The House of God

The House of God
First edition
AuthorSamuel Shem
CountryUnited States
LanguageEnglish
GenreSatirical novel
PublisherRichard Marek Publishers
Publication date
August 1978
Media typePrint (Hardback & Paperback)
Pages429
ISBN0-440-13368-8
OCLC7423035
Preceded byNone 
Followed byMount Misery 

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 etched its place into the evolving discussion of humanism, ethics, and training in medicine.[1]

Storyline

Dr. Roy Basch is an intelligent but naive, former Rhodes Scholar and BMS ("Best Medical School")-educated intern ('tern') working in a hospital called the House of God after completing his medical studies at BMS. Basch 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 follows the rules, unlike the Fat Man. However, she 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 commits suicide. Potts had been constantly badgered by the upper hierarchy and haunted by a patient — nicknamed "The Yellow Man" (due to the jaundice from his fulminant necrotic hepatitis) — who goes comatose and eventually (after months) dies possibly because Potts had not put him on steroids. 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.

Characters

Staff
Interns and residents
  • Dr. Roy Basch, the protagonist and one of the first-year residents (interns)
  • Dr. Fishberg ("The Fish"), the Chief Resident; keen on a GI fellowship
  • Jo, a high-achieving, by-the-book, gunner-esque resident; keen on a cardiology fellowship
  • "Fats" ("The Fatman"), an unconventional but effective second-year resident; keen on a GI fellowship
  • Dr. Chuck Johnston, a black first-year resident (intern) from Chicago; Roy's best friend
  • Dr. Jeff Cohen, the psychiatry resident
  • "Eat My Dust" Eddie, a first-year resident (intern) fixated on winning the Black Crow Award (awarded for most consents for postmortems/postmortems); keen on Oncology
  • Elihu, "a tall beak-nosed Sephardic Jew with a frizzy Isro-Afro, rumored to be the worst surgical intern in the history of the House"
  • Harry, another first-year resident (intern) fixated on winning the Black Crow Award (awarded for most consents for postmortems/postmortems)
  • "Hyper Hooper", a first-year resident who wins the Black Crow Award; (facetiously) "dreaming California Fellowship, in "Thanatology"
  • Dr. Howard Runtsky (Runt), a first-year resident (intern) who takes Valium for his nerves; a friend of Roy, having been a classmate of his at BMS; a "short, stocky product of two red-hot psychoanalysts"; has sex with one of the nurses and breaks out of his shell; "[goes] west for a "classic Eastern" psychiatric training program on the "mountain campus" of the U. of Wyoming"
  • Dr. Wayne Potts, a first-year resident (intern) from Charleston, South Carolina, who is insecure and uncertain; married to a MBH surgical intern; "a Southerner whom I [Roy]'d known at BMS, a nice guy but depressed, repressed, and kind of compressed, dressed in crisp white, pockets bulging with instruments"
Other doctors
  • Dr. Leggo, the Chief of Medicine who is out-of-touch and also believes in doing everything to "save" patients
  • Dr. Gath, a surgeon
  • Dr. Otto Kreinberg, one of the attendings
  • Dr. Pinkus, a "tall, emaciated-looking staff cardiologist, heading toward forty"
  • Dr. Putzel, a private doctor who has admitting rights
  • "Grenade Room" Dubler, a former intern/resident
Other staff
  • Sergeant Finton Gilheeny, a "huge, barrel-shaped" police officer, with "red hair growing out of and into most of the slitty features on his fat red face"
  • Officer Quick, a police officer who looks like a "matchstick, decked out, facially, in white of skin and black of hair, with vigilant eyes and a large and worrisome mouth filled with many disparate teeth"
  • Angel, one of the Medical ICU (MICU) nurses, "buxom, Irish, with wraparound muscular thighs and a creamy complexion"
  • Hazel, the head housekeeper; engages in a sexual relationship with Chuck
  • Molly, one of the nurses; engages in a sexual relationship with Roy, who "called the feeling of making love the feeling of having a centipede walk through wearing gold cleats"
  • Rosalie Cohen, one of the junior social workers; engages in a sexual relationship with Runt
  • Selma, the head social worker; engages in a sexual relationship with Roy
  • Lionel, one of the HELP, a "guy in the Blue Blazer", who "help[s] with anything"
Patients
  • Dr. Sanders, the first "Negro" doctor who interned with Dr. Leggo; diagnosed and dies from leukemia
  • Anna O., a 'gomere' who cries 'ROODLE ROODLE'
  • George Donowitz, a private patient
  • Ina Goober, a former New Masada resident who cries 'Go avay'
  • Mr. Itzak Rokitansky, a former college professor who had suffered a stroke; visited daily by his sisters; cries 'PURRTY GUD'
  • Rose Katz, a LOL in NAD
Other
  • Berry, Roy's girlfriend
  • Levy, a BMS student

Laws of the House of God

The Fat Man's laws
  1. GOMERS don't die.
  2. GOMERS go to ground.
  3. At a cardiac arrest, the first procedure is to take your own pulse.
  4. The patient is the one with the disease.
  5. Placement comes first.
  6. There is no body cavity that cannot be reached with a #14G needle and a good strong arm.
  7. Age + BUN = Lasix dose.
  8. They can always hurt you more.
Roy Basch's further laws
  1. The only good admission is a dead admission.
  2. If you don't take a temperature, you can't find a fever.
  3. 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.
  4. If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.
  5. The delivery of good medical care is to do as much nothing as possible.

Later "Laws"

Shem added four more "Laws" in his reflection on The House of God 34 years later.[2]

  1. Connection comes first.
  2. Learn empathy.
  3. Speak up.
  4. Learn your trade, in the world.

Context and impact

The book takes place during the Watergate scandal, and follows such events as the resignation of Spiro T. Agnew and Richard Nixon.

A 2019 short essay by Shem [3] and accompanying online documentary [4] document the origins of the book and the characters it is based on. The story is 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.[2]

Many of the terms defined in this book (see glossary) have since become widely known and used in medical culture.[1] 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.[5] Reimbursement rules have been changed to prohibit this under value based purchasing (see Pay for performance (healthcare)). 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.[6] The Fat Man's last law "The delivery of good medical care is to do as much nothing as possible" is supported.[6] Others propose that the book was the impetus for limiting medical resident work hours.[7]

Glossary

Several of the terms common to the jargon of junior hospital staff were widely popularized by the book:

Nouns

  • Gomer: an acronym meaning "get out of my emergency room" – a patient who is frequently admitted with complicated but uninspiring and incurable conditions
  • LOL in NAD: "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: 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"

Verbs

  • To buff the charts: to make a patient look well treated in the charts or medical records, without actually receiving any treatment
  • To turf: to find any excuse to refer a patient to a different department or team
  • To bounce: to return a turfed patient to its first department

Cultural references

References to life

In-jokes abound in the work. One of the principal characters is "Eat My Dust" Eddie, a doctor so-called because of the saying wiktionary: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" (EMD), otherwise known as pulseless electrical activity (PEA).

References by other works

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.[8][9]

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.

Sequel

Shem has published two sequels to The House of God: Mount Misery and Man's 4th Best Hospital.[10]

Notes

  1. 1 2 Markel, Howard (August 18, 2009). "A Book Doctors Can't Close". New York Times.
  2. 1 2 Samuel Shem (2012-11-28). "Samuel Shem, 34 Years After 'The House of God' - Samuel Shem". The Atlantic. Retrieved 2013-09-21.
  3. ↑ Bergman, Stephen (July 10, 2019). "Basch Unbound—The House of God and Fiction as Resistance at 40". JAMA. 322 (6): 486–487. doi:10.1001/jama.2019.9499. PMID 31290947. Retrieved July 11, 2019.
  4. ↑ JAMA Network. "The House of God". YouTube. JAMA Network. Archived from the original on 2021-12-22. Retrieved 11 July 2019.
  5. ↑ Wear D. The House of God : another look. Academic Medicine [serial online]. June 2002;77(6):496-501.
  6. 1 2 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.
  7. ↑ 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.
  8. ↑ "The House of God".
  9. ↑ "The House of God (1984) - IMDb".
  10. ↑ Shem, Samuel (2019). "Man's 4th Best Hospital". JAMA. 322 (18): 1746–1750. doi:10.1001/jama.2019.16384. PMID 31613307. Retrieved 20 April 2020.

Bibliography

  • Shem, Samuel (August 30, 1978). The House of God (1st ed.). Richard Marek Publishers. ISBN 978-0399900235.
  • Shem, Samuel (February 18, 1997). Mount Misery (1st ed.). Fawcett. ISBN 978-0449911181.
  • Shem, Samuel (November 12, 2019). Man's 4th Best Hospital. JAMA. Vol. 322. Berkley. pp. 1746–1750. doi:10.1001/jama.2019.16384. ISBN 978-1984805362. PMID 31613307.
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