“The essence of any hierarchy is retaliation.”
—ROY BASCH, MD, intern, The House of God
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.”1,pp. 43–44
So begins the first day of Roy Basch's internship in medicine at The House of God, a year chronicled in Samuel Shem's controversial best-selling novel of the same title. First published in 1978, The House of God was given little fanfare, indeed, almost none. It had, according to its author, “the worst publishing history of any book ever published, I mean no ads, no reviews, no appearances. The New York Times was on strike so it didn't get reviewed there. It started to sell by word of mouth in hardcover and then all the books were destroyed by a flood in a warehouse in New Jersey. So there were no books. It had a terrible start.”2 Since then, it has sold over two million copies in almost 50 countries.
In addition to these less-than-ideal publishing conditions, over the years The House of God has suffered another kind of problem with recognition in professional spheres. Other than several book reviews, only two critical articles on the novel itself can be found. Kathryn Montgomery, writing in the premier journal in literature and medicine, called it “not a great book … [but] an important one.”3 Anne Hudson Jones read the book more generously, and in an article for The Lancet she placed it in the company of Sinclair Lewis' Arrowsmith as one of the two most important medical bildungsromans of the 20th century.4 Exhaustive searches of both medical and literary databases yielded very little: a series of letters in the New England Journal of Medicine in the 1980s, passing references to The House of God as a label denoting less than satisfactory conditions in academic medicine,5,6,7 and recommended reading lists about medical training.8 The Modern Language Association's database contains no entries on this publishing phenomenon, and no dissertations have analyzed its place as a cult classic for a whole generation of medical students and residents. Moreover, many of the abuses of power detailed in The House of God, now a quarter-century old, are still found in medical training (for example, problems with severe stress during residency9 and the ongoing investigation of the abuse of medical students10,11,12,13). Changes have been made in end-of-life care, but these were initiated by forces outside of academic medicine.
Still, contemporary medical vernacular is replete with words and phrases from the novel, which signals an expectation that readers will recognize and share meaning with those who use such terms. As of this writing, over 100 hits for The House of God appear on the Science Citation Index database; however, the articles merely cite the novel or a term associated with it to illustrate a point being made. References to the book are found in journals as varied as The Journal of Family Practice, Medical Care, Academic Emergency Medicine, Gerontology, British Journal of Oral & Maxillofacial Surgery, and Journal of General Internal Medicine, not to mention prestigious mainstream journals such as JAMA, New England Journal of Medicine (NEJM), and The Lancet. The authors of most of these articles do not review or rehash the merits of the novel, but use its title and the now familiar terms associated with it as shorthand for the grueling, dehumanizing nature of residents' education, hospital-based end-of-life practices, and the treatment of the elderly in general.
Since its publication, there have been frequent attempts to discredit the book's content and, often, the author himself. In The Boston Globe, one reviewer wrote that Shem's “black-humored depiction of the modern teaching hospital as a place where medical technology runs amok left many establishment figures sputtering. One colleague says [Shem] is even now ‘regarded almost as a nonperson’ at the Beth Israel, where he was once barred from speaking to residents.”14 Shem himself disclosed that he is occasionally canceled as a speaker.2 In an annotated bibliography of literature on American medicine published in the NEJM in 1981, Borgenicht included The House of God but was, nonetheless, unimpressed with the book. Shem, he wrote, “writes in a contemporary ‘hip’ style that freely spews medical slang in forced attempts at humor.”8 In a letter responding to Borgenicht's bibliography, one medical student critic wrote of the novel, “With adolescent humor, intellect, and maturity, the characters in The House of God verbally attacked, abused, and berated patients to the detriment, if not the demise, of the latter.”15 He admitted, however, that “this mental framework exists and usually goes unchallenged.”
Different responses to Borgenicht's bibliography appeared in the following months in the NEJM letter section. One physician claimed that readers who had negative reactions to The House of God “miss the book's meaning,” arguing that the insults, pejorative terms, and humor are only “incidental” to the larger message of the book: residency programs produce “demoralized” and “depressed” young doctors, and “just as we attempt to understand why our patients have pain, so we must diagnose and treat the malaise that leads young physicians to use epithets like ‘gomer’ and ‘crock.’”16 Similarly, after reading the book, one graduate of a residency program was
stopped entirely—not by disgust, but by my own pain …. Shem has done what few in American medicine have dared to do. That is to share an unpolished, unglorified, and amazingly unegotistical experience of that revered institution, the internship. He has revealed the depths of caring, pain, pathos, and tragedy felt by all of us who spend our indentured servitude to our profession in caring for patients who have been rejected by much of the medical system.16
A more recent response to the novel by three physicians looking back on their training noted how “paradoxical” it is that “hospitals espouse the virtues of empathic care while ignoring the needs of the individuals they train. It is little wonder that Shem's acerbic acronyms have been adopted uncritically whereas the humanity that underpins his work is overlooked.”17
As these words indicate, The House of God evoked and continues to evoke strong feelings in readers. Why? The novelist's use of satire is the first vantage point for understanding its continuing impact.
WHAT IS THE HOUSE OF GOD?
One key to understanding the contribution of the novel is understanding the underlying structure the novelist uses to create a connection between its characters and its readers. The House of God is a satirical novel: It is not an autobiography, nor is it polemical nonfiction. That said, it contains elements of all these genres, blurring the ever-disappearing line between so-called fact and fiction. In the literature, The House of God has been variously classified by reviewers and scholars as autobiography, satire, a medical bildungsroman, and a roman à clef. Montgomery claims that “to examine the novel objectively … is to discover a quite conventional satire. It shares with Gulliver's Travels and Catch 22 a pattern of descent and return.”3 The year protagonist Roy Basch describes, Montgomery argues, is a story of trial, fall, and redemption. In a satire the novelist twists the story, using a mode of discourse that takes a “polemical or critical outlook, or as the ridicule of a subject to illustrate its faults.”18
Shem establishes the foundation of his satire on the story of Roy Basch's internship year at a prestigious teaching hospital in Boston, The House of God, which is attached to the country's best medical school (BMS). Roy is patterned after the author, just as The House of God is modeled after Boston's Beth Israel Hospital, and the BMS after Harvard Medical School. According to the author, the novel is “about” a young person in the U.S. medical system “who really wants to learn to be a doctor, how to doctor. In The House of God he learned how to deal with people's bodies but during the course of the book he realized he wasn't learning what he came to believe was the most important thing: how to be with people.”2 This is not a terribly brash proposition. The initial controversy over the book arose, however, when Shem opened to public scrutiny how the culture of residency training can actually work against learning to “be with” people. Instead of compassion, interns respond with a fatigued cynicism, indifference, and even callousness to the hospital's rituals, which are exposed through the narrator's ruminations. By any standards, Roy's attitudes and behaviors, along with those enacted daily in The House of God by attendings, residents, and other professional staff, are ageist, sexist, and occasionally racist. But they are also humorous to many of the thousands of medical students and residents who, by their responses to the book, have given it cult status. One reviewer admitted that the popularity of the book “astounds” him, and that even his “sensitive, caring compatriots … have found amusing aspects in the novel,” responses that induced him to read the book a second time, which “merely reinforced [his] initial negative reaction to the book.”8
While the practices that form the basis of much of the book's strong critique of residency education are well known to anyone affiliated with academic medicine (e.g., call schedules, overuse of technology, abuse of power between and among doctors, nurses, and patients, and so on), it is the book's humorous treatment of sacrosanct medical phenomena that caused the initial uproar and continues to evoke strong responses. In addition to Roy, a primary vehicle for the book's unsparingly irreverent and critical commentary on medicine is the Fat Man, a second-year resident in charge of much of Roy's socialization. The Fat Man is an enigmatic character who in one scene cranks up the bed of an elderly patient to demonstrate one of the “laws” of The House of God (“GOMERS GO TO GROUND”) while in another scene drops everything to comfort and play double solitaire with a patient who has just received bad news. A “gomer,” the Fat Man quickly instructs his interns on their first day, is an acronym for “get out of my emergency room,” which is what they will want to say to a 3-AM arrival to the emergency room from a nursing home. It is also, according to Fats, a more encompassing term that refers to “human beings who have lost what goes into being human beings.”1
The laws of The House of God, which the Fat Man provides piecemeal to the interns whenever an illustrative situation arises are
- 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 #14 NEEDLE.
- 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 WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
- IF THE RADIOLOGY RESIDENT AND THE BMS BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
- THE DELIVERY OF MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.1,p. 420
With the possible exception of XI, the laws are, when uttered or enacted, unprofessional if not unethical. As Montgomery observes, however, “as they issue from the Fat Man's fund of clinical experience, though still outrageous, they make sense.”3
Coming to understand the laws tells only part of the story of Roy Basch's internship year. The year-long trial also includes dealing with medical hierarchies and the Slurpers therein (those who advance by “licking” their way to the top); dying patients—all of them young—for whom nothing could be done; alcohol abuse; personal relationship cirses; a seemingly constant preoccupation with sex; LOLNAD (“Little Old Ladies in No Apparent Distress”) who were, nonetheless, given complete workups; and the endless stream of the elderly who would not and could not die in spite of their wishes into the hospital. All of these trials, no matter how sobering, no matter how sacred, are portrayed with humor, or cynicism, or both.
It is intriguing, therefore, that Shem resists the label satire4 because it implies a departure from reality, and he maintains that the events found in The House of God really happened—even the most horrific of them, the Black Crow Award given to the intern requesting the most postmortems. “In my mind [satire] is exaggeration in the service of polemic,” he argues. “There are parts of the novel that are exaggerated—the ‘orgy scene,’ for instance—but for better or worse almost all of the novel is as close to my describing the reality of that year as possible. Describing it, of course, with humor and imagination and an outrageous style.” Likewise, the author maintains he “did not coin the word gomer, nor did [he] invent the cruelty toward those with that label.”19 Still, Shem does not position himself as a objective essayist who chronicled the events of his internship year. Instead, he wrote a novel, using very specific rhetorical devices that signal satirical intent—to ridicule or criticize long-standing practices in academic medicine, derisively at times, ironically at others, often with great humor.
Thus, without aiming to write satire, Shem achieves its intent. For example, while the content of satire is criticism, its goal is social correction.20 Shem takes very ordinary, recognizable characters—the intern, the attending, the nurse, the patient—and depicts them in ways no one dared to do before, not even in the buffoonery found in 17th-century medical bildungsromans. He uses one tool of satire—humor—to portray how, in the hospital, those in power act inhumanely toward those without power—attendings act inhumanely toward trainees, doctors at all levels act inhumanely toward patients. It is this wit, this often macabre humor, that keeps the novel from falling into a direct expression of bitterness and anger. Further, good satire is the engine of anger rather than its direct expression, but it may produce anger in its readers.20
Satirical content can cause problems with interpretation in several ways that The House of God does not avoid. First, readers may limit their understanding of a satirical narrative based on what they believe are the author's intentions. Readers' personal values about the topic being satirized can deeply color their responses to the text: geriatricians may bristle at a nursing home satire, missing critical textual cues that signal satirical intent because of their strong feelings about care of the elderly. The result is that their anger is leveled against the author, not at the social conditions that prompted the satire. The attitudes, behaviors, and emerging values of Roy Basch during the steep learning curve of his internship year may be more than many medical educators want to view, given their life's work under such derisive scrutiny. Second, authors who write satire or employ the tools of satire may, themselves, misjudge what they believe is “part of their common ground with their audience.”18 In fact, some readers may actually think the author is being serious—it's okay to make fun of old people, it's a defense mechanism, no one gets hurt, etc.—never making the leap that satirists desire, which is for readers to see the fractures in medical training that need to be healed. Not recognizing such faults results in the “domestication of satiric potential in the interests of entertainment,”21 or in the case of The House of God, readers' viewing the novel as a hilarious, audacious, and sanctioned introduction to the culture of hospital-based medical education, with Shem being identified with the conditions he criticizes.
THE HOUSE OF GOD: OBSERVATIONS OF THE AUTHOR
Shem argues that the book is controversial because it tells the “truth.”22 Before The House of God, most books about medical training were of the “with my heart pounding I sewed in the valve” type, which keeps the mythic, larger-than-life aura of physicians (not “doctors,” Shem wryly notes) intact. Instead of propping the profession up, The House of God is a classic novel of the interns' resistance of
what seemed like inhumane treatment of patients. The core group in reality and in the House were products of the 60s who had succeeded in getting the civil rights laws on the books and the Vietnam war stopped. To resist inhumane treatment of patients seemed, given that, a piece of cake. We didn't even realize we were resistors. The passage that speaks to that is the Leggo round on “Moe the Toe” where the interns begin to respond “I don't know”—nonviolence at its best.22
In a previous interview,23 Shem disclosed that his own training experiences had been full of “wait-a-second moments … where you find yourself doing something or saying something and you think, ‘wait a minute, why am I doing this?’ With The House of God there were so many wait-a-second moments, I felt that I just had to write about the experience.” In addition to this series of moments, Shem realized that the overall experience of medical training had taught him nothing about how to “be with” people. Thus, The House of God emerged out of his activist orientation—that if people take initiative they can change the world—and his desire to write.
Controversial as it has been, Shem maintains that after its publication people did not talk to him directly about their problems with the book and that he heard criticism of it only indirectly. Occasionally he was canceled as a speaker. Criticism of the book continues even today, and now includes the belief that the book is “dated,” that its content is “all baloney and based on things that happened twenty years ago.”2 A 1995 review of The House of God in the NEJM includes the following lines:
One is struck early on by how much the book is outdated. The sycophantic attending physician who hospitalizes patients for extended testing, portrayed in the book as Dr. Putzel, has been all but eliminated by reimbursement based on diagnosis-related groups. Putzel represented a frustrating paradox. In the era of open-ended reimbursement based only on fee for service, the indiscriminate use of diagnostic studies during a protracted hospitalization generated substantial revenue for teaching hospitals, which considered the Putzels of their staff valuable assets. But medical students and house staff perceived them (often correctly) as doctors who not only increased their workload but also contradicted basic tenets of medicine. Physicians who trained during that era can easily understand the futility felt by the book's protagonist.24
However, to focus on how reimbursement patterns have changed rather than the more perennial problems in medical training is to ignore the “wait-a-seconds” that Shem believes are still the structural faults of medical training. “There is still great arrogance and brutality toward third- and fourth-year students and residents in the big academic medical centers,” he argues. “They haven't changed much.” In fact, he continues, “these kind of ‘power-over’ systems not only separate and isolate those who need to stick together, but they isolate each student and resident from his or her own authentic experience of the system itself. He or she starts to think ‘I'm crazy’ rather than realizing the system and its proponents are crazy. If connection is healing, isolation is deadly (see the fate of Potts).”22
Writing 21 years after the publication of The House of God about the specific issues of delivering medical care in residency training, Shem believes the “guts of the conflicts are still there.”22 He writes, “Managed care, I hope, will be seen as the low point in health care in this country.”22 The one real difference between the conditions of residencies then and now is the increased number of women students, residents, and attendings. Having been accused of writing a sexist novel, Shem defends the gender relationships portrayed between doctors and nurses as being historically based. On charges of sexual excess in the book, Shem reminds present day readers that the time portrayed was the sixties, “which lasted until 1975.”
Shem hopes that the increasing number of women physicians has possibilities for a healing trend in medicine. He believes that
you heal people by making good connections with them. Not by showing them how great you are. So if that's true, who are the carriers in this culture of making good connections? Well, they're women. Women are the ones who take care of relationships in this culture. We men, it's not that we can't, it's just that we're not valued for that from early on. So that you have systems that are basically male created and male modeled systems, hierarchical systems based on debate, not dialogue; they're based on ego, not connection. So in these systems someone who's looking for connection, compassion, mutuality, shared power, process, is going to be disappointed.2
Unfortunately for Jo, the lone female resident portrayed in The House of God, along with others like Roy who are searching for connection, compassion, mutuality, shared power, and process, the role models are few, with characters who are antithetical to these qualities lurking everywhere in the teaching hospital environment. In his 1990 revisitation of The House of God in JAMA, Shem calls for “women and men to face differences together and use the creative energy liberated by that process” to “stay human in medicine.”25
One of Shem's hopes for academic medical education, and one that could address the central theme of learning to “be with” people, is in the recruitment and retention of excellent clinical faculty whose role is to teach, not the “scientific MD types,” and not necessarily “the highest ranking clinicians.” In fact, Shem believes, “with some money and power anyone with some common sense and a heart could make the system a lot better. All you have to do is value connection more than self, mutuality more than power. It could work.”22
THE FUTURE OF THE HOUSE OF GOD
The House of God may actually be a more important book for medical students and residents to read now than it was when first published. Despite Montgomery's observation that the strength of The House of God was in its timeliness, I would argue that timeless questions for medical educators reside at the core of the novel: What does it mean for doctors to “be with” patients? How is this relationship best taught or fostered in medical training? What gets in the way of this relationship? Far from being relevant only to the 1970s, most of the stressors encountered by Roy Basch and his peers continue to be well documented, including “inordinate hours, sleep deprivation, excessive work load … too many difficult patients, and conditions for learning that are less than optimal …. limited free time to relax or develop new support systems; psychosocial concerns, brought on by the stress of residency; and inadequate coping skills.”9 Alcohol abuse and suicide are still concerns in residents' training, along with particular stressors surrounding gender.
In addition, The House of God is relevant for today's trainees because it is, indeed, a historical text that sheds light on current medical concerns, explaining in part how U.S. medicine has arrived in its current quandaries. Readers encounter doctors like Leggo, who believes in “doing everything always for every patient forever,” and Jo, whose mantra is “I never do nothing. I'm a doctor, I deliver medical care.” To read the text as a social commentary bound to particular cultural practices in U.S. medicine during the mid-20th century enables one to read that same culture today with greater insight. To read the text as a social commentary bound to issues of power, particularly a commentary on how power is enacted in medical hierarchies, is to become a more astute observer of inequities and injustices particular to medical settings. To read the text with an eye to the language that shapes medical students' and residents' conceptions about themselves, their patients, and their profession is to become more sensitive to how language creates and structures one's perceptions of reality.
In a 1995 introduction to the book, John Updike wrote that The House of God “glows with the celebratory essence of a real novel, defined by Henry James as ‘an impression of life.’” Acknowledging the changes in medicine that have occurred since the book first appeared, Updike nonetheless believes that the book's concerns are “more timely than ever, as the American health-care system approaches crisis condition—ever more overused, overworked, expensive, and beset by bad publicity.”26 Offering medical students and residents the “shock of recognition,” the book also continues to offer medical educators the sometimes unpleasant shock of what is sanctioned in academic medicine. Shem told the world what he had witnessed, and did so in an outrageous, irreverently funny way, and for that the book has never received the attention it warrants as “one of the two most important medical bildungsromans of the twentieth century.”4 As Montgomery notes, the novel's reception by the medical community when it first was published and still today is presaged by an intriguing passage. Roy, at the apex of his anger and cynicism toward the end of his internship, tells Berry, his girlfriend who is not in medicine, an unusually offensive joke involving a gastroenterologist. Fats, his resident and a would-be GI doctor, overhears the joke and responds angrily:
“Don't talk like that.”
“Hurt your feelings, Fats?”
“No, but it hurts hers. You can't use our inside jokes with the ones outside all this, the ones like her.”
“Sure you can,” I said, “they need to see—”
“THEY DON'T!” yelled Fats. “They don't need to, and they don't want to. Some things have to be kept private, Basch. You think parents want to hear school-teachers making fun of their kids? Use your damn head.”1,p. 295
We—past and present generations of students, residents, and medical educators—are fortunate that Sam Shem decided to tell everyone our inside jokes. If satire is an engine of social change and practices in medical training still need to be changed, then The House of God surely deserves another look.