost a century ago. Then there is Dr. House's relationship with the hospital administration, which exaggerates and skews some aspects of how physicians and hospital administrators deal with each other… while capturing the essence of some age-old conflicts. Here again, hospitals are not like other businesses. The CEO of a hospital often does not have total control over the physicians who work there. Certainly, Dr. Lisa Cuddy does not have Dr. House under her control. Bruce Traub, CPA has a special perspective on the management dynamics portrayed. He is the Chief Financial Officer of the University Medical Center at Princeton, NJ. His teaching hospital is just down the road from the fictional location of Princeton-Plainsboro Teaching Hospital, and in many ways could be considered a sort of model for Dr. House's hospital. “Like most organizations we have a President and CEO. But parallel to that, you have the elected officers of the medical and dental staff,” Traub points out. “The officers are elected by the physicians and dentists, not the administration.” So that's one part of the medical and dental staff leadership. And then within the departments of the hospital you have appointed chairs. This parallel hierarchy of the medical staff is one of the features that make hospitals different from other businesses. The department chairs and the medical/dental officers meet at least monthly with the leaders of the hospital administration. And while they may routinely work together to manage any issues that come up, including physician behavior, the division of responsibilities and authority means that hospital administrators cannot simply issue orders or make unilateral decisions about things that affect physicians. What's more, at most hospitals in the real world, even though physicians work in the building and use the hospital's facilities and other resources, they are usually not employees the way clerks or maintenance workers are. And yet, since doctors decide who is admitted to the hospital, they are responsible for bringing in business. Traub says that in some ways the physicians are the hospital's sales force. “So we have limited control over our ‘sales force;’ what they do, how they refer patients to us,” Traub says. “We spend all the money to provide the resources for them to do their jobs here, yet they actually make their money from their own billings to patients, not from a paycheck from us. So it's a unique relationship that I don't think has a parallel in any other industry.” That fact does not mean physicians are free to do whatever they want. In order to maintain their privileges to practice at the hospital, physicians must adhere to bylaws and procedures that address major issues, such as patient safety, and also smaller matters, such as when doctors should wear white lab coats. Of White Coats & ‘Functionless’ Ties When new Chairman of the Board of Princeton-Plainsboro Edward Vogler catches his first glimpse of Dr. House in the episode “Control” [Season 1, Episode 14], he notices something amiss. Dr. House is not wearing a white lab coat. Dr. Cuddy shrugs off Dr. House's aversion to the standard white coat, but Vogler seems unconvinced that exceptions should be made to the dress code. The white lab coat is as much a symbol of medicine as the stethoscope. But dress codes requiring physicians to wear lab coats are not as universal as they were. In a commentary in the Archives of Internal Medicine, gastroenterologist Lawrence J. Brandt, MD, mused about the increasingly casual attire of young physicians and medical students. Dr. Brandt wrote that as he looked out over the audience for an annual lecture he gives to medical students at Albert Einstein College of Medicine in the Bronx, NY, he saw a stark contrast to the starched white clean-cut student body he was part of in an earlier decade. “Obviously, these men and women were not aware of or chose to ignore Hippocrates' advice that the physician should ‘be clean in person, well-dressed, and anointed with sweet smelling unguents,’” Dr. Brandt wrote. He then undertook a review of the medical literature, not for the usual research findings on gastrointestinal issues, but for articles about medical dress codes and attire. Dr. Brandt found a rich mix of writings that explored both the practical and symbolic dimensions of physician attire. The white coat is a symbol of both sanitation and authority. It speaks to both the patient and to colleagues. And as Dr. Brandt noted, the ample pockets are useful for carrying everything from stethoscopes to textbooks to the latest PDAs full of downloaded medical data. Not all the symbolism is beneficial. The phenomenon of “white coat hypertension” is well documented. The term refers to the fact that some people have higher blood pressure when they are checked in a doctor's office or clinic than when the readings are taken at home…away from any white-coated physicians. Indeed, there is substantial concern that white coat hypertension may skew the treatment of some patients. In response, when physicians suspect patients may have high blood pressure, they are increasingly sending them home with blood pressure monitors, in order to get an accurate picture of blood pressure throughout a normal day, rather than just a snapshot in the clinic. Of course, white coat hypertension is not triggered merely by the sight of a doctor's coat. It probably involves a psychological response to the general stress some people feel when visiting their doctors' offices. There is no law or other regulation that requires doctors to wear white coats. Dress codes at some hospitals and other health care institutions may be prominently enforced, while at other hospitals the dress code may be informal or little known. At the Stanford University Medical Center in California, the dress code of one program says, in part: “White lab coats will be worn by staff members providing direct patient care, except in areas where other protective clothing is required, such as BMT. In out-patient areas, psych, and the rehab unit, lab coats are not required. Consult with your clinical instructor about clothing in the area you will be assigned.” And of course, the rules may vary depending on the status of the wearer. The rules may be stricter for students. The Student Handbook for the Carolinas College of Health Sciences in Charlotte, North Carolina states that medical students should wear three-quarter length white lab coats over street clothes when they are not wearing hospital scrubs or other special clothing.FigureDr. Brandt noted in his commentary that surveys of patients tend to show that most, though not all, prefer that their physicians wear white coats. And some surveys indicate patients are more likely to trust a physician wearing a white coat. Some studies, however, raise some practical issues. Sometimes the coats are not so sanitized, according to studies that found various microbes lurking on physicians' coats. And neckties are under assault in some corners. The British Medical Association created a stir when it classified neckties as “functionless clothing” that may do more harm than good. Shrugging off a dress code is one thing, but most hospital administrations would respond quickly if a physician tried to make an end-run around a decision of the hospital transplantation committee, in order to get a new heart for his patient, as Dr. House did in “Sex Kills” [Season 2, Episode 14], or used an injection of alcohol to temporarily shrink his patient's liver tumor, in order to fool a surgeon into agreeing to operate on her, as he did in “Socratic Method” [1, 6]. “If it's something of that magnitude, it is heard about that day. Usually it is reported by another physician, maybe directly to the CEO,” Bruce Traub says. The University Medical Center at Princeton recently added a physician to its administrative leadership. As at most hospitals, this Vice-President of Medical Affairs would be on the front lines of any potential disciplinary action or other serious issue involving a physician. In “The Mistake” [2, 8], Chase goes before a peer-review committee that is judging his actions in the case of a patient who died. After hearing his side of the story, the committee rules that Chase lied to his superiors and the patient's brother. But the committee members took into account the fact that Chase had just been told his father had died. They said this unexpected jolt mitigated his failure to properly follow up with the patient, and so they left intact his privileges to practice medicine at the hospital. Then the committee surprised Dr. House by announcing that allegations about his conduct were serious enough to warrant temporary restriction of his privileges. For a month, Foreman was put in charge of Dr. House. In real hospitals, physicians are reviewed by both their peers and administrators according to the bylaws of the medical staff and other rules. “Ultimately there is a governance process,” Traub says. “If somebody is not acting appropriately, it goes before the Executive Committee of the medical and dental staff. We as administrators can request that something be brought up before that group; or a physician can request that it be brought up before that group.” “There is a series of meetings and hearings that would be held, all the way up to the Board. A physician could be suspended, if he or she did something outrageously unsafe to a patient. That could bring a suspension pending an investigation. But it's a fair hearing process in which members of the medical staff and experts within the department would be convened to hear the physician on that particular question,” says Joanne Ritter-Teitel, PhD, RN. She is the Chief Nursing Officer of the University Medical Center at Princeton, a position that is part of the hospital's administration. “It is not an uncommon practice to send a physician for counseling or a course on collaboration,” she says. As discussed earlier, sometimes these referrals to counseling or training are part of the response to concerns about whether a physician is impaired by alcohol or other drugs, including prescription medications such as Dr. House's beloved Vicodin. What is “outrageously unsafe”? How about experimenting on a comatose patient? In “Distractions” [2, 12], Dr. House injects drugs into a patient who is in a coma, in order to satisfy his curiosity about the effectiveness of an experimental migraine treatment. He isn't secretive about it, showing no shame when Dr. Cuddy interrupts him. When she realizes that he has induced and then attempted to treat a migraine in a person who is unconscious and completely unable to give consent, she is dumbfounded. She asks Dr. House if he has ever read an ethical guideline; however, she doesn't take any action, despite having witnessed a blatant violation of a patient's rights. After Dr. Cuddy shrugs off the criminal assault, she then moves on to the issue she first came to see Dr. House about: a memo carrying her signature…apparently forged by Dr. House. He doesn't deny the forgery and then makes a sexually suggestive joke about the appropriate discipline. Dr. House again acts outrageously, and in direct violation of standard hospital procedures concerning organ donation, when he intrudes on the husband of a dying patient in “Sex Kills” [2, 14]. He wants to find out whether the victim of a car crash might be a potential organ donor for his patient. Clearly he knows he's skirting the rules, because he slides up to the husband's side wearing camouflage. Well, for Dr. House it is the ultimate camouflage: a white lab coat. While Dr. Cuddy appears exasperated by Dr. House's serial recklessness, ultimately she shrugs off each incident. It is extremely unlikely a real hospital administrator in her position would simply let Dr. House slide; no matter how much she likes him or respects his medical skill. In the real world, a hospital and its administrators can suffer serious consequences for permitting a physician to stray too far from standard practices. Myriad outside institutions monitor hospitals and some have the authority to levy heavy fines or even shut down a hospital. Doctors are not the only ones with state licenses; hospitals are licensed, too. And without a license, a hospital is out of business. Rules & Regulations In New Jersey, a hospital like the University Medical Center at Princeton, or the fictional Princeton-Plainsboro Teaching Hospital, must answer to its Board of Trustees, the New Jersey Department of Health and Senior Services, as well as other organizations that monitor and pay for health care in hospitals. The New Jersey Department of Health and Senior Services is the licensing agency for hospitals in the state. Similar agencies serve that purpose in other states. According to a statement from the Department, it conducts dozens of inspections of hospitals and other health care facilities each year. In addition, the department responds to complaints. The evaluations include reviewing buildings, equipment and personnel. Hospital policies and procedures are checked to make sure they conform to state laws and regulations. The results of facility inspections done by the New Jersey state inspectors can also affect a hospital's eligibility for reimbursement by federal health care programs, including Medicare. In “Failure to Communicate” [2, 10], Dr. House and Stacy have to fly up to Baltimore to answer questions about his bills for treating patients enrolled in Medicaid. Stacy is able to get the questions essentially to disappear by cajoling the Medicaid investigator into agreeing that Dr. House's handling of the cases was appropriate, even if it didn't always conform to the letter of Medicaid reimbursement rules. The almost-instantaneous resolution of a federal inquiry is a pleasant little fantasy. Federal health care regulations and their enforcement could certainly give the tax code a run for its money in terms of bewildering complexity…and anyone who has gone through an IRS audit knows that simple, quick and favorable solutions are rare, indeed. One odd element in the premise of this episode was that Dr. House would go to Baltimore to answer the questions. Assuming the matter required a personal interview, he should have gone to Trenton, the capital of New Jersey. Although a large share of Medicaid funding is federal, the program is largely administered by states. It is the states that take the lead on Medicaid fraud investigations. Boards and agencies of the state and federal governments are not the only ones hospital administrators have to answer to. There are also accrediting agencies. These bodies include groups that oversee medical education. Princeton-Plainsboro Teaching Hospital probably would need to meet the standards of the Association of American Medical Colleges in order to participate in the education of medical students. Then separate accreditation would be required from the Accreditation Council for Graduate Medical Education. The Joint Commission on Accreditation of Healthcare Organizations plays an important role in monitoring the quality of hospital treatment, even though it is not a governmental agency and has no regulatory authority. If Joint Commission inspectors were reviewing the accreditation of Princeton-Plainsboro Teaching Hospital, Dr. House would probably be a problem. A short list of concerns might include: ▪ Using treatments and running tests without the permission of patients. ▪ Lying to patients and coworkers. ▪ Verbally abusing and sometimes even striking patients and coworkers who don't agree with his recommendations. ▪ Possible impairment due to inappropriate use of Vicodin and other pain medications. ▪ Disregarding patient privacy by discussing the details of cases in the clinic and other open areas. ▪ Violating a patient's “Do Not Resuscitate” instructions. ▪ Violating hospital rules governing the care of patients with immune system disorders, potential organ donors, and others. ▪ Searching the homes of patients without permission, and more. “His personal behaviors are clearly inflammatory, irreverent, and at times even illegal.” That is the initial reaction of Peter Angood, MD to a list of incidents from episodes of the show. Dr. Angood is a Vice-President of the Joint Commission on Accreditation of Healthcare Organizations and Chief Patient Safety Officer of the Joint Commission International Center for Patient Safety. “There is not one of those that is not outside of the boundaries of regular medical staff guidelines for behavior. Anytime a physician is brought onto the staff of a hospital, they go through a review process and have to substantiate the education, their experience and their practices,” he says. “It's clear the guy has some kind of dependency problem. It's clear that he has a total disrespect for authority or the hierarchy. So his personal behaviors are way, way out of the reality of the true world.” Dr. Angood holds the hospital administration responsible, too. “The other component is that they portray the tolerance by the hospital in allowing him to continue on; and that just would not occur and does not occur,” he says. “In my 25 years of practice I have seen changes in the level of tolerance toward what we loosely term disruptive or abusive practitioner behavior.” “There is very little tolerance now. Almost all institutions have pretty tight human resources and medical staff processing, in terms of not only identifying these individuals, but also getting them into a counseling process or getting them out of the system entirely.” The response to behavior like the kind Dr. House displays can be much more forceful than what is portrayed on the show. “You would expect that the hospital, through one of its committees or processes, would have vetted those particular instances and said we're either going to sanction this guy or put somebody else on the case or he's going to go through [privacy] training or see the compliance officer or suspend privileges. And you never see any of that occur on the show, as if the hospital administrators, while they agree that he's done something outrageous or beyond the rules, [just say] ‘well’, ‘It's House,’” says Margaret VanAmringe, the Joint Commission's Vice President for Public Policy and Government Relations. “Hospitals are expected to review the competencies of medical staff on a periodic basis. So in the real world, he would come up for re-privileging in an annual review. And at that review, hospitals need to use information to make a decision about re-granting him privileges. So if there were a lot of complaints about drug abuse or suspicions, he likely would be asked some very pointed questions, and potentially be asked to undergo a medical evaluation,” she adds. Teamwork The Director of the federal Agency for Healthcare Research and Quality, Carolyn Clancy, MD, recalls the finale of a set of lecture slides often used by her predecessor, John Eisenberg, MD. It included images of clinical textbooks and other tools that young doctors have long relied on to learn the trade. “The other slide that went in this set was a picture of the Marlboro Man. Dr. Eisenberg would say that the myth around training doctors has always been that once you get through training, it's you and your patient and you ride off into the sunset together and you can do what you want. And it's a lie, because that's not what medical practice is like now,” she remembers Dr. Eisenberg explaining. Contrary to the strong theme of Dr. House's individual brilliance, modern medicine is a team sport. Dr. House does employ his fellows, Cameron, Foreman and Chase to do his grunt work, but this team is not like what most hospital physicians work with. For example, David Gilbert, MD, Director of Medical Education at Providence Portland (Oregon) Medical Center, says the teams of physicians are varied and extended. Dr. Gilbert, who is a specialist in infectious diseases, like Dr. House, says his hospital uses teams including a senior resident, a first-year resident, and a medical student. They take care of whoever comes into the hospital during their shifts. One key aspect of the show does capture an important trend in medicine: the growing ranks of physicians who specialize in treating patients in the hospital. Dr. House's work is done entirely within the hospital. He does not have an outside practice seeing patients for routine and continuing care. He's takes control during the crisis, and then sends the patients back to their regular physicians. “The old vision of American medicine was that your regular doctor, like Marcus Welby, would be your doctor wherever you went; in the office and in the hospital. That model doesn't work very well anymore, in part because doctors are extraordinarily busy in the office, and in part because, as the threshold for hospitalization has gone up and up, patients who do end up in hospital tend to be incredibly sick, with a lot of things going on, a lot of specialty consultations, different medications, a lot of complexity,” says Robert Wachter, MD, Chief of the Medical Service at UCSF Medical Center. “So the need for focused expertise and the need for around-the-clock presence has created real value in having a doctor who sort of lives in the place. It's what they read about. It's what they focus on.” Although Dr. House is called a diagnostician, he really is a hospitalist, a term that Dr. Wachter coined a decade ago with his colleague Lee Goldman, MD, in an article in the New England Journal of Medicine. Hospitalists take the handoff of a patient from their primary care physician or the emergency medicine physician who admitted the patient to the hospital. And then later they hand off the care back to the primary care physician. But during the hospital stay itself, the hospitalist takes the lead responsibility for a patient's care. Nurses The image of nursing takes a beating on the show. “When nurses and others do appear, they are somewhat portrayed as obstructionists to the brilliant doctor, or as mindless bureaucrats getting in the way of his unfettered brilliance,” says AHRQ Director Dr. Clancy. “In real life medical care isn't like that at all. No doctor does well who doesn't actually rely on, and practically venerate, the nurses around them; because it doesn't happen without them and the full cast of professionals.” Dr. House's attitude is captured in “Spin” [2–06]. He gives a patient who can't stand up an injection that momentarily restores normal muscle control. The patient stands, but then as the effect fades, he collapses to the floor. Dr. House just looks at the patient, but doesn't try to help him back to bed. “This is exactly why I created nurses. Clean up on aisle three!” Dr. House bellows. If instead of lording over the fictional Princeton-Plainsboro Teaching Hospital, Dr. House were practicing at the University Medical Center at Princeton, he would have to answer to Chief Nursing Officer Joanne Ritter-Teitel, PhD, RN. “I would have that physician in my office, and there would be a discussion about what appropriate communication is, and how I would not accept that kind of behavior, that all members of the health team bring value to our patients, whether it is a housekeeper or the person who brings the dietary tray or the nurse or the physician,” she says. Dr. House's treatment of nurses doesn't win any fans at the Center for Nursing Advocacy in Baltimore. “That's really a very limited view of nursing and they tend to show only the most unskilled aspects of nursing,” says Executive Director Sandy Summers, RN, MSN, MPH. In “Daddy's Boy” [2, 5], Foreman is examining a patient. “What's that smell?” he asks. When he pulls back the sheets on the bed, he sees that the patient has soiled them. “We're going to need a nurse,” Foreman says. “Yes, nurses do clean up patients' stool,” Summers says. “But you'd never know from watching “House” that you might actually find signs of a life-threatening illness when you are cleaning up a patient's stool. Maybe they have liver disease or a gall bladder disease or maybe they are having intestinal bleeding or maybe a parasite.” Indeed, the type of parasitic tapeworm that was the cause of the patient's illness in the first episode of the show is frequently spotted by nurses checking patient stools. In “Three Stories” [1, 21], Dr. House is the patient in a flashback to the infarction that crippled his leg. He is in a hospital bed when he