Stephen Bergman (nee “Samuel Shem”) recently wrote about his experience living and later writing The House of God. Every medical student I knew when I was in training read The House of God. Nearly every student I’ve known since has read it. My parents read it.
Like Arrowsmith, which I read a few months ago on the advice of Jerry Brungardt, and which surprised me in how little medicine has changed in the last hundred years, The House of God still has things to say. My experience and the experience of hundreds of thousands of other interns and residents over the last four decades has so much in common. Like the protagonist of The House of God, I have hoped for a quick death of dying patients so that I could sleep. I’ve given a patient cab fare just so that his inability to leave the grounds didn’t interfere with his discharge (placement—determining where patients will go after leaving the hospital—is still a huge part of internal medicine residents’ daily work). I have said over and over, maybe especially in my current role as an independent consultant, some variation on the phrase “the delivery of good medical care is to do as much nothing as possible.”
So much of the vocabulary that interns and residents use today comes straight from the book: “Turf,” “Buff,” “GOMER,” and others.
There is one black character in the book. There are fewer black medical students now than when the book was written, even though black men appear to receive better care from black doctors. This is a tragedy.
Regrettably, we recently had a physician in Wichita take her own life, probably for many of the same reasons that intern Wayne Potts does in the novel. Events like this need to remind us that the book was intended as satire, not as a manual.
Now we know, as Bergman and every other person who has ever completed a residency probably suspected, that the process ages you. Telomeres, the little shoelace aglets that prevent damage to the ends of our chromosomes, shorten each time a cell replicates. When they get too short it is a signal to the cell to self-destruct. Over time, we lose about 25 base pairs per year on our telomeres, a part of normal aging. First-year medical residents? They lose about 140 base pairs. The ones who work more than 75 hours a week, which I suspect is the majority, lose ~700 base pairs, the equivalent of 28 years’ worth of normal telomere shortening.
Like Bergman I hated—hated—my intern year. My experience was different than his in many ways, but something he said about the outside world imposing itself on his experience as an intern really struck me. You don’t get much exposure to the outside world in your first year of residency. Even I, working in the first year to have enforced work-hour restrictions, often went days without seeing the sun (I was at a high latitude). But one place where the world consistently inserts itself into the hospital is on the TVs in the patient rooms. We constantly judged our patients for their poor taste in TV: courtroom reality TV like Judge Judy, daytime talk shows, baseball if you were really lucky (and I don’t even like baseball). But Bergman remembers Nixon press conferences on hospital TVs; he was an intern during Watergate.
Such a momentous televised event didn’t happen during my intern year, but rather during my third-year Internal Medicine clerkship. On September 11, 2001 my team was rounding at St. Francis Hospital in Wichita when distracted patients started peering around us at the thick tube TVs to see what had happened in New York and Washington, D.C. We paused on rounds when the second plane hit the World Trade Center. When it was announced a plane had hit the Pentagon, and another had crashed in Pennsylvania, my attending said, “We’re under attack.” Then she went back to flipping through a heavy navy blue paper chart.
Before long, patients started throwing around wild conspiracy theories. One patient told me he heard that a third plane flew into the base of one of the World Trade Center towers before it collapsed. Patients did not believe that a fire alone on the upper floors could cause collapse of the building. My now-wife, then-girlfriend, who was on her inpatient psychiatry clerkship, had a patient scramble up to her and say, “I told you this was going to happen!”
For the next year we watched news about 9/11 on hospital TVs as we delivered babies, interviewed patients, scrawled marginally legible hand-written notes, examined patients, did paperwork, and worried about residencies. Many of the patients I’d rounded on on September 11, 2001 would not live to see the 2003 invasion of Iraq. But my classmates and I experienced it the day of our residency match ceremony. We tipped beers at Tanner’s and The Cedar—both since closed—as we watched Shock and Awe rain down on Baghdad. We were happy we were where we were and not in Iraq. Some of my classmates ended up there after residency.
Modern-day Stephen Bergman says that “…patients have no idea that electronic health records are designed to optimize billing and insurance payments rather than their care, and by the way non-physician executives at the top of hospital systems, having never been trained in patient care, dictate the terms of the profession.” Could this be the theme of The House of God’s sequel, Man’s 4th Best Hospital, out soon?