Meghan L. Bayer
University of Pittsburgh
28 March 2017
When we are, sick or injured, most people turn to doctors for help. The conversation might look something like this: “Doctor, please help me. I do not feel well.” Doctor: “What seems to be the problem?” Patient: “Well, I am tired all the time. I am coughing frequently, have a fever and I am very achy. What is wrong with me?” In this situation, the patient is presenting with very general symptoms, which may indicate something like the flu, a bad cold, or some other type of common virus. This is a common scene that plays out every single day all over the world. While we may have some ideas of what might be wrong, we usually do not know for sure. When the doctor has listened to the patient and conducted a thorough physical examination, they got through a series of steps to find out what is ailing their patient. The media plays a large role in how we portray doctors, how we expect them to act, and how we are supposed to act while interacting with them. That being said, how does House M.D. produce a particular vision of diagnosis and inference in medicine? For the remainder of this paper, various forms of reasoning will be discussed, examples from the show presented, the options of experts studied, and an exploration into why Dr. House and his brilliant team have so much success as diagnosticians. (Shore, 2011)
When they have reached their conclusion or diagnosis, the doctors should know how to effectively treat their patient. Sometimes, a disease is so rare or so obscure that a physician may not have the tools or the knowledge to effectively identify and treat the condition. While it is possible that a lack of knowledge on the condition is a possible cause for the delay in diagnosis, sometimes there is a flaw in the logical process. This process, which is known in medicine as diagnostics, is the inferential process by which physician reaches their conclusions. There are many different types of inferences like induction, deduction, and hypothesis, which will be discussed in greater detail throughout the remainder of this paper.
One such brilliant diagnostician is a doctor by the name of Gregory House. Now, if you have seen the show House M.D., you know that Dr. House is a stellar diagnostician. While his methods by which he reaches his diagnoses can be somewhat questionable, he has mastered the art of diagnosis, which is, in some ways, a form of the art of logic. While Dr. House and his team are fictitious characters in popular television show, there are many real elements of the show, including the diseases covered and the process by which a diagnosis is reached. For many people, especially those that go undiagnosed for long periods of time, Dr. House and his team composed of experts from many specialties, may be seen as the ideal medical team. In the following paragraphs, we will explore the perception of diagnostics that is portrayed by the television show and the specific rhetorical and logical elements of the diagnostic/inferential process.
Diagnostics is an inherently rhetorical situation, meaning that there is a problem somewhere in the human body and it is up to the physician to figure out what the problem is and treat it. Unlike some cases of real-world medicine, by the end of the hour-long episode of House M.D., a diagnosis has been reached, the patient has been treated, and they are usually ready to go home. For more common conditions, it is reasonable to believe that this is case. However, the show is misleading in that it leads the viewers to believe that a diagnosis is always identified, the condition is always treatable/curable, it is done in a timely manner, and that the patient doesn’t normally die. While this may be the case in some cases, this portrayal of diagnostics by the mainstream media can be somewhat inaccurate in real-life.
While you do not need a brilliant, Vicodin addicted, diagnostician with some pretty serious narcissistic personality disorder and a chronic pain issue to get results, there are three major reasoning strategies that Dr. House and his team use to identify their patients’ mystery conditions. (Shore, 2011) These are inductive reasoning, deductive reasoning, and hypothesis. Before I provide examples from the television show, I want to briefly explain the definitions of inductive reasoning, deductive reasoning, and hypothesis.
In Steven Beebe and Susan Beebe’s popular public speaking textbook, A Concise Public Speaking Handbook, inductive reasoning is defined as “reasoning that uses specific instances or examples to reach a general, probable conclusion”. (Beebe et al., p.263, 2015) A popular example of inductive reasoning is “Socrates is a man. All men are mortal. Therefore, Socrates is mortal.” As seen in this example, we started with Socrates, one very specific individual. Eventually, an assessment of the mortality of all men was made and because the first two parts are related and true, the third part about Socrates being mortal is correct. Inductive reasoning is not as common in medicine, simply because you need symptoms and evidence of dysfunction to be able to diagnose most conditions. However, medical knowledge is founded on inductive reasoning. In some cases, doctors may be able to jump to the diagnosis, but that is not always the case.
Stephen and Susan Beebe define deductive reasoning as “reasoning that moves from a general statement or principle, to a specific, certain conclusion”. (Beebe et al., p.261, 2015) A common example from rhetorical studies is “All men are mortal. Socrates is a man. Therefore, Socrates is mortal.” This time, we start with an assessment of all men and work our way down to the one specific person being referenced, which in this case is Socrates. In season 7, episode 18 of House M.D., House and his team are faced with a patient that has excruciating joint pain, fragile skin, easily bruising skin, and frequent joint injury. They are starting with the general symptoms and working toward the diagnosis of Ehlers-Danlos Syndrome from general to specific. (Shore, 2011) When using inductive or deductive reasoning especially, you must be careful that all facts are correct. One wrong part makes the entire reasoning false. A common pitfall to reasoning, one that Dr. House and his team frequently find themselves doing, is a causal fallacy. Just because something makes sense and is possible, does not mean that that is the true reason for the issue. For instance, a patient having pain could have a psychiatric problem making them think they are in pain when they are not, but in the case of season 7, episode 18, Ehlers-Danlos Syndrome (EDS) is the more likely cause of the pain. (Shore, 2011)
The third form of reasoning is hypothesis. For the hypothesis, you do not start with the most general idea or the most specific idea, rather you start with the middle concept. Using that concept, you can make more inferences. A common example of hypothesis from rhetorical studies is “Socrates is a mortal. All men are mortal. Therefore, Socrates is a man.”
Another important part of the logical process of diagnosis is inference. In the A Concise Public Speaking Handbook, inference is defined as “a conclusion made based on the available evidence or partial information; an evaluation that has not been directly observed.” (Beebe et al., p.263, 2015) This is exactly the kind of process that would occur in diagnostics. You establish the general problem, run tests to get evidence as to what is going on, and you use that available evidence to develop a conclusion/diagnosis. As with inferences, a doctor does not always have all the information, which, like many things, can be restricted for a variety of reasons. Sometimes the diagnosis can only be proved by treating the patient’s symptoms and if they respond to treatment, it is reasonable to believe that the diagnosis is correct. This is useful when diagnostic tests are inaccurate or there are several conditions that cannot be ruled. Most diagnoses begin as inferences obtained through various forms of reasoning.
Analogy is also an important part of the diagnostic process. Doctors spend years memorizing the many triads of symptoms that are indicative of a disease when they show up together in a patient. Every person is getting compared to cases they have seen, treated, or read about in the past. For instance, if you see symptoms x, y, and z show up in a patient and it is indicative of a particular condition, using past experiences with patients in a similar situation can be helpful. Part of the issue that poses a major barrier in diagnostics is the patients’ ability or inability to articulation what is happening. People that are more readily able to articulate what they are feeling are more likely to have an easier time then someone who cannot articulate what they feel. (Kuchinskaya lecture?) During the season 7, episode 18, the young woman with Ehlers-Danlos Syndrome, a rare connective tissue disorder that affects the strength of muscles, tendons, and ligaments, could effectively convey was she was feeling, which made obtaining a diagnosis somewhat easier. House and his team also deal with either/fallacies, which happens when they say it’s one condition or the other. We cannot figure it out, but it cannot be both. When they are restrained by this fallacy, patient outcomes are generally more poor, as we see in season 7, episode 18 with the young woman. (Shore, 2011)
Dr. House is famous for his abundance and frequent use of ad hominems, which are instances where one does not attack the argument being made by another, but rather the person and their character. Throughout the eight seasons that the show ran, House was attacking someone or calling them “stupid”, “idiots”, etc. when one of the other doctors presented an idea for a diagnosis that was so obviously far-fetched and wrong. This can be seen at least once an episode. (Shore, 2011) While often disconcerting for his team, it was his effective way of encouraging the search for the proper diagnosis.
Dr. House is also notorious for his disregard for the rules of Princeton-Plainsboro Teaching Hospital, the facility by which he is employed. This means that he does not listen to the head of the hospital, Dr. Lisa Cuddy at all. This paints an extreme example that may lead viewers of the show to believe that doctors do not follow the rules, when in fact the kind of behavior Dr. House displays would not be acceptable in most real-life hospitals. This may be a fictitious character, but the problems caused and portrayed in the show are very real problems faced everyday by doctors and patients alike in the process of diagnostics. Per Czarny, “The portrayals of physicians and the ethical issues they faced in televised medical dramas may influence popular attitudes, beliefs, and perceptions. Studies indicate that television viewing has a measurable influence on certain beliefs and practices. Inaccurate or unrealistic depictions of ethical issues and a lack of professionalism by television physicians adversely affect public perceptions as well as healthcare professionals in general.” (Czarny et al., pg. 203, 2009) This goes to say that how the public sees physicians portrayed on television may affect their perception of doctors. In the case of House, he is not sending a positive message consistent with an upstanding physician, but he is extremely bright. This helps lead people to believe that obtaining a diagnosis is quick and easy, when many times it is anything but easy. This perpetuates the notion that doctors know everything, which like any other human, is false. In their paper, Thomas et. al agree with this conclusion developed by the Czarny and his colleagues. This is a popular idea among researchers in this field. (Thomas, 2009)
House and his team spend a lot of time discussing different possibilities as to what is causing their patients’ problems. They engage in direct persuasion, mostly in cases in which there are not as many different potential diagnoses. Direct persuasion occurs when people work to convince others to believe what they believe using the available logic and facts. This is always occurring when each member of the team makes a case for a certain illness that is it their specialty. (Jacoby, 2009) During this process, the team brainstorms possible diagnoses and they all work to refute conditions that do not fit the profile.
The dynamics of House’s team are obviously dramatized for the purposes of entertainment, but the process by which they we reach their diagnosis and the reasoning strategies they employ throughout are still very important. Dr. House is portrayed as a socially awkward genius with a God complex, but not all doctors in real-life are like that, nor do average doctors diagnosis conditions as quickly as Dr. House. The logic and reasoning applied to the show are excellent examples of real world processes, even if the speed of the diagnosis and the characteristics of the team are dramatized for entertainment purposes. Over the eight seasons that the show ran, millions of people watched the show and has their perceptions of physicians altered, consciously or unconsciously. The show is a more subtle way to encourage people to look at physicians differently.
As you can see, House M.D. paints a very distinct picture of how diagnosis occurs in the world. However, there are some elements that are just simply not the case. This television show shows the average person the many ways conclusions can be reached and some of the dangerous pitfalls to logic and reasoning causing misdiagnosis or a delay in the diagnosis. Most people will probably take the show at face value and not read into it the way I just did, but if you do consider it more carefully, you can see the many ways that real reasoning strategies are used. House M.D. creates an accurate portrayal of the process to diagnosis, just in a more compact amount of time. If viewers can understand that the process, which shortened for the purposes of entertainment, they can really get a much better understanding or what goes into the diagnostic and inferential process and understand the image of diagnostics and inference in House M.D.. (Jacoby, 2009)
Beebe, Steven A., and Susan J. Beebe. A Concise Public Speaking Handbook. Boston, Pearson, 2015.
Czarny, Matthew J, et al. “Bioethics and Professionalism in Popular Television Medical Dramas.” Journal of Medical Ethics, vol. 36, no. 4, 2010, pp. 203–206., http://www.jstor.org/stable/20696763.
Jacoby, Henry. “Chapter 5.” House and Philosophy: Everyone Lies, Wiley.
Shore, David. “Season 7 Episode 18.1.” House M.D., FOX, 11 Apr. 2011.
Thomas, Rhys H, and Naomi J P Thomas. “House Calls.” BMJ: British Medical Journal, vol. 339, no. 7735, 2009, pp. 1416–1417., www.jstor.org/stable/25673523.
“Another potential reward or being an ‘anonymous expert’ [in the context of Wikipedia] lies in the ethos this generates. If an author’s name is not attached to her article, ownership of the work is uncertain. If personal ownership is uncertain, the expert can claim that she donates the work [selflessly] to the public, in a sense offering it for the greater good” (Hartelius, Rhetoric of Expertise, 147).- Anonymity of expertise- expert donates the idea; which displays a type of ethos, because the expert is licensed to speak to non-experts in the field.
-When you’re an expert, that is not important
-“I’m in pain”- everyone is an expert on themselves (which is where the idea of patients and their families being experts on themselves comes into play. Consistent with Hartelius’ beliefs)
Idea of eloquence- patient’s articulation of their signs and symptoms can make or break the diagnostic process. Can impact the diagnostic process for the elderly and the younger, two populations that be harder to diagnose due to their possible inability to articulate their feelings, signs, symptoms, discomforts, etc.
Exploration across different kinds of rhetoric- diagnostics would be considered a type of rhetorical situation according to Bitzer. Only apply to untreatable/incurable diseases?
Dr. K- anti-House in large part because of the idea of operating under the assumption that everyone lies. House MD- Everyone Lies, which they do, but it isn’t always to be deceptive, sometimes could occur because someone doesn’t have the word to eloquently explain what they are feeling/perceiving with their senses. Not the manner in which the people who wrote the show intended it; but may not be as far from the truth, contrary to my initial belief. This concept is twisted in a way so that the show is most entertaining (more fun for the viewers if the doctor is sarcastic and rude to his patients and accuses everyone of lying), so it is not the most accurate portrayal of diagnostics.
Lots of doctors gain their initial interest from shows like House, Grey’s Anatomy, Scrubs, ER and other reality medical TV shows. *Interesting study Dr. K mentioned that House was #1 for influence and the rest of the shows followed after that, see if I can find that
Interested to see if Grey’s Anatomy has overtaken House MD since it came off the air and how this has influenced the perceptions of doctors inspired by one or the other, could be an interesting question. How are aspiring doctors influenced by popular medical TV shows?
Doctors not believing patients, thinking they are lying, accusing them of functional, psychosomatic, or somatoform disorder is an all too real part of obtaining a diagnosis for many people with rare diseases. Even if it is not the patient, their caregivers may be accused of faking symptoms (Munchasen’s by Proxy, common with children of minor age, medical kidnapping (Justina Pelletier vs. Boston Children’s Hospital case), etc.)