Respectful Insolence

Dr. House on vaccinations

If you think I’m hardcore when it comes to my disgust at antivaccination advocates like Dawn Winkler, you should check out House, M.D.:

[House walks away. Cut to the clinic and House is in an exam room with a young mother and her baby.]

Young Mother: No formula, just mommy’s healthy natural breast milk.

House: Yummy.

Young Mother: Her whole face just got swollen like this overnight.

House: Mmhmm. No fever, glands normal, missing her vaccination dates.

Young Mother: We’re not vaccinating.

Young Mother: [Takes a toy frog and starts to make frog sounds] Gribbit, gribbit, gribbit. [Giggles]

[Baby smiles and giggles too]

House: Think they don’t work?

Young Mother: I think some multinational pharmaceutical company wants me to think they work. Pad their bottom line.

House: Mmmm. May I? [He takes the frog and starts to do the gribbit noise with the baby]

Young Mother: [Whispered] Sure.

House: Gribbit, gribbit, gribbit. [The baby laughs] All natural no dyes. That’s a good business: all-natural children’s toys. Those toy companies, they don’t arbitrarily mark up their frogs. They don’t lie about how much they spend in research and development. The worst a toy company can be accused of is making a really boring frog.

[Young Mother laughs and so does House. The baby giggles again]

House: Gribbit, gribbit, gribbit. You know another really good business? Teeny tiny baby coffins. You can get them in frog green or fire engine red. Really. The antibodies in yummy mummy only protect the kid for 6 months, which is why these companies think they can gouge you. They think that you’ll spend whatever they ask to keep your kid alive. Want to change things? Prove them wrong. A few hundred parents like you decide they’d rather let their kid die then cough up 40 bucks for a vaccination, believe me, prices will drop REALLY fast. Gribbit, gribbit, gribbit, gribbit, gribbit.

Young Mother: Tell me what she has.

House: A cold.

[Cut to House leaving the clinic.]

Of course, no doctor would ever actually say this to a patient, with rare exceptions.

Comments

  1. #1 Joshua
    September 28, 2006

    Yes, and that’s the brilliant thing about House. Don’t you wish you could sometimes? ;)

  2. #2 Aerik
    September 28, 2006

    I would. I’d even be cruel about it.

  3. #3 Emily
    September 28, 2006

    Sweet! Thanks for posting this.

    Shameless plug for a colleague: health journalist Andrew Holtz has written a book called The Medical Science of House, M.D., to be released in October. http://holtzreport.com/housemd/index.html

  4. #4 #1 Dinosaur
    September 28, 2006

    I’ve come close. Diabetic with chest pressure, nausea, short of breath and “his color is terrible” after shovelling snow.
    Me: Go to the ER.
    Pt’s wife: He doesn’t want to.
    Me: Ok; is his will up to date?
    (pause)
    Wife: We’re going.

  5. #5 Calli Arcale
    September 28, 2006

    I’m curious — how good is the show, in terms of medical accuracy? So many medical dramas are highly unrealistic that it’s delayed my watching it. Plus, I’ve loved watching Hugh Laurie in British comedies; for some bizarre reason it seems very jarring to me to hear him speaking in that horse American accent that makes me want to cough out of sheer sympathy. I’m sure I could get used to it, but is it worth it? Hubby won’t watch it; he’s squeamish. (I have to flick the channel fast when he comes home while I’m watching Discovery: Health. Especially one of those ER documentary programs. I love those.)

    My dad (a doctor with a rather varied resume; he’s family practise mainly but also moonlights in an ER) watched about half of one episode and got too frustrated to watch any more. So I assumed it wasn’t very realistic. (Then again, he’s known to be EXTREMELY picky. Even documentaries are hard for him to watch, if they dumb anything down at all.) So how is it really?

  6. #6 anonimouse
    September 28, 2006

    I’d be the doctor that all of the anti-vaxers belives exists – the one that “bullies” them into vaccinating, threatening them with reports to DYFS and presenting all kinds of scare stories about kids who die from vaccine preventable diseases. I’d even give them the CDC propaganda, which of course they’re going to ignore.

    Thus, why I’m not a doctor.

  7. #7 Greg P
    September 28, 2006

    As someone who also has trouble watching the show for very long, I’ll try to explain my take.

    Like many “medical” shows, the person-to-person interactions (not just between doctor and patient, but doctor and doctor, or doctor and nurse, etc. are rather surreal and not very much like real world interactions. You just can’t make a go of it in the world talking to others like this.

    In many respects the medical diagnoses in the show are reminiscent of the derogatory phrase used in training to describe someone who hears hoof beats and immediately starts looking for zebras. Beyond that, there is a pretty flagrant distortion of unusual presentations of unusual diseases, that seems very much like a nonmedical person’s interpretation of a strange case of some illness once reported somewhere, then altered for TV to make it more dramatic.

    And while they don’t necessarily portray every outcome an absolute success, you lose the reality of the disability associated with a “successful” treatment of an awful disease.

  8. #8 ThomasHobbes
    September 28, 2006

    This scene was my first exposure to House, M.D., and it got me hooked right away. House gives a voice to all those impulses that you normally suppress–like telling a mother that tiny coffins are expensive–and for that I salute him.

  9. #9 decrepitoldfool
    September 28, 2006

    I’m stumped by people who insist the science, procedures, interactions and bureaucracy all be accurate on drama-comedies – that would be boring and/or depressing. I watch the show for the same reason as THobbes above – he says all the things I wish i could say, translating for the difference in professions.

    Notice the other characters are starting to be more like him? and it worries them.

  10. #10 Joan
    September 29, 2006

    I love House, but you have to approach that show as a fantasy set in a pseudo-medical environment. It’s totally whacked, House’s hospital — the doctors do all the bloodtests and administer the meds, which is just, well, insane. Not to mention that at most we ever see one nurse, when everyone knows that there are way more nurses visible on any given ward than there are doctors. It’s just the way it is, IRL.

    What makes House a great show is, of course, Hugh Laurie. House is a jerk but he is right pretty much all of the time. The medical dx aspect of the show is also laughable (I love it when I guess before they do, although it doesn’t happen often.) But I like how they bring up really odd stuff, like chimeras and strange parasites.

    Re horses and zebras: House is the guy you go to when you know it’s not horses, so I don’t have a problem with that. If I thought about it, I’d have a problem with the fact that four doctors are assigned to one patient a week, roughly, and I have no idea how anyone can afford that.

  11. #11 Rob
    September 29, 2006

    I do biomedical science; the tests make me laugh, typical hollywood ‘done in an hour’ type stuff. My wife is in medical physics, she says the machines are always wrong; giving a person a CT with a MRI machine. Last episode it was a MRI using a PET scanner i believe. But we really really love it. My father (radiologist) also enjoys it (perhaps b/c it’s not about his speciality?) I looked up some of the diseases, they can present with symptoms seen on the show. I’m looking forward to getting that book though!

  12. #12 Judy
    September 29, 2006

    House is the one medical show I can watch without grumping about how unrealistic it is. My husband regularly asks me if any doctor could get away with the things House does.

    Nope. He’d have been in jail eons ago. It’s so completely fantastic it’s impossible to care whether it’s real or not.

    I did especially love the vaccination episode. As a homeschooling mom, I come up against non-vaccinators on a fairly regular basis. Some of them even challenge me on the subject. I dearly love it when they bring up the BS about “better sanitation” being responsible for the decline in childhood illnesses. I share my experiences with infants with pertussis and HIB meningitis (something most younger pediatricians have never seen). They’re generally squirming pretty thoroughly before the excuse themselves and make for friendlier environs. I thought House was pretty gentle with that mom.

    I’m not sure I could get away with stuff like that at work, though.

  13. #13 HCN
    September 29, 2006

    I don’t watch “House”, nor do I watch “24″… and I really only like the original “CSI”.

    Does that make me a bad person? Does Orac think less of me?

    Oh, dear.

    I did catch part of “Heroes” this week. That looks interesting.

    (side note: “House” and “24″ are on a local channel that does not come in well through our antenna — and we don’t have cable, except for internet… but as it turns out no one in this house watches much TV. Though they do game online, hence the need for high speed internet.)

  14. #14 NotMySecondOpinion
    September 29, 2006

    I am a big fan of House since a friend introduced me to the show during the second season… I thought that it was some makeover show going by that name.

    Even though House is a gruff guy, he does care about his patients. Some more than others, but he does care. He is good at what he does and he’s certainly not ashamed of that. I am interested to see where this show will go. Zebras all start to look boring black and white after a while.

    Too bad I moonlight at a homeless clinic on Tuesday nights (as a first year med student.) I’ve missed most of this season’s shows!

  15. #15 Willliam The Coroner
    September 29, 2006

    I like both House and Scrubs. I’m not allowed to watch CSI or the other forensic shows because I get too upset, I mean shoot just one CRT and you’re tagged for life. Really.

    True, there aren’t enough nurses. True, all the women are very good looking (nuthin’ wrong with eye candy) Yes, House would be in jail for the stuff he pulls. Yes, the zebras are unrealistic.

    But I’d watch Hugh Laurie read the phonebook. I really hope Steven Fry gets a guest appearance on the show.

    Though sometimes you do have to be gruff and tell things bluntly. Once, when I was on vascular surgery, I had a patient who kept insisting on walking on his ulcerated foot and smoking. He asked me “What’s the worst that could happen.” in rounds. I said “Your friends are going to call you ‘Stumpy’”. He decided to be compliant. The nurse yelled at me for being not caring, but the resident evaluating me liked it. That couldn’t have happened on anything but a surgical service.

  16. #16 Prup aka Jim Benton
    September 29, 2006

    For me, HOUSE is one of the three ‘unmissable’ shows on broadcast tv. with COLD CASE and LOST. (There are others I watch — and I’m someone else who only watches the original CSI — but these are special.)

    Laurie’s acting is incredible. Not only does he do the whole show in a — for him — foreign accent, not only is he on stage in almost every scene — but he has to use that accent to ‘talk medical,’ a language of its own.

    I don’t worry about the accuracy of the science, though I like it when things are right. The show is about the interplay of people, House with the patients, and the whole staff, his assistants, Cuddy, and Wilson, with House, and they don’t hold back. The whole scene in two earlier episodes this year where House was right, but Wilson convinced Cuddy not to tell him he was right because it had been such a wild guess that he’d start thinking he was god and next time he could be wrong was brilliantly done.

    Anyway, if you DON’T watch it, try it. If you have satellite — cable exists only for those who can’t get satellite — the earlier episodes are being rerun on the USA network.

  17. #17 Catherina
    September 29, 2006

    as much as I like this scene, it is still not medically correct. There is no specific protection from vaccine preventable diseases through breastmilk (no matter how yummy it may be), but it is that misconception that is perpatuated through “Dr. House” that makes many mothers decide not to vaccinate until after weaning their babies. Maternal immunity is confered through antibodies that pass the placenta in the last pregnancy weeks and of course critically depends on what diseases mum has had and whether these diseases cause any life long humoral immunity at all. So, as good as the non-specific anti-microbial properties of breastmilk are, they are no substitute for avid IgGs that the babies generate as a response to vaccination.

  18. #18 Julie
    September 29, 2006

    What I found interesting about this episode from Season 1 (“Paternity”) is that the clinic visit is lecturing a mom about vaccines being necessary because maternal antibodies are only protective for 6 months, but the team’s case was SSPE from a measles infection. The measles vaccine is specifically not given until age 12 months because of interference from maternal antibodies.

    The decline of maternal antibodies statement could have worked for most other diseases, but measles was a poor example. Usually the “lesson” from the clinic ties in a little more acurately with the team diagnosis.

  19. #19 emmy
    September 29, 2006

    I love House. I love that he doesn’t care what other people think about him, but he wouldn’t be my doctor for 10 minutes.

  20. #20 cfrost
    September 29, 2006

    Whatever became of a sense of civic obligation and pride with respect to vaccination? The transmissible disease I am vaccinated for, I will not transmit to someone else. A small amount of pain and a very small risk protects not only me (or my child), but others. Herd immunity requires that the herd is immunized. Relying on others to let themselves be immunized so that you may hide behind them is being a coward and a parasite. Of course that’s supposing the people who fear immunization know enough about the subject to think that far. I am old enough to have been vaccinated against smallpox, which barring its release by war criminals, is now history. A smallpox vaccination scar is a medal given to every private in the campaign against that scourge.

    As for House, it’s entertaining in a TV way. It is TV though.

  21. #21 cfrost
    September 29, 2006

    Whatever became of a sense of civic obligation and pride with respect to vaccination? The transmissible disease I am vaccinated for, I will not transmit to someone else. A small amount of pain and a very small risk protects not only me (or my child), but others. Herd immunity requires that the herd is immunized. Relying on others to let themselves be immunized so that you may hide behind them is being a coward and a parasite. Of course that’s supposing the people who fear immunization know enough about the subject to think that far. I am old enough to have been vaccinated against smallpox, which barring its release by war criminals, is now history. A smallpox vaccination scar is a medal given to every private in the campaign against that scourge.

    As for House, it’s entertaining in a TV way. It is TV though.

  22. #22 trrll
    September 29, 2006

    I started watching the show, but got so fed up with it that I gave it up. The last straw was the show that insisted that there are different specific antidotes for different organophosphates. And even though House is such a caricature, I don’t like the show reinforcing some of the worst tendencies of physician behavior. The shows I did see seemed very stereotyped. Patient comes in with odd symptoms, House jumps to a conclusion about what the problem is, browbeats or tricks everybody into letting him treat for that condition, only he’s wrong and the treatment all but kills the patient. After the patient amazingly survives a couple of iterations of this, House finally hits on the right diagnosis and saves the patient in time for the final credits.

  23. #23 anjou
    September 30, 2006

    As a person who is totally deaf in one ear as a result of mumps as vaccines werent available in my childhood, I applaud your efforts on this vaccination issue. Had vaccines been available, maybe Id hear in stereo rather than mono…..

  24. #24 Jeb
    September 30, 2006

    Catharina,

    It’s been a while since immunology, but don’t babies imbibe specific immunity in their mother’s breast milk through secereted IgA and IgM?

    Thanks,
    Jeb

  25. #25 Manduca
    October 1, 2006

    House lost his credibility as a doctor for me as soon as I saw him walking with the cane on the wrong side! In his defense, I have to say that you see this mistake so often in movies and TV that real injured people don’t know how to use a cane.

  26. #26 SV
    October 2, 2006

    Another example of TV tackling the issue was an episode of ER from a few years back, one where a mother bragged about not vaccinating her kids only to have one of them die of measles hours later.

    The didn’t try to play it for laughs – that would be sick – but they didn’t soften the message, either.

  27. #27 James
    October 2, 2006

    Actually Manduca I’ve read an interview of Hugh Laurie and he did it deliberately. Laurie researched which side he should use the can on and decided to do the opposite figuring there was no way House would take the advice of a physical therapist.

  28. #28 MartinM
    October 2, 2006

    The last straw was the show that insisted that there are different specific antidotes for different organophosphates

    Bit harsh. As I recall, those were supposed to be new, experimental treatments. IOW, they practically screamed ‘we made this up.’

  29. #29 Catherina
    October 2, 2006

    Jeb,

    there are few specific IgA antibodies in breastmilk right after birth. This study looked at measles antibodies in breastmilk samples: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15601649
    I have a number of German sources from prevaccine and preformula days (mid 1920ties) that state that after 3 months (basically the decay time for transplacental IgGs) infants are no longer protected against measles. In measles outbreaks in that time (turn of the 19th to 20th century), between 2 and 7% of all patients were under 1 year of age (and made up up to a third of all deaths). Further, there is indication that while maternal immunity may prevent clinical breakthrough of measles, it does not prevent infection, hence children who contracted measles subclinically in the first year of their life may still get SSPE.

    So I guess, colostrum may contain some antibodies to some (few) vaccine preventable diseases, but not for very long, not against many diseases and not very potent in preventing your typical VPD. Still, breastmilk is great in reducing the risk of Hib, severe rotavirus infection and generally boosts the immune system (and immune response to vaccine), so I am definetely for both, breastfeeding AND vaccinations. The idea that either one could replace the other does not hold up to scrutiny.

  30. #30 Jeb
    October 2, 2006

    Catharina,

    Thanks for the update. But, what about IgM. I seem to remember that as being the “memory” antibody and produced in larger quantities than IgG. Isn’t the paradigm that breast milk provides waning coverage as the infant’s immune system is challeneged and develops its own Igs? if that is true, then are some breast-feeding mother’s mis-informed?

    Cheers,
    Jeb

  31. #31 Catherina
    October 3, 2006

    Jeb,

    IgMs are the “first response” antibodies, come in pentamers and are much more labile than IgGs (monomers, which are the most abundant and the “memory” antibodies) and usually indicative of a fresh infection. There are some IgMs in breastmilk, but transfer via breastmilk is ineffective and the protective effect is very low. IgAs are “secretory” antibodies to begin with and line mucosa in our bodies as monomers or dimers (therefore get to the appropriate place from the breastmilk into the baby’s mouth). IgAs are the most abundant antibodies in breastmilk and protect mainly from gastrointestinal infection (think rota, polio, cholera, but also hib).

    So the baby’s immunity before s/he makes own antibodies comes from two sources: IgGs that pass the placenta in the last pregnancy weeks and IgAs that pass through the breastmilk during nursing. Although some IgMs may be passed through breastmilk, they would be quickly degraded and IgMs found in the baby’s blood would be from the baby’s own immune reaction. Babies can effectively generate antibodies very early, but will only make IgMs against carbohydrate antigens (as found on many bacterial pathogens, like meningococci and hib) in their first 5 years.

  32. #32 Lisa Kenefick
    October 4, 2006

    They have had quite a few shows on Cushing’s Disease (the ultimate zebra), which isn’t as rare as it is thought to be. I just wish they’d do surgery as quick as they showed! Dream world.

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