Revisiting The House of God

Dr. Stephen Bergman, a psychiatrist, published his now-famous satirical novel The House of God under the pseudonym Samuel Shem in August 1978. The book’s protagonist, a young intern, describes the emotional and physical difficulties during the first year of residency. With more than two million copies sold, the work is something of a classic within the
medical profession.

Even in medical school, before we started our clinical rotations during our third year, some of my
friends and professors recommended I read the novel, so I borrowed it from a fellow student. I enjoyed it but couldn’t fully identify with the
characters in the story, which dealt with the hardships of residency: terrible hours, unsympathetic attending physicians, obstreperous and ornery patients, horrible deaths, and flailing personal relationships outside of the hospital because of the amount of time spent inside it. As a student, I hadn’t yet seen
these things and from the outside this all seemed unrealistic: How, I asked myself, could this even be close to the reality of a modern academic hospital?

Now that I am through my third and fourth years of medical school as well as my first year of residency I have re-read the book, and I thought it would be
interesting to reconsider my initial impression. Indeed, the novel is so much more relevant to me now. In order to illustrate this, it is worth looking at
just a few passages.

I got more and more tired, more and more caught up in the multitudinous bowel runs and lab tests. The jackhammers of the Wing of Zock had been wiggling my
ossicles for twelve hours. I hadn’t had time for breakfast, lunch, or dinner, and there was still more work to do. I hadn’t even had time for the toilet,
for each time I’d gone in, the grim beeper had routed me out. I felt discouraged, worn. (p. 41)

Though slightly hyperbolic, all this is scarily familiar to me. On some days there is so much work to do that one doesn’t really have time to sit down and
eat. Or, when one does finally have a spare moment (after 6 or 7 hours of running around), animal instincts take over and without being cognizant of
it one ravenously attacks any food available. Some of us stick granola bars in our white coat pockets to prevent this sudden and unfettered hunger attack
but even this is just enough to make us want more. Occasionally, the issue is that one forgets to eat and when we smell the trays of food being
delivered to hospital rooms during lunchtime, our intestines do somersaults, squeeze, shiver, and groan as we are reminded of our baser needs. We experience
pangs of hunger that occur throughout the day because meals, and even glasses of water if one has time for them, are far apart. I have, in multiple instances, come home at night or in the morning and stood for a moment in the kitchen while having an internal debate with myself: Am I more tired or
hungry?

And Shem’s line about the “grim beeper” made me laugh out loud. I remember twice walking into the bathroom to answer the call of nature, when suddenly the shrill sound from my pager or phone prompts me to abort the mission, walk out, and
answer the other call.

The talk was, on the part of the doctors, all medicine….

The accuracy of this is stunning. When residents get together or when we have a spare moment to chat at work, we don’t usually talk about politics or
friendships or relationships so much as we talk about medical stories. We trade tales of difficult procedures or illnesses or we tell hilarious medical jokes. Friends who spend time with us
outside of the hospital are shocked at how much we speak about work with each other. But a resident’s life revolves around the hospital. We (almost)
literally reside at the hospital and the eventful aspects of our lives usually occur in the healthcare setting. As one can see from even a quick glance at
some posts on this blog, medicine is filled with human drama, humor, sickness, death, and life. How do we avoid talking about all that in our spare time?

The House of God found it difficult to let some young terminal guy die without pain, in peace. Even though Putzel and the Runt had agreed to let the Man
With Agonal Respirations die that night, his kidney consult, a House red-hot Slurper named Mickey who’d been a football star in college, came along, went
to see the Agonal Man, roared back to us and paged the Runt STAT. Mickey was foaming at the mouth, mad as hell that his “case” was dying…. Mickey called a
cardiac arrest. From all over the House, terns and residents stormed into the room to save the Man With Agonal Respirations from a painless peaceful
death. (p. 245)

These can be traumatic moments, indeed (I have written about coding patients herehere, and here). Shem’s point is that we in the hospital sometimes do
chest compressions on patients we surely will not be able to resuscitate or, if they are resuscitated, will be dependent on a ventilator and unconscious
for the remainder of their days. Do we try to revive a 90-year-old with metastatic cancer to the spine and brain? Or do we try instead to make the patient as comfortable as possible?
From the patient’s side (and the patient’s family’s side) the difficulty, which seems insurmountable, is in accepting the end. For most physicians, like the
narrator of The House of God, the difficulty lies in cracking ribs and sending electrical shocks through someone’s body with no clear purpose. In fact, we
frequently ask families to let us make their loved ones comfortable, at least, before they pass away. But that is not always the decision that is made.
And in the passage above Shem satirically chides those who believe the best course is always to be as aggressive as possible.

Eat My Dust Eddie, being run ragged in the death-house, the MICU [Medical Intensive Care Unit], looked awful, and was talking about his previous night on
call: “I was admitting my sixth cardiac arrest and I got this call from the E.W. — Hooper, it was you — saying that there was a guy down there who’d
arrested and you were thinking of sending him to me if he survived. I hung up the phone, got down on my knees, and prayed: Please, God, kill that guy! I
was on my knees, I mean ON MY KNEES!” (p. 126) 

My colleagues and I have never wished that anyone would die. But, undoubtedly, we all identify with the feeling of being overwhelmed. When you’re exhausted
and still admitting patient after patient and trying to work them up for a new diagnosis while also taking care of other patients on the service, writing notes,
fielding pages or phone calls from nurses, drawing blood, and doing CPR, there are moments when it feels as if there is no more time or effort left to give.
You are working with rope with no slack or trying desperately to tread water. This is especially true in a place like the Intensive Care Unit, where patients are sicker
and require closer monitoring. During those moments, we beseech the hospital gods: “please, no more admissions, please no more.” Or, “please don’t let
anyone get sicker than they are.” It’s not every day one feels this way, but it is often enough that the sentiment is familiar.

*   *   *

When The House of God was first published it was not received well by Dr. Bergman’s colleagues and peers. As he tells it,

… my book The House of God enraged many among the older
generation of doctors. I was maligned and disliked. The book was censored by medical school deans, who often kept me from speaking at their schools. None
of it really bothered me, though. I was secure in the understanding that all I had done was tell the truth about medical training.

Thus, the book is not only a brilliant and witty piece of satirical literature, it is also a “fiction of resistance,” as Bergman describes it. Its most sinister and clueless
characters are the ones in charge. And in many cases their worship at the altar of medicine and science damages their relationships with patients,
residents, or each other.

Much has been written about this aspect of the book in recent years: Dr. Howard Brody of the University of Texas Medical Branch

wrote about its relevance in the American Medical Association’s Journal of Ethics in 2011
. Dr. Suzanne Koven, a primary care physician,

interviewed Dr. Bergman about the book for the Boston Globe in 2013
. Dr. Howard Markel, a professor of pediatrics, psychiatry, and the history of medicine at the University of Michigan, discussed the book in a piece for the New York Times in 2009.

The reason for this interest may have something to do with a story Bergman tells in his own 2012 piece for The Atlantic:

And then one day I got a letter forwarded from my publisher, which included the line:
“I’m on call in a V.A. Hospital in Tulsa, and if it weren’t for your book I’d kill myself.”
I realized that I could be helpful to doctors who were going through the brutality of training. And so I began what has turned out to be a 35-year odyssey
of speaking out, around the world, about resisting the inhumanity of medical training.

But the culture in medicine has changed dramatically since this book was written. Institutions are far more humane than they once were. Nevertheless, what we see and how much we need to see cannot change. Doctors ought to be exposed to a wide range of pathology; they
must be exposed to death. This is how one learns to be a great doctor, to diagnose obscure diseases, to treat common diseases successfully, and to save
lives during a hectic code in the hospital.

No matter how authority figures treat residents, Bergman’s book will always be precious to future generations of doctors. Like any great novel it identifies common yet significant human experiences. The author tells us, as it were, that “yes, I know
exactly what this is like and I laughed at the same things you did. I made the same mistakes. I had the same
difficulties.” Such commiseration ameliorates that unsettling feeling residents experience: the feeling that the hospital is a rabbit hole
that spirals into a detached and harrowing yet hilarious world. And, because of The House of God, there will always be a shared understanding
among residents and readers of the triumphs and tragedies accompanied by this feeling.

Becoming Cynical, Part 4

I have written quite a bit about why physicians become cynical (see herehere, and here). What follows are some more thoughts on this topic
that relate to my previous post on Parkinson’s Disease (PD).

Recently, a sixty-three-year-old patient came to the neurology clinic for a left-handed tremor that had become worse. He and his wife gave a classic history of the
onset of PD. His tremor occurred only at rest. He felt his left arm was weaker than his right arm — this was evident in some sessions with his personal trainer. He noticed his handwriting had become slightly smaller. And his wife said she couldn’t hear him well anymore.
She initially thought it was due to her own hearing loss, but her friends also found that his voice had become harder to hear. The attending physician and I asked other questions
regarding sleep (sometimes PD patients act out their dreams), drooling, and cognitive status. After a physical exam, a cognitive test, and some more
questioning, the attending physician concluded that the patient had PD.

At this point in my short career I had seen multiple patients with PD, some in its early stages, some advanced, and some in-between.
I was at least superficially familiar with the course of the disease. So when we broke the news to the patient and his wife, it felt slightly banal:
another PD patient, another diagnosis, and another prescription for PD drugs.

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But this patient’s reaction took me by surprise. Most people are upset, ask for some information about the disease, take
their prescriptions and leave. But in this case, the patient’s questions were far more detailed than I was used to (the attending, given the extent of
his experience and knowledge knew exactly what to say). The conversation eventually led to a discussion about the advanced stage of the disease. We explained
that medications and deep brain stimulation would become less and less effective. Ultimately, he would get dyskinesias and end up in a wheelchair.

We all know we’re going to die — that is one of the few things in medicine that one can say is 100 percent certain. But there is something eerie about hearing
exactly how you’re guaranteed to deteriorate. The attending was telling the patient in a very diplomatic way that his life would look just so in about twenty
years. It was said gently, but the patient understood the meaning well. His wife began to cry and he teared up, too. His movements, his hobbies, and control
would slowly peter out and vanish.

After I told this story to someone with experience in the medical field, the person responded with, “I don’t know what they’re so upset about — it’s just
Parkinson’s Disease.” This probably seems callous and insensitive. Just PD? Think of the horrible symptoms, the side effects of the medications, the
creeping debilitation. Imagine, eventually, being locked-in, frozen and unable to move, relying on a pill that becomes less and less effective for allowing such simple functions as turning
around or walking. It is indeed a terrible disease.

But for a physician who has seen far worse — such as ALSCreutzfelt-Jakob diseasetrauma, Sudden Infant Death Syndrome (SIDS), all of which involve rapid debilitation and death — PD can seem preferable, with its long course and all the available treatments, however limited they may be.

This tendency to compare the severity of varying illnesses is perhaps one of the greatest traps in practicing medicine. Physicians see so much that
diseases that are serious to most patients seem mild relative to the more horrifying ones. I have found myself falling into this pit more than once. I remember
doing CPR on a patient who had burst a pulmonary artery (a major artery in her lungs) as a complication of her lung cancer. As I did chest compressions, blood poured out of her mouth and onto my pants, soaking my shoes and scrubs. While this was going on, I got
a call from a nurse about a patient with a history of drug abuse who wanted more pain medication. He may very well have been in serious pain. But compare
his needs to this woman’s death. Clearly, one was much more affecting, disconcerting, and significant than the other, and it was a while before I
could address the drug patient’s pain appropriately. It can be all too easy to dismiss as a “mild” disease or complaint the sorts of conditions against which our exposure has hardened us.

Thus, with experience, our expectations change; it takes more to move us. We shrug off the majority of hospital cases as “not that bad” or “benign.” I think
all this is inevitable in a career in medicine. One must pinch oneself every day, at the very least, to recognize it.

Becoming Cynical, Part 1

One of the things I hope to accomplish in this blog is to document my change in perspective as third year progresses. Part of this means addressing the
topic of cynicism in medicine, which refers to an unhealthy skepticism towards patient complaints, callous detachment from death and sickness and even,
perhaps, nastiness in situations when kindness is most needed. When, during a physician’s education, can this cynicism take root?

In the third year of medical school, argues Danielle Ofri, an associate professor of medicine at NYU School of Medicine
. As she writes, “Many of the qualities that students entered medical school with — altruism, empathy, generosity of spirit, love of learning, high ethical
standards — are eroded by the end of medical training. Newly minted doctors can begin their careers jaded, self-doubting, even embittered (not to mention
six figures in debt).” I think Dr. Ofri is absolutely right.

The first of many contributory factors to this change is the way the third year of medical school is set up. Medical students spend weeks or a month in
different specialties and subspecialties, also known as services. In surgery, this may mean spending a month on vascular surgery and then a month on
pediatric surgery. In internal medicine, this may mean spending a month in the Intensive Care Unit and then a month on the Infectious Disease service.
Throughout our training we switch rapidly between different areas of medicine in order to gain a broad understanding of medical pathology. This is a clear
educational advantage. There is, however, a downside.

As students we seemingly establish a deep relationship with the attending physicians and residents, a natural result of spending twelve hours a day
together. We become comfortable with each other’s habits, musical tastes, food preferences, and career ambitions. And then, two weeks later we leave and a
new group of students arrives. Despite the intimate knowledge we have of each other, the goodbyes we say are polite and brief. Next week we have a whole
new group of residents to meet, and we don’t linger. Similarly, the residents will have a new set of students with them. We all learn to avoid the kind of
human attachments which colleagues normally form in the workplace because we probably won’t see each other again.

But it is not just with coworkers where we learn this rapid emotional release tactic. It happens with patients as well. In multiple instances, I switched
services before discovering a patient’s diagnosis or witnessing the effects of a newly proposed treatment. I saw a one-year-old boy in pediatric surgery
clinic with an embryological disorder that required corrective surgery. But the next week I moved to a different surgical service and never saw him again.
On a separate occasion, a newborn child had a kidney problem that needed surgical management. I went into the patient’s room for nearly seven days in a
row, got to know her parents and followed her course closely. But I left for a different hospital floor and never found out what happened to her. A patient
with a psychiatric disorder refractory to many different medications began a new medication. I knew the patient’s story and saw him every day for nearly
two weeks. And then I moved to a new service and have no idea what happened to him.

I find an apt comparison in starting a fascinating and powerfully
moving novel and suddenly having the book taken away as I approach its resolution. Each new story has an equally elusive conclusion as each month or week
comes to an end. Thus, medical students assimilate the need to form loose attachments. We care when we are on a service but let it go when we switch. A
patient becomes a transient learning experience. Though not everything can tie neatly together with a beginning, middle, and end, unquestionably something
is lost in this hurried change. How can any relationship begin when its end is so near and a new one looms so soon?

Dr. Ofri endorses this explanation: “Every four to eight weeks, the students are whisked through a new world: surgery, internal medicine,
obstetrics-gynecology, psychiatry, neurology, pediatrics, and outpatient medicine. This ensures that students have a good grounding in the broad field of
medicine, but it also ensures that any relationships formed — with patients, nurses, senior physicians, or mentors — are serially disrupted. It’s no wonder
that so many students spend the year in a daze.”

It certainly can feel like a daze — more on this in Part 2.