The Merits of Nitpicking: A Doctor Diagnoses House

My son and I are both big fans of the television series, >em>House. I watch the show for the characters and their interactions -- especially for Hugh Laurie's performance but also for his interplay with the other doctors. My son has shown a bit more curiosity about the medical dimensions of the series and in search of information, he stumbled onto a fascinating blog, Polite Dissent, which offers medical insight into House, superhero comics, and a range of other popular culture texts. The blog promises us "Comics, Medicine, Politics, and Fun." Its author, Scott, describes himself as being part of a large family practice in Southwestern Illinois. Scott's blog is a good illustration of a mode of fan criticism which sometimes goes by the name of nitpicking. Nitpickers examine their favorite programs through a particular lens -- in this case, medicine -- in which they have developed expertise. I became very interested in nitpicking when I did research for Science Fiction Audiences about the reception of Star Trek at MIT. What I found at that time -- the late 1980s -- was that MIT students were often drawn to our school because of an early interest in science fiction and used science fiction -- especially debates about the lines between known science, reasonable speculation, and implaussible technobabel -- to work through their own mastery of core scientific concepts. The pleasure was in being able to prove to each other what was "wrong" with the science in a particular Star Trek episode and to explain a more plausible or realistic way of dealing with the same themes. Indeed, they classified the ST:NG episodes by discipline, often using the numerical codes ("Course 6") which are most often used to refer to majors within the MIT Context, suggesting just how much the shows functioned in parallel with what they were learning in their classes.

These scientists and engineers in training were not being obnoxious in trying to show their superiority to the program: part of the pleasure for them came in sorting out the differences between real and bogus science. In some senses, this was to look at the series through a realist lens but that's too simple a way to understand what is going on since all science fiction fans recognize that science fiction involves speculation and about social commentary, not simply about reproducing the world of known science but pushing beyond it to explore alternative possibilities. There were just "rules" that governed how far outside known science science fiction "should" stray and in what directions.

The classic nitpicker has a love/hate relationship with their favorite program: the show has to be good enough to stretch the outer limits of their knowledge at a regular basis and yet at the same time, it has to be flawed enough that they can catch it when the authors "fake it" in a particular domain of knowledge.

So, Scott takes House apart in terms of hospital procedure, medical tests and equiptment, and the specifics of the various ailments they appear in the speculations surrounding a particular case. Taken as a whole, Scott seems to enjoy the speculative aspects of the series but to be displeased by the various shortcuts the writers take to get us through a complex medical process in under an hour of screentime. Scott recognizes the tension between story telling and communicating actual medical knowledge but remains frustrated, as he puts it, "when House does a "character show," the medicine suffers."

Here, for example, are some of the key concerns he raised about "TB or Not TB", a second season episode about a grandstanding doctor who works on the medical problems in the third world and who provokes special ire from the series protagonist:


f the patient is suspected of having TB, why is no one treating him wearing a mask? Why he wandering around the hospital and not in isolation? Why is he not in a negative-pressure room?

PPDs are not read by sight, but by feel. It doesn't matter how red it looks, but instead how indurated it is.

TB is slow growing. How did the team know almost immediately that it was resistant TB? How did the antibiotics kick in so fast?

A nesidioblastoma would explain most of Dr. Charles's symptoms, but *wow* that's a convenient tumor. Small enough that it can't be seen on x-rays or MRIs. Intermittent, so it only releases insulin periodically. And yet strong enough to lower the sugar level in his CSF. It's more of a deus ex machina than a diagnosis.

When Dr. Charles coded, why did no one in a room full of doctors start CPR while waiting for the paddles to charge?

I'm certainly no surgeon, interventional radiologist or endocrinologist, but the scene where the team is trying to induce the tumor to release insulin seemed wrong. Injecting calcium directly into the pancreatic blood supply may be a legitimate procedure, but I doubt those four are qualified to perform it. Also, since they expected the blood sugar to drop to dangerous levels, they should have had the D50 ready to inject and not scramble for an IV setup

Frankly, most of these questions never crossed my mind: for me, the medical language on >em>House is as much technobabel as anything heard on Star Trek, but I found I had to stop watching Jack and Bobby a few years ago because I got so frustrated in how they dealt with academic life and I am starting to get more frustrated with Veronica Mars along similar lines. It all depends on where your expertise and interest lies but that's part of the value of creating a space where shared texts get examined through multiple lens.

It has been widely observed that procedural shows like House or CSI can play an important role in exciting the American public about the professions being represented. They are often accompanied both by an increase in sales of nonfiction works on the same topics and by increased applications to colleges which offer programs in those areas of specialization. The obvious parallel here is to the MIT students who got turned onto science through Star Trek. In such a context, sites like this one play an important role in providing a corrective to some of the more hairbrained ideas that find their ways into dramatic television or simply to provide further background on the medical conditions and practices discussed on the program.

I wonder how we can incorporate something like the nitpicking process into the educational system. What is the value of getting students to apply their knowledge to deconstruct a popular representation? What is gained by the process of walking through such critiques and then trying to verify competing truth claims through reference to concrete evidence and information? What gets added when we move from a single knowledgible critic like Scott to the incorporation of a larger community of interested people who might bring slightly different expertises to the table or who might have competing interpretations and evaluations of what is represented in the program (as occurs in the comments section of this site)? The key point is that the procedural shows themselves do not have to be 100 percent accurate as long as they offer problems for students to work through and solve and as long as a spirit of playful debunking is built into how they get discussed in the classroom. Indeed, the shows may be a better basis for such an experiment if they are good enough to capture the imagination but ultimately flawed or compromised in their representation of real world practices. Such an excercise would seem to be a great way to introduce media literacy concepts into the biology classroom.