November 10, 2016
I’m not a big fan of war movies. I liked the first few I watched. It was all downhill from there. They all seem so similar. The Part Where You Bond With Your Squadmates. The Part Where Your Gruff Sergeant Turns Out To Have A Heart After All. The Part Where Your Friend Dies But You Have To Keep Going Anyway. The Part That Consists Of A Stirring Speech.
The problem is that war is very different from everything else, but very much like itself.
Medical internship is also very different from everything else but very much like itself. I already had two examples of it: Scrubs and my own experience as a medical intern (I preferred Scrubs). So when every single person in the medical field told me to read Samuel Shem’s House of God, I deferred. I deferred throughout my own internship, I deferred for another two years of residency afterwards. And then for some reason I finally picked it up a couple of days ago.
This was a heck of a book.
On some level it was as predictable as I expected. It hit all of the Important Internship Tropes, like The Part Where Your Attendings Are Cruel, The Part Where Your Patient Dies Because Of Something You Did, The Part Where You Get Camaraderie With Other Interns, The Part Where You First Realize You Are Actually Slightly Competent At Like One Thing And It Is The Best Feeling In The Universe, The Part Where You Realize How Pointless 99% Of The Medical System Is, The Part Where You Have Sex With Hot Nurses, et cetera.
All I can say is that it was really well done. The whole thing had a touch of magical realism, which turns out to be exactly the right genre for a story about medicine. Real medicine is absolutely magical realist. It’s a series of bizarre occurrences just on the edge of plausibility happening to incredibly strange people for life-and-death stakes, day after day after day, all within the context of the weirdest and most byzantine bureaucracy known to humankind.
Just in the past week, for example, I had to deal with an aboulomaniac patient – one with a pathological inability to make up his mind. He came to my clinic for treatment, but as soon as he saw me, he decided he didn’t want treatment after all and left. The next day, he was back on my calendar – he’d decided he needed treatment after all – but when his appointment came around, he chanegd his mind and left again. This happened five times in five days. Every day he would phone in asking for an appointment. Every day I would give it to him. Every day he would leave a minute or two before it began. Unsure how to proceed, I sought out my attending. He ignored my questions, pulled me into a side office, took out his cell phone, and started playing me a video. It’s a scene from his musical, The Phantom Of The Psychiatric Unit, which he’s been forcing his interns to rehearse after rounds. I watched, horrified. It was weirdly good.
If I were to write a book about this kind of thing, people would criticize me for being unrealistic. The only way to get away with it is to pass it off as “a touch of magical realism”, and this The House of God does to excellent effect.
The story revolves around an obvious author-insert character, Roy Basch MD, who starts his internship year at a hospital called the House of God (apparently a fictionalized version of Beth Israel Hospital in Boston). He goes in with expectations to provide useful medical care to people with serious diseases. Instead, he finds gomers:
“Gomer is an acronym: Get Out of My Emergency Room. It’s what you want to say when one’s sent in from the nursing home at three A.M.”
“I think that’s kind of crass,” said Potts. “Some of us don’t feel that way about old people.”
“You think I don’t have a grandmother?” asked Fats indignantly. “I do, and she’s the cutest dearest, most wonderful old lady. Her matzoh balls float – you have to pin them down to eat them up. Under their force the soup levitates. We eat on ladders, scraping the food off the ceiling. I love…” The Fat Man had to stop, and dabbed the tears from his eyes, and then went on in a soft voice, “I love her very much.”
I thought of my grandfather. I loved him too.
“But gomers are not just dear old people,” said Fats. “Gomers are human beings who have lost what goes into being human beings. They want to die, and we will not let them. We’re cruel to the gomers, by saving them, and they’re cruel to us, by fighting tooth and nail against our trying to save them. They hurt us, we hurt them.”
This is where the magical realism starts to come in:
Rokitansky was an old bassett. He’d been a college professor and had suffered a severe stroke. He lay on his bed, strapped down, IV’s going in, catheter coming out. Motionless, paralyzed, eyes closed, breathing comfortably, perhaps dreaming of a bone, or a boy, or of a boy throwing a bone.
“Mr. Rokitansky, how are you doing?” I asked.
Without opening his eyes, after fifteen seconds, in a husky slurred growl from deep down in his smushed brain he said: PURRTY GUD.
Pleased, I asked, “Mr. Rokitansky, what date is it today?”
To all my questions, his answer was always the same. I felt sad. A professor, now a vegetable. Again I thought of my grandfather, and got a lump in my throat. Turning to Fats, I said, “This is too sad. He’s going to die.”
“No, he’s not,” said Fats. “He wants to, but he won’t.”
“He can’t go on like this.”
“Sure he can. Listen, Basch, there are a number of LAWS OF THE HOUSE OF GOD. LAW NUMBER ONE: GOMERS DON’T DIE.”
“That’s ridiculous. Of course they die.”
“I’ve never seen it, in a whole year here,” said Fats.
“They have to.”
“They don’t. They go on and on. Young people – like you and me – die, but not the gomers. Never seen it. Not once.”
“I don’t know. Nobody knows. It’s amazing. Maybe they get past it. It’s pitiful. The worst.”
Potts came in, looking puzzled and concerned. He wanted the Fat Man’s help with Ina Goober. They left, and I turned back to Rokitansky. In the dim half-light I thought I saw tears trickling down the old man’s cheeks. Shame swept over me. My stomach churned. Had he heard what we’d said?
“Mr. Rokitansky, are you crying?” I asked, and I waited, as the long seconds ticked away, my guilt moaning inside me.
“But did you hear what we said about gomers?”
Someone once said that the point of art is to be more real than reality. The House Of God is way more real than reality. Reality wishes it could be anywhere close to as real as The House of God. This is a world where young people – the kid just out of school, the blushing new mother – die. Even normal old people – your grandmother, your grandpa – can die. But the most decrepit, demented people, the ones for whom every moment of artificially-prolonged life is a gratuitous misery and you pray at every moment that God will just let them find some peace – somehow they never die. They come into the hospital, they go back out to nursing homes, a few weeks later they’re back in the hospital, a few weeks later they’re back in their nursing homes, but they never die. This can’t be literally true. But it’s the subjective truth of working in a hospital. The Fat Man is right. I’ve been working in medicine for three years now, and I have seen my share of young people tragically cut off in the prime of life, and yet as far as I can remember I have never seen a gomer die. The magical realism of House of God describes the reality of medical professionals infinitely better than the rational world of hospital mortality statistics.
In the world of The House of God, the primary form of medical treatment is the TURF – the excuse to get a patient out of your care and on to somebody else’s. If the psychiatrist can’t stand a certain patient any longer, she finds some trivial abnormality in their bloodwork and TURFs to the medical floor. But she knows that if the medical doctor doesn’t want one of his patients, then he can interpret a trivial patient comment like “Being sick is so depressing” as suicidal ideation and TURF to psychiatry. At 3 AM on a Friday night, every patient is terrible, the urge to TURF is overwhelming, and a hospital starts to seem like a giant wheel uncoupled from the rest of the world, Psychiatry TURFING to Medicine TURFING to Surgery TURFING to Neurosurgery TURFING to Neurology TURFING back to Psychiatry again. Surely some treatment must get done somewhere? But where? It becomes a legend, The Place Where Treatment Happens, hidden in some far-off hospital wing accessible only to the pure-hearted. This sort of Kafkaesque picture is how medical care feels, and the genius of The House of God is that it accentuates the reality just a little bit until its fictional world is almost as magical-realist as the real one.
In the world of The House of God, medical intervention can only make patients worse:
Anna O. had started out on Jo’s service in perfect electrolyte balance, with each organ system working as perfectly as an 1878 model could. This, to my mind, included the brain, for wasn’t dementia a fail-safe and soothing oblivion of the machine to its own decay?
From being on the verge of a TURF back to the Hebrew House for the Incurables, as Anna knocked around the House of God in the steaming weeks of August, getting a skull film here and an LP there, she got worse, much worse. Given the stress of the dementia work-up, every organ system crumpled: in a domino progression the injection of radioactive dye for her brain scan shut down her kidneys, and the dye study of her kidneys overloaded her heart, and the medication for her heart made her vomit, which altered her electrolyte balance in a life-threatening way, which increased her dementia and shut down her bowel, which made her eligible for the bowel run, the cleanout for which dehydrated her and really shut down her tormented kidneys, which led to infection, the need for dialysis, and big-time complications of these big-time diseases. She and I both became exhausted, and she became very sick. Like the Yellow Man, she went through a phase of convulsing like a hooked tuna, and then went through a phase that was even more awesome, lying in bed deathly still, perhaps dying. I felt sad, for by this time, I liked her. I didn’t know what to do. I began to spend a good deal of time sitting with Anna, thinking.
The Fat Man was on call with me every third night as backup resident, and one night, searching for me to go to the ten o’clock meal, he found me with Anna, watching her trying to die.
“What the hell are you doing?” he asked.
I told him.
“Anna was on her way back to the Hebrew House, what happened – wait, don’t tell me. Jo decided to go all-out on her dementia, right?”
“Right. She looks like she’s going to die.”
“The only way she’ll die is if you murder her by doing what Jo says.”
“Yeah, but how can I do otherwise, with Jo breathing down my neck?”
“Easy. Do nothing with Anna, and hide it from Jo.”
“Hide it from Jo?”
“Sure. Continue the work-up in purely imaginary terms, buff the chart with the imaginary results of the imaginary tests, Anna will recover to her demented state, the work-up will show no treatable cause for it, and everybody’s happy. Nothing to it.”
“I’m not sure it’s ethical.”
“Is it ethical to murder this sweet gomer with your work-up?”
There was nothing I could say.”
After learning these medical secrets, Dr. Basch uses hook and crook to prevent his patients from getting any treatment. They end up healthier than anyone else in the hospital, and Basch becomes a contender for “Most Valuable Intern” – in typical House of God style, nobody knows if this award really exists or is just a rumor. His colleagues compete for another award, the “Black Crow”, which goes to the intern who gets the most autopsy consents from grieving families – and which the administration doesn’t realize incentivizes doctors to kill their patients. This is so reminiscent of the bizarre incentive systems in real hospitals that it hurts.
But as the year goes on, everyone gets more and more frazzled. One intern has a mental breakdown. Another commits suicide by jumping out of a hospital window (this isn’t dramatic exaggeration by the way; three junior doctors have committed suicide by jumping out of windows in the past three years in New York City alone). Dr. Basch runs through all sorts of interesting forms of neurosis. Finally, the end of the year approaches, the original crop of interns thinned-out but triumphant – and then they realize they have to do the whole thing again next year as residents, which is maybe a little less grueling but still in the same ballpark.
So they decide, en masse, to go into psychiatry, well-known to be a rare non-terrible residency. The author of House of God is a psychiatrist, so I guess this is only a spoiler insofar as you aren’t logically omniscient. When the Chief of Medicine learns that every single one of his hospital’s interns are going into psychiatry and there aren’t going to be any non-psychiatry residents in the whole hospital…
…okay, fine, I won’t spoil the ending. But suffice it to say I’m feeling pretty good about my career path right now.
House of God does a weird form of figure-ground inversion.
An example of what I mean, taken from politics: some people think of government as another name for the things we do together, like providing food to the hungry, or ensuring that old people have the health care they need. These people know that some politicians are corrupt, and sometimes the money actually goes to whoever’s best at demanding pork, and the regulations sometimes favor whichever giant corporation has the best lobbyists. But this is viewed as a weird disease of the body politic, something that can be abstracted away as noise in the system.
And then there are other people who think of government as a giant pork-distribution system, where obviously representatives and bureaucrats, incentivized in every way to support the forces that provide them with campaign funding and personal prestige, will take those incentives. Obviously they’ll use the government to crush their enemies. Sometimes this system also involves the hungry getting food and the elderly getting medical care, as an epiphenomenon of its pork-distribution role, but this isn’t particularly important and can be abstracted away as noise.
I think I can go back and forth between these two models when I need to, but it’s a weird switch of perspective, where the parts you view as noise in one model resolve into the essence of the other and vice versa.
And House of God does this to medicine.
Doctors use certain assumptions, like:
But in House of God, the assumptions get inverted:
Everybody knows that those first three assumptions aren’t always true. Yes, sometimes we prolong life in contravention of patients’ wishes. Sometimes people mistakenly receive unnecessary treatment that causes complications. And sometimes care suffers because of doctors’ scheduling issues. But it’s easy to abstract away to an ideal medicine based on benevolence and reason, and then view everything else as rare and unfortunate deviations from the norm. House of God goes the whole way and does a full figure-ground inversion. The outliers become the norm; good care becomes the rare deviation. What’s horrifying is how convincing it is. Real medicine looks at least as much like the bizarro-world of House of God as it does the world of the popular imagination where doctors are always wise, diagnoses always correct, and patients always grateful.
There have been a couple of studies finding that giving people health insurance doesn’t make them any healthier – see for example the RAND Health Insurance Experiment and the Oregon Medicaid Experiment. I’ve always been skeptical of these studies, because it seems logical that people who can afford health care will get more of it, and there are ten zillion studies showing various forms of health care to help. Insulin helps diabetes. Antibiotics help sepsis. Surgery helps appendicitis. To deny claims like these would be madness, yet the studies don’t lie. What is going on?
And the answer has to be somewhere in the bizarro-world of House of God. Real medical treatment looks precious little like the House MD model of rare serious disease → diagnosis → cure. At least as often, it’s like the House of God model where someone becomes inconvenient → send to hospital → one million unnecessary tests. Everyone agrees this is part of the story. House of God is a brilliant book in that it refactors perception to place it in the foreground.
But it’s brilliant because in the end it’s not just a romp through hilarious bureaucratic mishaps. There is as much genuine human goodness and compassion in this book as there is in any rousing speech by a medical school dean. The goodness is often mixed with horror – the doctor who has to fight off hordes of autopsy-consent-form-seekers to let a dying patient spend his last few seconds in peace, or the one who secretly slips euthanasia to a terminal patient begging for an end to the pain because he knows it’s the right thing to do.
The question posed here is “what do you do in a crazy cannibalistic system where it’s impossible to do good work and everyone is dying all around you?”, and the answer is “try as hard as you can to preserve whatever virtue you can, and to remain compassionate and human”. The protagonist swings wildly between “this is all bullshit and I’ll just make fun of these disgusting old people and call it a day” and “I need to save everybody and if I don’t I should hate myself forever”, and eventually like everybody, comes to some kind of synthesis where he recognizes he’s human, recognizes that his patients are human, and tries to deal with it with whatever humor and grace he can manage.
It’s hard enough for a book to be funny, and it’s hard enough for one to be deep, but a book like House of God that can be both at once within the space of a few sentences is an absolute treasure.
I talked to my father about House of God, and I told him a few parts that seemed unrealistic. He told me that those parts were 100% true in 1978 when the book was written. I looked into it more, and ended up appreciating the work on a whole new level. Uncle Tom’s Cabin is credited with kickstarting the emancipationist movement and maybe even causing the Civil War. The Jungle is famous for launching a whole new era of safety regulations. House of God has a place beside them in the pantheon of books that have changed the world.
The book’s “Second Law” is “GOMER GOES TO GROUND”: demented old people will inevitably fall out of their hospital bed and injure themselves. The book has a whole funny/horrifying scene where the senior resident explains his strategy for this eventuality: He leaves their beds low enough that patients won’t kill themselves when they fall, but high enough that they’ll probably break a bone or two and have to go to orthopaedic surgery – which takes them off his hands. Later, a medical student apes this procedure, a patient falls and breaks a bone or two, and everyone freaks out and tells him that it was a joke, that of course you don’t really arrange skeletal fractures for old people just to save yourself time, what kind of heartless moron could think such a thing? This is some nth-level meta-humor: the reader probably mistook it for real advice because it meshes so seamlessly with all of the other madness and horror, yet most of the other madness and horror in the book is easily recognizable by practicing doctors as a real part of the medical system. Actually, on the n+1st meta-level, I’m not at all sure that the resident wasn’t meant to be completely serious and then backtracked and called it a joke when it went wrong. For that matter, I’m far from sure this wasn’t a real medical practice in the 1970s.
I see enough falls that I wasn’t surprised to see them as a theme, but I thought the book exaggerated their omnipresence. My father said it didn’t – there were just far more falls back in the Old Days. Now hospitals are safer and falls are comparatively rare. Why? Because the government passed a law saying that insurance wouldn’t pay hospitals extra money for the extra days patients have to stay due to fall-related injuries. I am so serious about this. This, I think, is the n+2nd meta-level; amidst all its jokes-played-straight the book treats encouraging falls as an actual in-universe joke, and yet in the real world once hospitals were no longer incentivized to let patients fall the falls stopped.
How did people become aware of this kind of thing? How did the movement against it start? A lot of it seems to be because of House of God. Everyone in medicine knew about this sort of thing. But House of God made it common knowledge.
People were scared to speak up. Everyone thought that maybe they were just a uniquely bad person, or their hospital a uniquely bad institution. Anyone who raised some of these points was met with scorn by prestigious doctors who said that maybe they just weren’t cut out for medicine. House of God shaped medicine because it was the first thing to say what everybody was experiencing. Its terms like “gomer” and “turf” made it into the medical lexicon because they pointed to obvious features of reality nobody had the guts to talk about before.
Shem writes an afterword where he talks about the reaction to the book. Junior doctors and the public loved it. Senior doctors hated it. He tells the story of going to a medical conference. Someone asked who he was, and he said jokingly “I’m the most hated doctor here”. His interlocutor answered “Oh, don’t worry, I’m sure you’re not as bad as the guy who wrote that House of God book.”
But House of God gets credit for helping start movements to cut intern work hours, protect doctors from sleep deprivation, reduce patient falls, and teach empathy and communication skills. The moral of the story is: the courage to tell the truth is rare and powerful. More specifically: the courage to tell the truth is rare and powerful not just in Stalinist dictatorships and violent cults, but in apparently normal parts of everyday First World life. All of these differently loaded terms like “culture of silence” and “political correctness” point at a fear of rocking various boats with nothing but your imperfect first-person knowledge to go on. But a tiny crack in the wall can make a big difference.
In a closing scene, Dr. Basch and all of his fellow interns – interns who had broken into tears weekly, gotten burnt out, starting seeing psychiatrists, considered suicide, all this stuff, these interns who had smashed up against the unendurable horrors of medicine and held themselves together only by the promise that it would soon be over – the minute they graduate internship they change their tune:
It looked like all but two or three [interns] would stay. The Runt and I were definitely leaving; Chuck hadn’t yet said. The others were staying. In years to come they would spread out across America into academic centers and Fellowships, real red-hots in internal medicine, for they had been trained at the Best Medical School’s best House, the House of God. Although a few might kill themselves or get addicted or go crazy, by and large they’d repress and conform and perpetuate the Leggo [the Chief of Medicine] and the House and all the best medical stuff. [Eddie] had been praised by the Leggo that he could start off the second year as ward resident, with “a free rein” on his interns. And so, saying already that the internship been “not so bad,” he was preparing to indoctrinate his new charges: “I want them on their knees from day one.”
Shem’s author mouthpiece character Berry says:
It’s been inhuman. No wonder doctors are so distant in the face of the most poignant human dramas. The tragedy isn’t the crassness, but the lack of depth. Most people have some human reaction to their daily work, but doctors don’t. It’s an incredible paradox that being a doctor is so degrading and yet is so valued by society. In any community, the most respected group are doctors. [It’s] a terrific repression that makes doctors really believe that they are omnipotent healers. If you hear yourselves saying, ‘Well, this year wasn’t really that bad,’ you’re repressing, to put the next group through it. [But] it’s hard to say no. If you’re programmed from age six to be a doctor, invest years in it, develop your repressive skills so that you can’t even recall how miserable you were during internship, you can’t stop.
Shem’s thesis is that it isn’t just about not wanting to make waves or offend the Chief of Medicine. It’s about denying your own pain by identifying with the system.
This puts me in a weird spot. My internship (I find myself saying) wasn’t so bad. I can give you some arguments why this might be true – things have gotten a lot better since The House of God was published (with no small credit to Shem himself), a small community hospital in Michigan is less intense than Harvard Medical School’s training hospital, psychiatry interns sometimes have it easier than internal medicine interns since everyone knows this isn’t a permanent deal for them.
And yet I distinctly remember one night a long time ago, coming home from high school. I had noticed that all of the adults around me said high school was some of the best years of their lives and I would miss it when I was gone, and yet high school seemed objectively terrible. I wondered if there might be some bias or bizarre shift in memory that happened sometime in people’s twenties and gave them a localized amnesia or insanity. So I very distinctly recall telling myself “My current assessment is that high school is terrible, and if you ever find yourself remembering that high school was lovely, please be aware that your memories have been hijacked by some malevolent force.”
And God help me, but every single part of my brain is telling me that high school was lovely. I fondly remember all the friends I made, the crazy teachers I had to put up with, the science competitions I won, the lunches spent in the library reading whatever random stuff I could get my hands on. It seems like it was a blast. It’s hard for me to even trust that one memory as anything more than imagination or the product of a single bad day. But although high-school-me had a lot of issues, he generally had a decent head on his shoulders, and if he says my memories have been hijacked, then I grudgingly believe him.
So was my intern year a good learning experience? I have no idea and I’m not sure anyone else does either. It’s another type of figure-ground inversion: parade of horrors broken only by the occasional triumph, or clear sailing with a few bad moments?
On my last day of internship, one of my colleagues who was moving on said “I’m going to miss hating this place”. I’ve always remembered that phrase. Now I wonder if it’s some kind of weird snapshot of the exact moment of transition, the instant when “nightmarish ordeal” morphs into “halcyon days of youth”. This is why medicine has to be written as magical realism. How else to capture a world where people reliably go from agony to Stockholm Syndrome in the space of a day, and where the transition is so intermixed with the general weirdness that it doesn’t even merit special remark?
I found myself having more emotions reading House of God than I’ve had about anything in a long time. I don’t really know why. But I think it has something to do with this resignation to the general incommunicable weirdness all around anyone who works in medicine. Somehow Shem manages to avoid the normalization of insanity that happens to every young doctor, capture the exact subjective experience and write it down in a way that makes sense. And then, having put his finger right on the unbearable thing, he makes it funny and beautiful and poignant.
I tell her. Again I tell her about Dr. Sanders bleeding out in my lap, about the look in Potts’s eyes that night before he jumped, about my pushing the KCl into poor Saul. I tell her how ashamed I am for turning into a sarcastic bastard who calls the old ones gomers, how, during the ternship, I’d ridiculed them for their weaknesses, for throwing up their suffering in my face, for scaring me, for forcing me to do disgusting things to take care of them. I tell her how I want to live, compassionately, with the idea of death clearly in sight, and how I doubt I can do that, ever again. As I think back to what I’d gone through and what I’d become, sadness wells up and mixes with contempt. I put my head into Berry’s folds and weep, and curse, and shout, and weep.
“… and in your own way, you did. Someone had to care for the gomers; and this year, in your own way, you did.”
“The worst thing is this bitterness. I used to be different, gentle, even generous, didn’t I? I wasn’t always like this, was I?”
“I love who you are. To me, underneath it all, you’re still there:” She paused, and then, eyes sparkling, said, “And you might even be better.”
“What? What do you mean?”
“This might have been the only thing that could have awakened you. Your whole life has been a growing from the outside, mastering the challenges that others have set for you. Now, finally, you might just be growing from inside yourself.
He also frames all of it in the language of psychoanalysis, which is jarring and sounds preachy. I’ve ordered the sequel, Mount Misery, about his training as a psychoanalyst. Expect a review of that soon.