The Medical Science of House, MD Chat

Conducted on Thursday 21^st December 2006 at 8.00pm EST

Attendees –

Andrew Holtz

lauradugan

Gothic_Phantom

sparsons

michelle ann

Pip

tantrums

goodship_a_k

Emily

PamelaJaye

dreamer

jaew

[lauradugan] I'm Laura, most of you know me as the substitute ListMom for House_MD - or the one who puts the smack down when people act up. Well, Pip is really the muscle.

[Pip] I was just going to say...

[lauradugan] But tonight we have a very special opportunity to chat with Andrew Holtz, author of The Medical Science of House, MD. Andrew Holtz, MPH, is a health journalist with an MPH. He is here today to share his medical expertise and to help clarify what on “House” is medical fact and what is medical fiction. Our first question comes from Veronica (aka Pip), in Lake Placid, New York - “There seems to be a general feeling that the writers have taken more creative license with the medical aspect of the show in the second two seasons than in the first. What's your take on the accuracy of the medicine in the latter episodes of House”

[Andrew Holtz] First... thanks for the opportunity to connect with some of the fans of House, and for the work you do maintaining the group. Now to your question... I'm sure the writers have to keep pushing harder and harder to maintain the high level of excitement and entertainment the show is known for but I don't think they've abandoned their efforts to maintain at least a reasonable connection with medical reality. The show has never been 100% accurate in every details but I think they are still staying just this side of “sci-fi”

[Pip] Thanks, Andrew

[lauradugan] Our second question comes from Michelle – “What was the inspiration/reason for writing the book?”

[Andrew Holtz] You were.

[lauradugan] I'm flattered.

[Andrew Holtz] Really... it was the interest of fans that sparked the idea

[lauradugan] (I had to)

[michelle ann] Awww shucks .. thanks

[Pip] You'll have to excuse Laura...she thinks she's witty.

[michelle ann] *blush*

[Andrew Holtz] The publisher, Berkley Books, figured that each Tuesday lots of viewers were wondering what is real and what's fantasy. They came to me because of my background covering health and medicine for CNN and others and they asked me to compare House to the real world. To be honest, I wasn't watching the show every week before I started working on the book, but once I got into it, I became a regular viewer, too.

[sparsons] But now you are hooked just like we are?

[lauradugan] When did you start watching regularly?

[Andrew Holtz] It was near the start of the second season. Fortunately the DVD of season 1 had just come out, so I was able to go back and see the episodes I'd missed and then I started digging into the medicine of each episode

[lauradugan] Our next question comes from me, in Pennsylvania, and goes along the lines of the reality of ‘House’ – “we often see House and his team breaking into ‘visiting patients’ homes. Does this ever happen in reality?”

[Andrew Holtz] Never. Never. Never! That's one of the things that's really just made up.

[lauradugan] Well, that was emphatic enough!

[Pip] I would also have the same question about them running their own labs.

[Andrew Holtz] Physicians wouldn't check out a home, but epidemiologists and other public health investigators might if they were investigating a disease outbreak. I think the episode in which a home search at least made some sense was the one in which a couple of high school students showed up sick at about the same time and then they went looking for a link between the two

[lauradugan] As Pip said, - “the “ducklings” - Cameron, Chase, and Foreman - often run their own labs. Is this typical?”

[michelle ann] The toxic jeans episode

[Andrew Holtz] But in the real world it would be a public health investigator who would question the family and maybe look in the home. As for the lab... again, nope. Doesn't happen in reality. Physicians do work in labs, but they are specialists. In fact in most cases now, federal law requires anyone doing lab tests to get annual certification, so a doctor who is seeing patients just wouldn't have time to stay up on all the latest tests

[lauradugan] Sharon, in College Park, MD, wants to know – “who a physician who is known to have an addiction be able to keep their job or would it be too much of a liability for the hospital?”

[Andrew Holtz] You guys are really good at spotting the places where the writers stretch reality

[lauradugan] That was kind. We usually just call ourselves anal.

[Andrew Holtz] In the real world, Cuddy and the other physicians would have intervened. About 10% of physicians run into substance abuse problems just like other human beings and there are now very strict rules. The hospital would get into huge problems if they let a physician continue to practice if there were suspicion of impairment BUT... that doesn't mean chronic use of painkillers is banned. The proper use of pain medication is fine, but it probably wouldn't be Vicodin because it is a short acting pain killer and the peaks and valleys of pain control would be a problem for most people

[lauradugan] I believe in your book it was mentioned Vicodin can be taken about every 3 hours? Which would explain House's incessant pill popping.

[Andrew Holtz] Yes... it doesn't last a long time so one pain expert I interviewed said it wouldn't be her choice for long term control. I have interviewed people who have chronic pain and are on powerful pain killers and they can function well, if the dose is right. I'd guess that in the real world with House's extreme pain they might consider a pump that slowly drips an opiate into his system thus keeping things nice and level.

[lauradugan] Pam, in Boston, wants to know - “are there rehab facilities specifically for doctors?”

[Andrew Holtz] Yes. For the book I interviewed a physician at Vanderbilit in Nashville who treats other physicians with substance problems. It's a big issue that used to be hidden.

[PamelaJaye] (That was “from” Boston, dear)

[Andrew Holtz] but I think is dealt with better now... though not perfectly

[lauradugan] (My bad... Pam, *in denial*)

[PamelaJaye]

[lauradugan] Michelle would like to know – “Is the pain gating mechanism as effective as House made it seem when he broke his hand and then cut himself? Or is it more complicated then that?”

[Andrew Holtz] Actually, I haven't looked into that phenomenon closely so I can't offer a solid answer without checking around a bit more. Sorry.

[lauradugan] That's just fine!

[michelle ann] No worries.. was just curious.. I guess that is what google is for .. thanks

[Andrew Holtz] Actually yes, Google is a great place to start and then there are some really good online resources from the National Library of Medicine.

[michelle ann] Great.. I will look around - thanks

[lauradugan] And PubMed - but for most of those articles, I think you need a subscription. Karen from Florida would like to know – “How accurate was the depiction of house's ketamine treatment, the length of time it lasted, the pain it diminished?”

[Andrew Holtz] OK. You got me again. I haven't checked all the details of recent cases. I'm interested in the ketamine but don't have a firm answer.

[michelle ann] We are an anal bunch

[lauradugan] Tantrums would like to know about House's actual muscle death in his leg – “With the amount of muscle removed, how could House run again as he did in the start of season 3? Is it just a pain problem that necessitates the use of the cane then?”

[Andrew Holtz] Oh... to jump back a bit regarding online medical articles... often your local library will have a subscription to some databases and you may be able to log on from home using your library card number.

[PamelaJaye] Karen - There is an article online regarding ketamine and a teen girl with.. I think it's reflexive sympathetic dystrophy?

[michelle ann] Great I will look into that

[goodship_a_k] Thanks Pamela

[Andrew Holtz] I've talked to patients with reflexive sympathetic problems and it really is hard on them. As for House running... I'd want to talk to a physician who has worked with such cases before saying for sure... but I can guess that if his main problem is pain, that he might be able to function better when he's feeling good. Though, like with many cases on House and other shows... time is compressed. So a recovery that takes many months or years happens almost instantly on TV.

[lauradugan] Speaking of... Michelle would like to know: “In reality how long would it take for all the tests to be run and results analyzed in a typical episode?”

[Andrew Holtz] A loooooong time. There was one test for sarcoidosis that Cameron ordered. The results seemed to come back within a couple of hours but in reality that test takes four to six WEEKS!

[lauradugan] They do love sarcoidosis

[Andrew Holtz] Yes...

[michelle ann] Wow.. that is a long time.. what makes it take so long?

[Andrew Holtz] The test requires a cell culture to grow, I think... though I'd have to check the details. Speaking of sarcoidosis

[michelle ann] And you can't rush that.

[Andrew Holtz] And lupus and paraneoplastic syndrome and some of the other common suspects... I think they come up so often because they actually do masquerade as different problems

[PamelaJaye] The lost and lamented vasculitis...

[Andrew Holtz] Or have a wide variety of symptoms so that it can be hard to rule them out

[lauradugan] (quack... quack... vasculitis) Pam, *in denial* (spelled Florida), wants to know – “how long does a fellowship typically last.”

[Andrew Holtz] Well, the whole arrangement between House and the cottages is odd. In the real world you don't have a sort of ‘strike force’ for weird cases. So I guess they can make up what they want about the length of a fellowship in the real world... I think most docs would kill for the luxury of treating one patient at a time

[lauradugan] dreamer wants to know, “In the episode “All In” (recap at http://www.fox.com/house/recaps/217.htm) it seemed that the disease hid itself, so to speak. How is that possible?” (All In was the one with House gambling and the old patient that died... and the young patient with the same symptoms. So basic and non descriptive summary, but..)

[dreamer] The disease was erdheim chester

[Andrew Holtz] I haven't talked to any docs specifically about that case. What I do remember about “All In” is that it showed off House's memory for detail. So he linked a case from a dozen years earlier with a new one. That's the kind of memory and observational skills that a good physician puts to use. It also points out why computers are taking a bigger role in diagnosis. They can remember everything and link a new case to similar features seen in odd cases from anywhere in the world.

[dreamer] Thanks Andrew

[lauradugan] Sharon, who was once my teacher and who now has to obey my rules, wants to know – “Do you think House M.D. has changed perceptions of the general public's attitude toward the medical profession to the positive?”

[Andrew Holtz] That's one of the other un-real things about the show... The doctors are rarely seen consulting computerized diagnostic aids. Actually... I don't know if the effect is positive... I think in some ways the show might raise expectations

[PamelaJaye] Are those hand held aids, on internet searches?

[Andrew Holtz] And leave patients frustrated when their real world docs can't find the right answers. Many, many cases in the real world are never solved or are only figured out during an autopsy. In fact, when I was researching the book... many of the cases that looked like episodes of the show were based on autopsy reports. Back to the handlhelds... Yes, docs are using them more and more. I loaded one called Marck Medicus on my PDA

[lauradugan] (In part due to an initiative by Pres. Bush to have all doctor's offices electronic by 2010 - and in part due to funding by Medicare to get certain physician practices electronic by 2008)

[Andrew Holtz] And it provided the solution to the second episode almost instantly.

[PamelaJaye] On TV I've only seen one once, several season ago, on ER

[Andrew Holtz] I remember hearing a speech from a leading health care expert that compared the way doctors work to how other businesses worked a hundred years ago. It's going to take some time to get medicine entirely into the computer age, but it is happening.

[lauradugan] (slowly) Back to the lupus, this question is from me.... “why is it so often a result of differential diagnosis? Common symptoms? Funny name?”

[Andrew Holtz] I think lupus is a favorite because it can be hard to diagnose and the symptoms may vary a great deal between patients. I think in the real world a lot of people with lupus went a long time getting incorrect diagnoses, so doctors trying to look for unusual causes of certain symptoms would want to keeping something like lupus in mind

[PamelaJaye] As for doctors who don't know what people ‘have’-- nope. I’m used to it.

[lauradugan] Similar to fibromyalgia? Which is never mentioned... yet they seem to be cousins, symptom-wise.

[Andrew Holtz] Yes, fibromyalgia is another example of something patients really suffer from... but doctors have a hard time working with.

[lauradugan] (Tell me about it!)

[Andrew Holtz] In part because the symptoms come and go and change also... If there isn't a 'cure'... then docs may have a hard time dealing with something.

[lauradugan] Pam, in a river in Egypt, wants to know “Why did the standstill in Autopsy take only 2 minutes on House, while it took 45 minutes on Grey's and 30 minutes on 3 lbs?” (the one where they drained her blood and stopped her heart)

[Andrew Holtz] I suspect that's an example of the liberty writers take with TIME. They stretch and compress things to suit the pace of their show. I did read up on real world examples, but I'd have to check my notes to see about the duration of the procedures

[PamelaJaye] Okay, how long can they stop your heart and drain your blood (and freeze you) before something bad happens, actually

[lauradugan] (She's planning an experiment)

[PamelaJaye] You really are evil, you know that?

[lauradugan] Yes

[Andrew Holtz] Well some 'drowning' victims have been revived after a half hour or so underwater... I seem to recall if they were in very cold water. Now they may have some neurological problems, but at low temperatures, cells can hold up without blood far longer than the 4 to 8 minutes that you have at room temperature

[PamelaJaye] When is Andrew writing the book on Grey's Anatomy (he can research the statistics of medical providers having ..um... stuff in closets)

[lauradugan] Speaking of neurological problems... “on ‘House’ they seem to crack open a skull every other week or so. Is exploratory (as it often is on ‘House’) neurosurgery really that common?”

[Andrew Holtz] They probably just can't resist the 'ick' factor that drilling through the skull triggers in many viewers.

[PamelaJaye] Well, for that, needles in the eye is better (for ick)

[lauradugan] Thanks for reminding me of that visual, Pam

[Andrew Holtz] yeah... the eye needle was a classic... both times

[PamelaJaye] Sowwy. Jay will be sad he's not here

[lauradugan] Is that really done?

[Andrew Holtz] I did talk to a doctor who has done that eye needle biopsy... but he says it's rare because there are usually other ways to get the info. As for brain surgery... there is a lot of it and one of the really interesting things to me is that patients often are really awake and talking during the procedures. There are no pain sensors inside the brain, so you just need to numb the scalp and then because brain surgery can be dangerous. It's good to have the patient awake, so the surgeon knows he/she is doing okay.

[PamelaJaye] Like when they do DBS?

[lauradugan] But you still hear the saw... Karen, who doesn't deny being in Florida, wants to know “can you really wake up a coma patient like House did this season?” (I know this is a question about a recent episode - any feedback would be great.)

[Andrew Holtz] yup... that's another one I haven't checked into. People do come out of semi-conscious states sometimes.

[PamelaJaye] Didn't you know we'd be a “tough room”

[lauradugan] And nice mention of the “semi-conscious state”, House

[Andrew Holtz] But I'm not sure about how often someone has been woken up so dramatically from being familiar with the show and the writer... I'm guessing they were able to find at least one case that was at least reasonably close.

[lauradugan] Again, from Laura, here in PA's lovely capital, “What moment, if any, stands out for you as being the most medically incorrect?”

[Andrew Holtz] There are so many to choose from. ha ha. I tend to focus more on the ethical and legal issues as being fantasy. But in “Sex Kills: 2-14”, much of the plot was based on the premise that a potential organ donor wouldn't be used if she was infected with hepatitis and that's just wrong. Organs with hepatitis and other infections are used all the time. Not because they are perfect, but because there is such a shortage. Given the choice between dying in days or probably developing a chronic infection many patients would opt to accept an infected organ. In fact I read a number of medical articles about the proper “treatment” of potential donors that is intended to get the organs in the best possible condition.

[PamelaJaye] How about rabies? (that was a plot on Scrubs -- donor died of rabies)

[lauradugan] Really...

[Andrew Holtz] I don't recall a rabies example. HIV is a no-no, but organs with hepatitis are used.

[lauradugan] From Michelle – “In Maternity they had to 'experiment' on the babies knowing one would die.. in real life is that possible? I would guess there is more stringant control of medical protocols.”

[Andrew Holtz] Well, you can't do an experiment that you know will harm someone, but there might be a situation where you would do something that might be harmful as long as there was at least an equal chance it would help.

[lauradugan] Again, from Michelle – “Do you think there is an effort to compile information from the autopsies and presenting problems to build in a diagnostic data base that could be accessed world wide?”

[Andrew Holtz] I can't think of an example right now that's like the one you are talking about, but the whole nature of experiments is that no one knows whether the benefit will outweigh the harm and in an emergency, some things are allowed that would not be considered if you have time to try something else.

[lauradugan] (We're going to wrap up in about 15 minutes. If you have questions for Andrew, please instant message me.)

[Andrew Holtz] Actually... you know new treatments are often first tried on people who have no real hope of recovery

[michelle ann] *nod* .. I thought it was an interesting episode b/c of the ethics

[Andrew Holtz] Not because they are hoping for a miracle, but because something may be learned that could help someone else in the future... and a dying patient doesn't have much to lose... to put it brutally.

[michelle ann] That is interesting.. and it makes sense.. thanks

[lauradugan] Was there ever a case that, for you, had an extremely surprising diagnosis? The rarest of the rare? A spotted zebra, if you will? (a “zebra” is medical lingo for the cases House gets - those outside the traditions of medicine - from the expression, and I'm paraphrasing (badly) here, “if you hear hoof beats, don't think of a zebra, think of a horse”

[PamelaJaye] (Mac said the original quote was “don't forget to look for zebras”)

[lauradugan] (I said paraphrased badly)

[PamelaJaye] (Yes but you paraphrased it just the same way everyone does )

[Andrew Holtz] Well, since I'm not a physician... I'm often surprised by the final diagnosis. What surprised me when I looked into the show was how easily (some more than others) I could find real cases that had some parts of episodes of the show. Really weird things really do happen

[michelle ann] That must be a testament to those who research for the show

[PamelaJaye] (my point was Mac said everyone had it backwards) Well, so far, no one’s been set on fire by a Bovey during surgery...

[Andrew Holtz] But of course they don't all happen at one hospital. They've boiled down the weirdest cases from around the world. And as for zebras, medical students are routinely cautioned not to expect to see zebras. But then a good physician also has to keep the possibility in mind because every now and then... it IS a zebra.

[lauradugan] From Pam, “Is Wilson leaving House on the floor after his overdose a violation of.. the hypocratic oath, something worthy of losing his license, or other?”

[PamelaJaye] (Who is not from *anywhere* anymore.. )

[Andrew Holtz] That was mean... although I can understand how Wilson felt

[michelle ann] You are universal Pam

[lauradugan] (I've just run out of material)

[PamelaJaye] I’ve stumped Laura!

[Pip] You HAD material?

[Andrew Holtz] Just speculating... I think that if House were harmed by being left there... then yes, it’s possible Wilson could be in trouble for failing to give aid

[lauradugan] From Michelle: “Clinic patients - are there less medical liberties taken for those cases.. are they more real?”

[Andrew Holtz] Yes, the clinic is a small window into the normal world and even House acts differently here.

[michelle ann] *giggles* How so?

[Andrew Holtz] He immediately assumes the common thing... and he's almost always right. What's really weird about House's main patients is that they are almost all between 15 and 40, those are the years when people are least likely to have sudden medical problems.

[PamelaJaye] That *is* odd...

[Andrew Holtz] Hospitals are really filled with the very young, the very old, and people with chronic diseases

[PamelaJaye] (the assuming the common. for him) (AKA -- good point)

[Andrew Holtz] Their case may be tough, but not at all surprising

[lauradugan] From Pam, in the land of milk, honey, and Carl Hiaasen – “Did you do a press tour for your book? Why or why not?”

[Andrew Holtz] I haven't done a tour. The fact is that publishing is a tough business, so they tend to spend the marketing money on the really big books.

[PamelaJaye] Ah

[Andrew Holtz] And you know... in the case of House... I think the number of fans connected to groups like yours means it isn't as important to travel around in person, because “word of mouth” now spreads by e-mail and group messages

[Pip] You're acting like this book is in a niche market or something...

[PamelaJaye] ...they don't even advertise it during the show

[lauradugan] We're a niche, all right...

[Andrew Holtz] Naturally, I'd love to have top the best seller list

[PamelaJaye] Gee, Pip, we're a niche?

[Andrew Holtz] But you have more to say about that than I do

[lauradugan] (you and Pip sure are, Pam) we'll do our best!

[michelle ann] I am sure it is on many holiday gift lists

[lauradugan] Two more questions

[Andrew Holtz] I haven't seen solid sales figures yet... but I think it's doing better than the publisher expected

[PamelaJaye] When was it released?

[Andrew Holtz] They recently ordered more copies to be printed... so that's encouraging. The book came out at the beginning of October

[lauradugan] From Michelle - “Are you planning another book for the later seasons?”

[PamelaJaye] Ken Jennings actually started a blog to promote his book. It's an idea...

[Andrew Holtz] We haven't talked about following up with another book on House

[PamelaJaye] (Blog is great and I *will* get to his book. Jay has it now)

[Andrew Holtz] Well, see... it all depends on the sales of this one

[lauradugan] Final question – “What do you think makes House such an extraordinary diagnostician? Experience? Perception and observation skills? Luck?”

[Andrew Holtz] The easy answer is all of the above but I think his greatest skill is being able to change his mind. He often gets an argument when he suddenly changes direction but in reality one of the hardest things for a person to do is to give up on a pet theory, even when facts change. House follows the facts wherever they lead and when he makes a mistake or sees something new he doesn't hesitate to spin around and run a new direction

[PamelaJaye] That's a really good answer/insight

[michelle ann] Or limp

[Pip] Hee

[lauradugan] Ha

[Andrew Holtz]

[PamelaJaye] Evil Michelle

[lauradugan] Does anyone have anything else they'd like to ask Andrew?

[michelle ann] *halo*

[dreamer] I'd like to thank him for his time

[michelle ann] This has been wonderful - thanks for your time.. I really appreciate it

[Pip] Yes, thanks so much Andrew.

[Andrew Holtz] Thank you!

[PamelaJaye] Yes, longer than most chats! Thank you

[sparsons] Thanks for the insights and information!

[Pip] *Virtual round of applause*

[PamelaJaye] *clap, clap*

[dreamer] This has been very interesting

[tantrums] Thank you!

[Andrew Holtz] Of course... please tell everyone you know get the book!

[lauradugan] Andrew, thank you very much for chatting with us. We wish you all the best luck with your book.

[michelle ann] I will be pimping in my Live Journal tomorrow

[lauradugan] Hehe

[Andrew Holtz] great!

[PamelaJaye] “suck up!”

[michelle ann] *ponts to halo*

[PamelaJaye] A dyslexic angel!

[lauradugan] We will have a transcript of this chat posted to our Yahoo groups page in a few days

[PamelaJaye] And thanks to whosever room this is!

[michelle ann]

[lauradugan] Shannon

[michelle ann] Yes thanks

[Andrew Holtz] Yes. Thanks to the room owner

[Gothic_Phantom] You're welcome And I'll work on getting the transcript done in the next day or so for you all.

[dreamer] Andrew, I hope you'll come back and chat with us again sometime

[Andrew Holtz] Certainly

[PamelaJaye] After he studies up on the stuff he didn't know

[Andrew Holtz] Got that right!

[PamelaJaye] Don't mind me, I’m a smartass

[lauradugan] Hey, we're a tough crowd

[dreamer] Yeah! a follow-up chat,

[Andrew Holtz] I'll start researching ketamine tonight

[goodship_a_k] Yeah!

[dreamer] Cool

[PamelaJaye] And Anne and Amy aren't even here...

[Pip] Great! There'll be a test at the next chat.

[michelle ann] Essay test

[PamelaJaye] I researched it a little one day, only found the RSD, but I don't speak medical so there was probably a lot I skipped. http://www.rsdfoundation.org/en/Ana.htm

[lauradugan] Well, folks, Shannon was kind enough to lend us the room for the evening. But I feel we ought to give it back.

[PamelaJaye] *clutches room and runs to corner* Mine, mine! Okay

[Gothic_Phantom] Don't make me get mad Pam

[PamelaJaye]

[lauradugan] Really, I just kind of want to go to sleep.

[Pip]

[PamelaJaye] Works for me

[Pip] Good Night Everyone

[sparsons] Goodnight, good people!

[Pip] Thanks again Andrew

[PamelaJaye] Just have Pip beat us till we.. or that night all

[michelle ann] Bye look forward to transcript bye

[lauradugan] Bye. Thank you, again, Andrew for your time. I really appreciate it.

[Andrew Holtz] You're welcome.