Dr. Gregory House hung up his stethoscope and cane for the last time last night and shuffled off into eternal life in the Land of Reruns. House — the brilliant, misanthropic, drug addicted, my-way-or-the-highway physician — has been an entertaining presence on FOX television for the past eight years. I enjoyed the series and even learned a little medicine. I also took some pride in the show, since House was television’s first hospitalist, a term I helped coin and now the fastest-growing specialty in modern medicine.
But as entertaining as he was, House was a throwback to an era in which the antisocial tendencies of some physicians were seen as irrelevant to their doctoring. As medical leaders strive to redefine “the great doctor” of today, House’s departure is both timely and welcome.
When I went to medical school in the 1980s, many of us valued nothing more than our autonomy. We saw medicine as an individual, not a team, sport, and interpreted professionalism as unwavering advocacy for our patients. While this was often healthy and noble, in some cases it crossed the line into obnoxiousness, even rage. (Today, we call doctors who cross this line “disruptive physicians.” Dr. House would certainly qualify.)
Hospitals were co-dependent. All too aware of their heavy reliance on the physicians’ control over their revenue stream, hospital administrators learned to coddle doctors, with everything from prime parking spots to a personalized menu of surgical equipment. This kept the doctors happy, but also led to wildly expensive and sometimes risky variations in practice, even within the same institution.
This reliance also made everyone tiptoe around the dysfunctional behaviors that Dr. House so memorably illustrated each week. In one survey of more than 700 nurses, 96% reported seeing doctors engaging in disruptive behavior, and almost half pointed to fear of retribution as the reason such acts went unreported. Another survey found that one in four doctors and nurses believe that disruptive behaviors are associated with preventable deaths. I agree, having seen cases of medical errors in which a scrub nurse or physician trainee suspected that a senior doctor was about to commit a terrible error, but kept quiet rather than risk the physician’s ire.
Former secretary of State Henry Kissinger once observed that “weakness is provocative.” When it comes to taking decisive steps to address the problem of disruptive doctors, we have been both weak and provocative. The reasons are several and knotty. We doctors are not schooled in managing confrontation, and we’re particularly timid when asked to judge the behaviors of our colleagues under our system of “peer review.” Moreover, we worry about being sued if we act decisively against another physician.
But another reason goes to the heart of House’s widespread appeal: patients seem to believe that the Gregory Houses of the world must have terrific clinical skills, whether in performing brain surgery or diagnosing a rare case of strongyloidiasis. While Dr. House did have Sherlock Holmesian diagnostic acumen, the insider’s secret is this: great doctors are skilled at both medicine and teamwork. Patients shouldn’t have to choose one or the other.
Spurred by the patient safety movement, the medical community is finally taking steps to address the problem of antisocial doctors. Gerald Hickson, MD, of Vanderbilt has created a program that begins with a “cup-of-coffee conversation” but escalates to the loss of hospital privileges for physicians who fail to respond to education and counseling. In my own hospital, we have dismissed several physicians over the past few years for behavior that I’m certain would have been tolerated a generation ago. These are wrenching decisions, but ultimately correct ones.
While we’re getting better, we are still not where we need to be. Hospital peer review committees are only partially shielded from lawsuits, which creates a chilling effect. Options for counseling aimed at improving the behavior of disruptive doctors are limited. And doctors released from one hospital for behavioral problems are generally able to continue practicing in other settings, even if their behavior hasn’t changed.
Over the past decade, we have come to realize that, for all its miracles, the American health care system produces uneven, error-prone, and backbreakingly expensive care. These problems are complex and require an array of solutions, ranging from computerization to standardization, from simulation training to patient engagement. But we also need physicians who are smart, well-trained, innovative, intensely focused on delivering the best care to their patients, and who can play well with others. While House had many of these skills, the teamwork part was his fatal flaw. If he worked for me, I would have fired him, somewhere around Season Three.
So rest in peace, Dr. House. Thanks for being in our lives for these past eight years.
And thanks for leaving.
This post first appeared in USA Today.
Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is chair-elect of the American Board of Internal Medicine. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.