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Dr. JAUHAR: Magical Medicine on TV by NY Times
作者:USMedEdu
发表时间:2009-01-10
更新时间:2009-01-10
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发信人: docrockville (docrockville), 信区: MedicalCareer
标 题: NY Times: Magical Medicine on TV
发信站: BBS 未名空间站 (Sat Jan 10 12:55:14 2009)

July 19, 2005
Magical Medicine on TV

By SANDEEP JAUHAR, M.D.

On the Fox television show "House," a misanthropic, pill-popping, grizzled
über doctor named Gregory House leads a group of impossibly bright young
physicians in the department of diagnostic medicine at a teaching hospital
in New Jersey.

Dr. House and his team solve medical mysteries with the flair and
resourcefulness of private investigators. On a recent show, doctors made
multiple visits to the home (even the school bus) of a teenager with
convulsions before determining that he had a rare pesticide poisoning.

My wife, a general internist, finds the show absurdly "unrealistic." "
Doctors don't do that," she cries whenever a House physician blithely
ignores the boundaries of medical subspecialties. (The same doctors, for
example, might perform cardiac catheterization, gastrointestinal endoscopy,
bone-marrow biopsy and liver ultrasound.) I agree the show is unrealistic,
but for a different reason. It portrays a world where doctors have time to
solve problems.

I have worked in teaching hospitals in New York for seven years, first as a
resident and now as an attending physician, mentoring residents and fellows.
Over this period, I have discerned a gradual decline in the intellectual
climate of these institutions. It has been dispiriting to watch. Of all the
places one might expect doctors to be curious about medicine, teaching
hospitals should be first.

Young doctors I work with today seem disengaged and mentally fatigued. With
patient rosters of 15 or more, they are preoccupied with getting their work
done. Interesting cases tend to generate anxiety, not excitement. Mysteries
are, by and large, abhorred.

I recently met a pulmonologist, a soft-spoken woman who told me that she
used to work on the staff of a teaching hospital in New York City but had
gone into private practice a few years ago. I asked her why. "I loved to
teach," she replied sadly, "but the residents and fellows just didn't seem
to want to learn. They had other things on their minds.

"I met an intern the other day," she went on. "He was asking me questions
about a case we were managing together. I told him that it was wonderful to
see a young doctor so curious about medicine. He said: 'Thank you for saying
so. Now can you tell my chiefs because they are always telling me that I am
too inefficient?' "

Doctors in teaching hospitals today are operating in a kind of Zip drive,
where patients are compressed into smaller and smaller space. There are
probably several reasons: sicker patients, quicker patient turnover,
administrative pressures to cut costs, even rules limiting work hours.

Work-hour restrictions, which limit residents to 24 hours on call, with 3
additional hours to hand off patients, were instituted in 2003. They were
supposed to improve the learning environment, but in fact they have had the
opposite effect.

Today I see staff reflexively calling consultants, not because they have
legitimate questions but because they don't have the time or inclination to
think through a difficult case for themselves. Unlike Dr. House, no one
wants to take on challenging cases, so they are tossed back and forth
between consultants.

In his 1999 book "Time to Heal: American Medical Education From the Turn of
the Century to the Era of Managed Care," Dr. Kenneth Ludmerer, a Washington
University physician and historian, bemoaned the deteriorating intellectual
environment in teaching hospitals.

He wrote: "Most pernicious of all from the standpoint of education, house
officers to a considerable extent were reduced to work-up machines and
disposition-arrangers: admitting patients and planning their discharge, one
after another, with much less time than before to examine them, confer with
attending physicians, teach medical students, attend conferences, read the
literature and reflect and wonder."

Today, everyone in medicine wants a number, a lab test, a simple objective
measurement to make a diagnosis. Unlike Dr. House, few have the time or
patience to cope with uncertainty. We want to make medicine easier than it
deserves to be, easier than it actually is.

Which is why I like to watch "House." The show reminds me of the wonders of
medicine. It allows me an hour each week to relish the magic and mysteries
of my profession, even if it's only on TV.

--

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