ALiEM Bookclub: The House of God

ALiEM Bookclub: The House of God

2016-11-11T19:03:47+00:00

Screen Shot 2013-08-11 at 7.11.29 AMWritten as satire when published first, The House of God polarized the medical community. Doctors in training cheered the book as a voice for their generation to describe the grueling nature of medical training. Others were appalled by the crass language and apparent lack of humanity when describing patient care. Reading the book became a rite of passage for young trainees. 

Brief Synopsis

The book follows the internship year of Dr. Roy Basch. According to wikipedia, the book “portrays the psychological harm done to medical interns during the course of medical internship in the early 1970’s.” Throughout the year, the reader follows Roy on a turbulent and treacherous roller coaster journey. The readers feel the pity of watching the residents essentially lose touch with their loved ones from the work stress, and feel the outrage when young patients die horrible deaths, as opposed to the ‘gomers’ who always manage to live. A particularly touching scene is the patient who is the same age as the young doctors who suffers a terrible death from brain hemorrhage. Even more jarring, a colleague of Roy’s commits suicide from the stress of training and guilt of mismanaging patients. Sexual trysts and alcohol flow through the pages in attempts to make the book entertaining, but also uncomfortable to read at times. Roy and his colleagues increasingly turn towards unprofessional behavior to cope with their stresses: groping the majority female nursing staff, mocking the higher ups who apparently have career ambitions at the expense of others, deriding the socially inept residents who seem unaware of a world outside of medicine, and even turning on each other at times through ridicule. The book concludes where it starts, in France, a safe place far away from The House of God, with Berry the one constant and (?sane) element of Roy’s life-altering year of internship.

Clinical Relevance 

“The House of God continues to afford medical students the shock of recognition, and to offer them comfort and amusement in the midst of their Hippocratic travails.”

This quote is from the 1995 introduction by John Updike. The question now stands, is this book still relevant for this new generation of medical professionals? Has medical training changed so much as to make the book meaningless to the current generation of trainees?

Written as satire about internship year, this book still raises pertinent talking points. As such, we would argue that these topics are timeless and will keep this book present on bookshelves and reading lists. Particularly poignant areas of debate brought up by the book include principle of do no harm, ethics of end of life decisions, health care economics, among others.  In order to focus the discussions, we have chosen three questions for debate and consideration.

BOOK CLUB QUESTION CORNER

  1. House of God was written over 35 years ago and was widely read by medical students preparing to enter residency training. Are there any current books, writings, or publishing that you would recommend a medical student to read, in order to prepare for today’s medical training?
  2. Some say that the House of God illustrated the dehumanization that occurs in medical doctors while on call and working 100+ hours a week on patient care. Since the publishing there has been significant changes and restrictions to work hours, in particular for interns, and now there are some who state that the work hour restrictions, particularly for interns, has swung too far the other direction. What are your thoughts on this?
  3. Do you think TV shows such as Scrubs and Grey’s Anatomy connect with an audience of medical professionals as much as they connect with the general public audience?

Post your responses to our questions or comments below or tweet us using the Twitter hashtag #ALiEMbook.

Further Related Reading

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Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University
  • Threehills

    I’d say the book as still relevant. I read as an intern a few years back and still related to a lot of what was said. The one thing that rang most true, is how horrifying the job can be at times. The things we see, witness and are a part of, they can eat away at you if you let them. But I think that’s a fair price for all the beautiful, wonderful and amazing experiences we get to behold as well. At least now it’s recognized how difficult it can be. That we are not impervious to it all, and that if we don’t learn to cope and process it all, it can break you and your love for the job.

    To answer one of the specific questions, I think Grey’s anatomy did a decent job of portraying the residency experience. While I don’t know anyone who hooked up with an attending, the strong bonds formed, the intense experiences, the pressure, all rang true for, but so did the laughs, the learning, and the growth of the characters across the seasons.

    • TChanMD

      Thanks for your thoughts. For sure, people who got through intense experiences form tight bonds. My residency-mates are some of my best friends for sure.

      Personally, I like Scrubs more than Grey’s… But hey, to each his/her own!

      • njoshi8

        Its interesting to think of HoG meaning different things to a premed, medical student, intern, and practicing physician. Some of my best friends also are from residency, and the conversations I had with them were conversations that I couldn’t have with my mother or other loved ones, because they never were able to really understand!

  • Todd Raine

    House of God resonates because Shem created a fable – a set of Archetypal characters, plus a string of caricatures, in an epic struggle to find Truth.
    Roy is the Common man striving for Truth (how to maintain his humanity in the face of a system designed to undermine it). The Fat Man is the Hero/Sage/Gude in one – wise and strong enough to prevail over the system, trying to help others do the same with his ‘Laws of the House of God’.
    The system is the villain embodied in the caricatures of attending (all Fools and not the good kind), the Dept Chair (the False Prophet), the Chief Resident (the Self Important Know-it-All), the Social Workers (Dragons to be Slayed, or Lions to be Tamed), etc.
    The archetypes are timeless, the writing is superb but accessible, and the details haven’t changed sufficiently to make the story seem outdated. In all a near perfect fable, and we know how long those stick around.

    I always Recommend ‘The Cunning Man’ by Robertson Davies to learners looking for an excellent story and some great lessons. check it out..

    • TChanMD

      Thanks for your analysis of the HoG structure. The question is… does the ‘truth’ really lie within the hallowed halls of the House? I think the fable ends with Roy finding truth far from HoG. 😀

      Thanks also for the recommendation – will be sure to check out the Davies’ book.

      • njoshi8

        Wow, love the analysis! Thanks for your comments!

  • TarHealer

    As a peds EM fellow via pediatrics, I found it much harder to connect with HoG. It did make me think of my limited experiences in adult medicine, but ultimately, I connected more with a book focused on a pediatric training experience. I suspect that more field specific and more contemporary writings may be more relevant to today’s trainees rather than recommending everyone read HoG.

    As far as shows, Grey’s is entertaining, but doesn’t anyone else get annoyed at the medical fallacies in the show? ESPECIALLY WITH SURGICAL RESIDENTS RUNNING THE ED/PIT?!?!?! My husband frequently reminds me that yelling at the TV doesn’t really change things. The medical untruths really detract from my enjoyment of the show (but I still watch it).

    Scrubs was much easier to watch, because I think they actually got their facts right more often than not. And the depicted pediatrician in Scrubs was freaking awesome.

    • njoshi8

      I definitely was very frustrated with Greys and couldn’t get past the first season. I felt that Scrubs was often touching in ways that was refreshing, maybe because it was more of a comedy and less drama.

      Which book did you relate to for your peds training?

    • TChanMD

      I totally year ya… As a EM trainee I railed against Grey’s. What kind of hospital was it?? More recently, the cancelled show “Emily Owens” had a bit better grasp on the role of surgical interns.

      Still the show that probably ‘got’ medical training the most was ‘ER’. Especially in the later seasons where they had more residents and followed Neela & Abby off service to NICU etc.. Even had Neela switch programs, which is far more realistic. At times too dramatic… but overall portrayals were realistic of the modes of training I think.

  • Guest

    1. Two books I would recommend are Cutting Remarks, by Sidney Schwab, and This Won’t Hurt a Bit: (And Other White Lies): My Education in Medicine and Motherhood, by Michelle Au. CR was written by a general surgeon who trained at UCSF in the 1970s. Dr. Schwab is a fantastic writer with a gift for storytelling, and his book is a quick and entertaining read. TWHaB was written by the author of the widely circulated “Scut Monkey” comics and chronicles her med school and residency years. Dr. Au is also a great writer, and her struggles to balance her work and home life are worth reading for anybody who has children of their own or is thinking of having kids during med school or residency.

    2. Anecdotally, I’ve heard from (medicine) attendings that they’ve had to pick up some of the slack because the interns and R2s are not where they should be in terms of knowledge and skill set. Whether this is true or just senior docs looking back with an air of “back in my day,” I don’t know. I also think it remains to be seen if work hour restrictions have resulted in better outcomes, or if the constant cycle of sign-outs and hand-offs is making for worse patient care.

    3. I know a lot of medical professionals who love those shows, but I know some who think “why would I want to watch shows about work?” In my opinion, despite the absurdity of the show, Scrubs was the most accurate in terms of capturing the personalities of the hospital and the people who work there. Interesting factoid: the entire first season of Scrubs was based on The House of God, and the book was even required reading for the cast.

    • TChanMD

      Yeah, I’ve read that Dr. Cox was supposed to be a bit more of a senior version of the jaded, experienced doc (e.g. like the Fat Man)… 😀

      • Robert

        Very explicitly. If you watch the pilot Cox repeatedly quotes the Fat Man word for word.

        Fortunately the brilliant actors and writers of Scrubs quickly moved beyond imitation and established unique characters of their own.

  • Robert

    Absolutely the House of God is relevant and will remain so for generations to come.

    Despite progress in end-of-life care, we still torment the dying with futile medical interventions. Even if we someday overcome this problem completely, there will still be pain, anguish, and loss of dignity at the end of life, and physicians will be hurt and damaged in bearing witness to it.

    No matter what else changes in the world, it will always be true that many of those who excel at advancing themselves via hierarchy and at amassing power and money will not excel at being human — at caring for and about people. It will also remain true that the glad-handlers and the ladder-climbers will rarely be the most skilled clinicians in the field.

    No matter if medical education advances by leaps and bounds, internship will still be terrifying. In fact, it may be becoming more terrifying, as the emphasis on patient safety and the fear of lawsuits gives trainees fewer opportunities to practice their craft and grow confident in their own decision-making.

    • Thank you for your insights Robert! I agree that part of the beauty of the book was in relaying how frightening it can be in those early years. And you hit it right, we all want to be good humans and treat our patients with dignity and care for them. And especially now, this book is still relevant, consider the latest articles that have been circulating on death and dying in social media!