Should we have a Dr House?

You’ve seen House, right? Prince George from Blackadder III plays a misanthropic “diagnostician” in a fancy Boston Hospital, taking on the hardest cases, those without a diagnosis, and works out what’s wrong through a range of tests carried out by his underlings, a whiteboard that *always* has sarcoid on it, and by being quite rude to the patient, relatives, and anyone else within earshot. He’s addicted to narcotics too, seemingly.

It strikes me that Gregory House is all well and good, reaching diagnoses that no-one else can make, devoting hours and hours to cogitation and diagnostician-ing, but he only has 1 patient at a time. The Royal College tells us we should have 25 in-patients each, and we have a variable out-patient workload. Greg has an out patient clinic to do, once an episode, but I don’t think he follows people up much. If I had only 1 patient at a time, I’d like to think that I’d be able to bury myself in the case, and come to a diagnosis, whether it’s Sarcoid or not.

Do the general public watch House and have the expectation that their doctors should be like him? I don’t mean grumpy, walking with a limp, and doped up on Vikodin – do they expect that we have as much time to dedicate to a single patient? Not to mention that the underlings seem to do all the tests, from gram stains to brain biopsies, via bronchoscopies and interventional radiology. I can do one of those tests, and ask experts for their opinions on the rest.

TV drama silliness aside, it makes me think – how many of my patients do I know really really well? How many do I see in clinic and know in depth the tests they’ve had, not had, the results, trends, discrepancies? Some. But not all – that’s unrealistic. But what if we had a special team of doctors, a ‘special ops’ unit, headed by a ‘House’? The team has a small number of the the most complex patients, and they know everything about that small number of patients, in depth. But that’s ICU, isn’t it? So House-UK is an intesivist? But intensivists are there for the intubated patients, in most places I’ve worked – although outreach ICU is more and more commonplace. So perhaps House-UK is an HDU doctor? HDU patient are awake, sick, complex – ideal House-fodder.

I’m on call for our HDU tomorrow, all weekend, in fact. Maximum of 6 patients, 2 to 1 nursing, and me. Not so many gram staining, colonoscopy-ing, brain biopsy-ing underlings, though. So I can play House-UK tomorrow? Consider sarcoid for every patient? Perhaps. But I’ll have all of the chest ward to see afterwards!

We chest physicians get a lot of ‘grey cases’ through out in patient, and out patient books, many with multi system disease that just happens to involve the chest, or, often, they come in with a co-incidental chest infection, or ‘breathlessness’ due to their unrecognised metabolic acidosis. We’re all Dr House to some degree, facing challenging cases in our clinic rooms, an on our weekend ward rounds. I rely heavily on second, and third opinions – formal, and informal multi-disciplinary discussions, sometimes in organised meetings, other times over a caffeinated beverage in the Drs’ Mess. None of us are Dr House, and none of us want to be – I hope our patients don’t expect us to be. A difficult case takes multiple brains, and takes time to get through.

My HDU ward round tomorrow will be the start of a weekend of ‘diagnostician-ing’. Perhaps I should get a white board, and write sarcoid on it?

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