Returning to The House of God

I was recently able to do something I could not accomplish as a medical student: I finished reading The House of God.¹  This 1978 novel by Samuel Shem (the nom de plume of Harvard psychiatrist Stephen Bergman) is a brutal satire depicting the first year of medical residency. Set in the thinly disguised Beth Israel Hospital in Boston (the titular “House of God”), the novel’s reception as an instant classic can be attributed to its exaggerated-yet-true portrayals of the “bad old days” of medical training and the psychological and physical harms inflicted on resident physicians.

When I was a medical student, I was revolted by the novel’s disrespect toward patients and families, the self-loathing of its doctors-in-training, the hypocrisy of its senior physicians, and the denigration of its female characters. I couldn’t get past the first few chapters, and neither can the book’s personnel without utterly abandoning their humanity. The wards are depicted as battlegrounds, in which patients are the adversary and doctors engage in a daily struggle to survive a system that penalizes vulnerability and expects them to have an infinite capacity for work. One of the residents dies by suicide. First-person narrator Roy Basch completes his internship, but in an act of self-preservation, abandons internal medicine to become a psychiatrist.

The system of medical education depicted in the novel forces its young physicians to prioritize the tactics of surviving a toxic workplace over the well-being of the people entrusted to their care. As a result, the overworked and psychologically damaged trainees lose track of why they chose careers in medicine. They rarely if ever consider the possibility that part of their mission is to help people. Instead, they act as though empathy is a character flaw.

In my recent rereading, I was better able to appreciate the book’s virtues. Many truths are bound up in, or in some cases, obscured by its satire. The novel is laugh-out-loud funny. Its use of language to express the emotions of its characters is exquisite, something I did not recognize on my first read. Yet I confess that returning to The House of God reawakened one of the shameful realities of my own training. Like the beleaguered denizens of the novel, during the first 2 years of my residency in obstetrics and gynecology in the late 1980s, I struggled not to view each experience through the prism of my own distress. Everything was a burden: the 100-hour and longer work-weeks; the late admission of a complex patient after I thought my day was finally done; the surgical complication that necessitated returning to the OR; the attending physician who insisted on conducting interminable rounds, resulting in an interminable to-do list. The book’s famous “Rules of the House,” presented as aids for keeping things in perspective (eg, “The patient is the one with the disease” and “At a cardiac arrest, the first procedure is to take your own pulse”), seemed feeble defenses against the single, overwhelming reality of both the novel and my life: “They can always hurt you more.” Thankfully, by the mid-point of my training, I was able to overcome this distorted view of the world and find joy in my residency. Those 4 years remain the most thrilling of my career.

I am happy to report that The House of God has not aged well. Many changes for the better have occurred in medical training over the last 46 years. Weakened is the cruel hierarchy of attending physicians and senior residents, who are ground down by the system but somehow conclude they ought to perpetuate its injustices. And good riddance to the debilitating work hours of years past. I am proud to function within an educational framework which, though challenging, achieves better results by nurturing, rather than bludgeoning, trainees. I believe that today’s learners have emotional reserves unavailable to many prior participants in American residency programs. They respect their patients, their calling, and themselves too much to coexist with the cynicism prevalent in The House of God. I have been inspired many times by moments of compassion and selflessness our trainees have shared with patients.

The novel provides an important reminder, even from my vantage point as a senior physician: I should focus less on the mechanics of what I do in the workplace (the moment-to-moment tactics of functioning in the House of God), and more on the values that sustained me throughout my career: trying my best to help people in need, improving human life through research, and contributing to the education of the next generations of physicians. My impact is amplified when I imbue my words and actions with nurturing and compassion. The extent to which these intangibles can have beneficial effects on both patients and learners continues to amaze me all these years later.

The House of God was always about how not to behave. In that sense, at least, it remains a classic.