I planned on posting about how formulaic House, MD episodes are, but Paulo beat me to it. Paulo states his observations succinctly, but I need to add just a few more comments. There’s a reason why the protagonists always jump on the “obvious diagnosis.” One fundamental principle in diagnosing illnesses is brilliantly summarized in the saying “When you hear hoof beats, think horses before zebras.” Given a set of symptoms and signs, think first of the more obvious / commonplace diseases. So if your patient presents with changes in behavior, think of a stroke, infection or electrolyte imbalance before you start thinking of weird illnesses like kuru (I think I saw this example dramatized on Scrubs). These past few years, “medical TV programs” — for lack of a better term — have been very popular. House, MD on Fox. Grey’s Anatomy on ABC. Scrubs (a personal favorite, because it doesn’t take itself too seriously) and Medical Investigation on NBC. And ER, of course. The problem with shows like House, MD is that they have to entertain. They will have a tendency to showcase “zebras” — weird, not-so-common illnesses or common diseases with atypical manifestations. You won’t get episodes where patients go in with a simple upper respiratory infection or uncomplicated gastroenteritis. Tune in as John Carter treats a couple of septuagenarians with pneumonia. Nope. In TV land, it always has to be weird or “exciting” like neurocysticercosis (worm in the brain), African sleeping sickness, smallpox or some obscure toxin. Obviously, not “real world” medicine.

When ER was still a cutting edge show, the writers put great effort to avoid medical show cliches. But now, even plot devices and contrivances that were considered unconventional in the 1990s, having been done over and over by shows that followed, no longer pack the same sting. Here are some medical show cliches that I’ve noticed:

• Child or infant comes in with a history of multiple admissions due to repeated fractures. Docs initially think the patient is a victim of abuse, but brilliant doctor-protagonist checks child’s eyes and conclude that the patient has osteogenesis imperfecta (also known as brittle bone disease). [Saw this in ER and Medical Investigation.]
• One of main characters becomes a patient himself / herself. The character learns a valuable lesson.
• The more experienced doctors cannot be reached and an inexperienced trainee is forced to manage a difficult case… and manages to pull it off.
• Doctors routinely become too attached to their patients.
• Doctor becomes attached to patient but the patient goes into arrest. All the code team’s efforts are futile. Said doctor is shown frantically doing chest compressions long before the prescribed time has elapsed while everyone stands aside quietly. A less-involved doctor tells him to stop and to declare the patient dead, or calls it for him.
• Young, inexperienced doctor has to tell family members some bad news.
• Main character has a substance abuse problem. [In ER, John Carter became addicted to pain killers. House is also shown to be overly dependent on pain killers due to his bum leg.]
• Higher ranking doctor gets involved with a trainee, and both try to hide their relationship from the hospital staff.

By the way, my favorite “House-ism” so far: [About a patient who has been sleeping excessively] “Redo the blood work and get a new MRI with 2 millimeter cuts through the mesodiencephalic… And check for evil stepmothers. This much sleep usually indicates poisoned apples.”

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