BOOK REVIEW: The House of God by Samuel Shem

This book, originally published in 1978, became an almost instant cult classic.  The author Stephen Bergman (pen name Samuel Shem) was a Boomer  child of the fifties and sixties, and he wrote this, his first novel, when he was in residency at Oxford as a Rhodes scholar.  As far as I know he does not claim this, but it appears to me that the book is autobiographical to some degree.  The book is about a year as a medical intern in a Jewish hospital called The House of God.  It is funny, irreverent, occasionally salacious, and was frowned on by the medical establishment when it was first published.  

The book pulls the reader into the lives of the interns serving under intense, almost brutal conditions, and confronting what appears to be the very worst in life, its end and all the degrading things that happen to the human mind and body as they gradually shut down.  It is a revelation for the casual, non-medical reader to learn what  happens in the hospital to real people, the interns, members of the hospital hierarchy, and most of all the patients, most of whom are on the last part of the downhill slide. Read more..

The author doesn’t spare any of the gory details.  He discusses and describes in vivid technicolor many of the most unglamorous tasks undertaken by medical students and the attendant sights, sounds, and smells, work that may make you rethink your desire to go to medical school.  What was of the most interest to me however was what was happening to these young men and women as they struggled with the overwork, the authoritarianism of the hospital regime, and the realities of sickness, disease, and death.

The interns develop their own house rules and vocabulary, the first of which is that gomers don’t die.  A gomer (acronym for Get Out of My Emergency Room) applies to mostly elderly patients who have lost most or all of what makes them a human being.  They are existing and taking up space, but they have no awareness of what is going on around them.  As anyone who has spent time in a nursing home knows, their behavior can be humorous and tragic at the same time.  The patient load at The House of God was mostly gomers, and Rule #1 above means that gomers come in and out of hospitals like a revolving door, but they rarely die.  Their organs seem to function on auto-pilot.  It is mostly the younger patients who die in the hospital.  It’s hard to kill a gomer, and it’s impossible to cure or even save many of the young ones.

Even though this is fiction, there is a lot to be learned from this novel, and I am very glad I have read it.  I am amazed at how well known The House of God is, with over two million copies in print; I mentioned it to two middle-aged doctors just this week and they both immediately confessed to having read it many years ago, and they both broke into a grin when I mentioned the word gomer.

The hero among the interns was a fat black doctor who taught them that the goal of medical care was not to cure anyone, but to buff them and turf  them, which meant to make them look better, and then to transfer them out of the ward, either to another department (surgery, psychiatry, the morgue, or just back out onto the street).  When it came to treatment, they learned that less is better, and Rule # 13 was, heretically :  “The delivery of medical care is to do as much nothing as possible.”  It would appear this is a rule that modern medicine lost and is just now rediscovering–that there is a point of diminishing returns with continually prescribing more, and often unnecessary treatments.  Many of these do more harm than benefit.

The reader cringes at the descriptions of what the interns put the sick and dying through in the name of doing something, anything, even if it puts the patient through pointless, agonizing pain.  The concept of modern hospice, i.e. make the patient as comfortable as possible and let them ease into death, was incomprehensible and unacceptable.  You as the reader watch time and again the horrific prolonging of life out of “collective impotence and guilt” — of the interns and the families of the patients.  I cannot imagine anything being more graphic other than  being personally involved in such useless miscarriages of medicine.  I know that such things still happen, because I  remember the final weeks of my sister’s life when she was demented due to brain cancer and procedures for no known purpose were performed on her that obviously caused enormous stress and pain, because she shoved violently at the restraints that kept her bound to the bed.  She did not scream because apparently her brain was not able to transmit or translate the pain signals to other parts that controlled cognition and vocal ability.  It was modern medicine at its best and it was horrible to watch.  The author describes situations that make my sister’s situation pale in comparison, and the reader just prays for the damn interns to let this poor soul die.  And of course they can’t, because their code of ethics requires them to torment their subjects until there is nothing left of them.  That brings us to Rule #8  “”They can always hurt you more.”

I have to believe much of the medical information in the book is based on reality, and the novel is a fun way to explore how young men and women become doctors.  The reader also learns how normal, and sometimes even humble interns gradually evolve into the narcissistic god frame of mind that is partly responsible for the closed society that the medical fraternity has been.

The book is a good read and you will occasionally find yourself laughing out loud, and there will be times when you turn the pages in horrified anticipation of what is done next  in the name of medicine to the defenseless old or dying.

I will leave my readers with a very important question that remains unresolved in my mind:  How many patients have to die, on average, for one medical student to become a doctor?  Students, interns, and residents do practice on, and occasionally kill their patients, and very, very few of these become malpractice lawsuits.  What is the price in human lives and suffering for each apprentice to learn “to do no harm?”