The House of God
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The House of God is a satirical novel by Samuel Shem (a pseudonym used by psychiatrist Stephen Bergman), published in 1978. The novel follows a group of medical interns at a fictionalized version of Beth Israel Hospital over the course of a year in the early 1970s, focusing on the psychological harm and dehumanization caused by their residency training. The book, described by the New York Times as "raunchy, troubling and hilarious", was viewed as scandalous at the time of its publication, but acquired a cult following and ultimately came to be regarded as a touchstone in the evolving discussion of humanism, ethics, and training in medicine.
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Dr. Roy Basch is an intelligent but naive intern working in a hospital called the House of God after completing his medical studies at the BMS ("Best Medical School"). He is poorly prepared for the grueling hours and the sudden responsibilities without good guidance from senior attending physicians. He begins the year on a rotation supervised by an enigmatic and iconoclastic senior resident who goes by the name The Fat Man. The Fat Man teaches him that the only way to keep the patients in good health and to survive psychologically is to break the official rules. The Fat Man provides his interns with wisdom such as his own "Laws of the House of God" (which amount to 13 by the end of the book). One of his teachings is that in the House of God, most of the diagnostic procedures, treatments, and medications received by the patients known as "gomers" (see Glossary, below) actually harm these patients instead of helping them. Basch becomes convinced of the accuracy of the Fat Man's advice and begins to follow it. Because he follows the Fat Man's advice and does nothing to the gomers, they remain in good health. Therefore, his team is recognized as one of the best in the hospital, and he is recognized as an excellent intern by everyone, even though he is breaking the rules.
Later, the Fat Man must leave for a rotation with another team. Roy is then supervised by a more conventional resident named Jo, who, unlike the Fat Man, follows the rules, but unknowingly hurts the gomers by doing so. Basch survives the rotation with Jo by claiming to perform numerous tests and treatments on the gomers while in reality he does nothing. These patients again do well, and Basch's reputation as an excellent intern is maintained.
The book also details the great amount of hard, distasteful work the interns must perform, the sometimes poor working conditions, their lack of sleep, their lack of time to spend with friends and family, and the emotional demands of the work.
During the course of the novel, working in the hospital takes a psychological toll on Basch. His personality and outlook change, and he has outbursts of temper. He has adulterous trysts with various nurses (portrayed in great detail) and social service workers (nicknamed the "Sociable Cervix") and his relationship with his girlfriend Berry suffers. A colleague, Wayne Potts, who had been constantly badgered by the upper hierarchy and haunted by a patient (nicknamed "The Yellow Man" for his fulminant necrotic hepatitis, who goes comatose and eventually dies possibly because Potts had not put him on steroids), commits suicide. Basch becomes more callous and he secretly euthanizes a patient, a man called Saul the leukemic tailor, whose illness had gone into remission but was back in the hospital in incredible pain and begging for death. Basch becomes more and more emotionally unstable, until finally his friends force him to attend a mime performance by Marcel Marceau, where he has an experience of catharsis and recovers his emotional stability.
By the end of the book, it turns out that the psychiatry resident, Cohen, has managed to inspire almost the whole year's group of interns and two well-spoken policemen, Gilheeney and Quick, to pursue a career in psychiatry, and that the terrible year has convinced most of the interns to receive psychiatric help. The book ends with Basch and Berry vacationing in France before he begins his psychiatry residency, which is how the book begins as well, because the whole book is a flashback. But even while vacationing, bad memories of the House of God haunt Basch. He is convinced that he could not have gotten through the year without Berry, and he asks her to marry him.
Laws of the House of GodEdit
- GOMERS don't die.
- GOMERS go to ground
- At a cardiac arrest, the first procedure is to take your own pulse.
- The patient is the one with the disease.
- Placement comes first.
- There is no body cavity that cannot be reached with a #14G needle and a good strong arm.
- Age + BUN = Lasix dose.
- They can always hurt you more.
- The only good admission is a dead admission.
- If you don't take a temperature, you can't find a fever.
- Show me a BMS (Best Medical Student, a student at The Best Medical School) who only triples my work and I will kiss his feet.
- If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.
- The delivery of good medical care is to do as much nothing as possible.
Shem added four more "Laws" in his reflection of The House of God 34 years later.
- Connection comes first.
- Learn empathy.
- Speak up.
- Learn your trade, in the world.
Context and impactEdit
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The book is very likely autobiographical, as the BMS is a thinly veiled Harvard Medical School (commonly called HMS), and The House of God representing the Beth Israel Hospital, now a part of Beth Israel Deaconess Medical Center, one of the HMS-affiliated hospitals in Boston, Massachusetts; "Man's Best Hospital" (MBH) represents Massachusetts General Hospital (MGH). There are also references to a community hospital called Mt. St. Elsewhere or Mt. St. E.'s, which likely represents Boston City Hospital, St. Elizabeth's Medical Center or Mount Auburn Hospital (Cambridge) which was part of the Harvard Medical School teaching hospital system.
Some American doctors felt that The House of God resonated with their own experiences during their internship training. However, according to the author, many older physicians were offended by the work.
Many of the terms defined in this book (see glossary) have since become widely known and used in medical culture. It is difficult to say which came first, the book or the terms, but terms such as 'bounce' back and 'turf' are now in standard medical usage. Similarly, many of the concepts central to the book are now well accepted medical truisms. For example, since the 1970s "falls risks" has become a standard assessment for all patients and the notion that "gomers go to ground" is well established, if not always phrased in those terms. It has been argued that 'The House of God' was revolutionary in that it brought to light paradoxical issues of care in modern medicine. Patients (in the book under Putzel) who were not acutely ill could nevertheless be admitted to the hospital and undergo multiple invasive procedures, creating a revenue stream for the hospital but exposing the patient to risk and discomfort, and demoralizing the residents. Reimbursement rules have been changed to prohibit this under value based purchasing (see Pay for performance (healthcare)). Others propose that the book was the impetus for limiting medical resident work hours. JAMA (the Journal of the American Medical Association) has a distinct collection of hundreds of articles titled "Less Is More" that discuss multiple areas of medicine where standard interventions seem to hurt patients. The Fat Man's last law "THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE." is supported.
Several of the terms common to the jargon of junior hospital staff were widely popularized by the book:
- To turf (verb: to find any excuse to refer a patient to a different department or team)
- To bounce (verb: a turf that has returned to its first department)
- Gomer (noun (acronym)): "get out of my emergency room" – a patient who is frequently admitted with complicated but uninspiring and incurable conditions)
- LOL in NAD (noun: "little old lady in no apparent distress" – an elderly patient who following a minor fall or illness, would be better served by staying at home with good social support, rather than being admitted into a hospital with all the iatrogenic risks of modern medicine. Compare "NAD" = "no abnormality detected" or "no apparent distress" (used to record the absence of abnormal signs on examination).
- Zebra (noun: a very unlikely diagnosis where a more common disease would be more likely to cause a patient's symptoms – from the common admonition that "if you hear hoof beats, think horses, not zebras").
- Buff the charts (verb: to make a patient look well treated in the charts or medical records, without actually receiving any treatment.)
In-jokes abound in the work. One of the principal characters is Eat My Dust Eddie, a doctor so-called because of the saying embroidered on his jacket. His name often is abbreviated as EMD, which is also the acronym of the feared, often terminal, cardiac event electromechanical dissociation, otherwise known as pulseless electrical activity.
In 1984, a film was made out of the book but never released in theaters or on VHS/DVD. The film was shown on HBO a few times, mostly as filler in non-peak hours. It starred Charles Haid as The Fat Man, Tim Matheson as Roy, and with Bess Armstrong, Ossie Davis, Sandra Bernhard, and Michael Richards in supporting roles.
The TV medical sitcom-drama Scrubs features numerous references to The House of God, which was reading material for some of the show's writers.. "Turfing", "Bouncing" and "Gomers" occasionally feature in the show's dialogue. In the episode "My Balancing Act", Dr. Cox quotes the Zebra rule ("Newbie, do you happen to know what a zebra is? It's a diagnosis of a ridiculously obscure disease when it's much more likely that the patient has a common illness presenting with uncommon symptoms. In other words, if you hear hoof-beats, you just go ahead and think horsies -- not zebras.") And in the episode "My Student", J.D. quotes the medical student rule, "A famous doctor once said, 'Show me a med student that only triples my work, and I'll kiss his feet.'" One episode focuses on Dr. Dorian saving a patient by "doing nothing," which is a major theme of the novel.
- Markel, Howard (August 18, 2009). "A Book Doctors Can't Close". New York Times.
- Samuel Shem (2012-11-28). "Samuel Shem, 34 Years After 'The House of God' - Samuel Shem". The Atlantic. Retrieved 2013-09-21.
- Wear D. The House of God : another look. Academic Medicine [serial online]. June 2002;77(6):496-501.
- Brody H. The house of god-is it pertinent 30 years later?. The Virtual Mentor: VM [serial online]. July 1, 2011;13(7):499-502.
- Lagu, Tara (2015-03-01). ""Less is more" and the house of god: was the fat man right again?". JAMA Internal Medicine. 175 (3): 459–460. doi:10.1001/jamainternmed.2014.8116. ISSN 2168-6114. PMID 25730562.
- The Fat Man's Laws of the House of God
- Film review at the NYU Literature, Arts, and Medicine Database site
- The House of God on IMDb
- Rob Reid Hood (10 October 1996). "The House of God - 15th anniversary review". New England Journal of Medicine. 335 (15): 1165–1166. doi:10.1056/NEJM199610103351521.
- 30th anniversary review by Kit Boyes in the NZMSJ
- Winter R, Birnberg B (2004). "The clan of the cave bear meets The house of God" (PDF). Fam Med. 36 (2): 95–7. PMID 14872355.