I don’t think House of God should be read like an ethnographic study of a hospital, which seems to be the way some people want to read it. Even in its day, it was satire. That said, many people have written retrospectives on the book since the themes, characters continue to have such an outsized impact on the psyche of the medical profession
Rereading The House of God prompts us to ask, first, do we take better care of house staff today and, second, if we do, have those changes resulted in better patient care?
journalofethics.ama-assn.org
the author has written their own retrospective:
Samuel Shem, 34 Years After 'The House of God'
I’ve met physicians now who’ve scoffed at being asked about the book, annoyed that it might’ve given generations of docs excuses to be cynical without having the right experience and others who said the book was immensely cathartic not just the first time they read it but offered up something new each time they revisited it at different stages of their training.
I’m somewhere in the middle on the book, leaning towards the latter side. On the one hand, I think it’s a terrific novel, very well written, almost like what if Portnoy’s Complaint had been about a medical doctor. My non-literary takeaway as I read it the first time as a premed was that medicine asks for a lot and you need to go in eyes wide open, ready to compromise or it’ll swallow you whole. Looking back on it a couple of years later after finally getting into medical school the first thought that comes to mind is that there was so much humanity missing in the practice of hospital medicine that the main character chose to abandon it altogether for psychiatry, ostensively because he wanted to wear jeans to work but more importantly because he needed to save the last bit of humanity he had left. On the other hand, I’m somewhat concerned the impact the book has had may have been limited to “how do we inject humanity into medical training? How do we take care of ourselves in the profession?” (albeit, worthy questions in and of themselves) but not “how do we inject more humanity into the treatment of patients?”, a question that appears to be only of incidental importance in the modern day when it can be made to serve the more “practical” needs of quality assurance, cost reduction, and patient satisfaction (which, while very valuable, are metrics primarily relevant to hospital bottom lines more so than the professional fulfillment of providers and even patient satisfaction has more to do with consumers appreciating a service they have purchased than being satisfied by their relationship with their provider). In short, physician wellness is great and all but there’s little substantial discussion, from what little I’ve seen, about the importance of the alignment between physician and patient wellness beyond vague (albeit accurate) handwaving that physicians who take care of themselves are better equipped to take care of patients.
Psychiatry and surgery are both written in the book as almost kinds of “anti-medicine”. Psychiatry represents the human element which has been obliterated on the House assembly line of GOMERs on the inpatient services. Surgery is the heroic specialty which is actually able to heal and cure in the book, instantly, and even though the surgeons like Roy’s classmate at Man’s Greatest Hospital are just as overworked as them they seem to be more fulfilled and are portrayed as in some sense doing more real work; contrast this with Law 13, “the delivery of good medical care is to do as much nothing as possible”. I think it’s interesting to think about how House of God might deliver these comparisons in the modern day because I do think here there has been some substantial change within the pop-cultural and professional cultural views of medicine.
For example, if someone were to write a satire of modern medicine I don’t think they would make as sharp a distinction between psychiatry and the rest of clinical medicine. House of God was written during the sunset of the dominance of psychoanalysis which, while still practiced today, has become secondary to other modalities which are more obviously similar to the pharmaceutical management and outpatient procedures one might do on a day to day basis in any other non-surgical specialty. Similarly, many branches of internal medicine have gained interventional branches since House of God was written and plenty of specialties, even Radiology, can have some of the instant-fix and procedural appeal short of actually being Surgery. Our ability to intervene in disease in general has become much better and frankly we can “do” more for people than we could in the past even if “doing the most nothing as possible” still remains true.
house of God in 2019 would have many, many more jokes about EMRs.
anyways that’s my naive take.
