A Book Doctors Can’t Close

August 18th, 2009 by samuelshem
The New York Times

August 18, 2009

It was a raunchy, troubling and hilarious novel that turned into a cult phenomenon devoured by a legion of medical students, interns, residents and doctors. It introduced characters like “Fat Man” — the all-knowing but crude senior resident — and medical slang like Gomer, for Get Out of My Emergency Room.

Called “The House of God,” the book was drawn from real life, and 30 years after its initial publication, it is still part of the medical conversation.

Written by a psychiatrist, Stephen Bergman, under the pseudonym Samuel Shem, M.D., the novel is based on his grueling, often dehumanizing experiences as an intern at Harvard Medical School’s Beth Israel Hospital in 1974. More than two million copies have been sold, and the book has been continuously in print since its 1978 publication. A recent edition (Delta Trade Paperbacks, 2003) features an introduction by John Updike, who ranks the book alongside Joseph Heller’s famed military satire, “Catch-22.”

Over the years, it has served as a required guidebook for medical neophytes and a clarion call for the old guard to make striking changes in the way we train young physicians.

When the novel first appeared, many doctors were hesitant to admit they had heard of it, let alone were willing to discuss it. Several prominent physicians denigrated it as scandalous and without merit. And based on such scabrous reviews, hundreds of thousands of medical students eagerly read it, first laughing at how the protagonist, Dr. Roy Basch, and his fellow interns survive a year of being on call every third night and working 100-plus-hour weeks, and then shuddering when thinking about their coming internships.

“I got a lot of flak for this book,” Dr. Bergman recalled in a telephone interview. “Older doctors attacked it and me, students would ask me to speak and deans would cancel me.”

Stories of doctors learning the ropes have been a theme in American popular culture for decades.

What makes “The House of God” singularly compelling is its brutally honest portrayal of the absurd tragedies and occasional triumphs of hospital life; the once-common abuse of young physicians by their superiors; and the anger and frustration these interns directed at themselves and patients.

The novel introduced many derogatory terms to the medical culture. Gomer referred to the elderly, chronically ill patients no intern wants to deal with. The shorthand LOL in NAD (Little Old Lady in No Apparent Distress), was for patients needlessly admitted by their private physicians for expensive work-ups in an era when health insurance reimbursements flowed like the Mississippi.

Apparently, time does heal most wounds. Interns and residents who were the profession’s protesting young Turks in the 1970s are now lumbering toward retirement. Today, doctors of all stripes discuss the novel in medical classes, book clubs and academic meetings.

Perhaps more important, “The House of God” helped initiate a dialogue on the effects of sleepless medical training that continues, albeit in a milder form, as evidenced by an Institute of Medicine report in 2008 recommending major reforms in resident physician duty hours.

Dr. Bergman, now 65, is retired from psychiatry and works as a full-time novelist and playwright. In 2007, “Bill W. and Dr. Bob,” a play he wrote with his wife, Janet Surrey, about the founders of Alcoholics Anonymous, had a respectable run off Broadway. His fourth novel, about a primary care physician in the Hudson Valley, “The Spirit of the Place,” was published in 2008 by Kent State University Press.

He is enjoying a 30th anniversary victory walk with “House of God.” The book, he notes, has been praised in a number of recent publications and honored at several academic gatherings, including the 2008 meeting of the American Society for Bioethics and Humanities.

This past winter, Dr. Bergman was invited to deliver a prominent lecture in humanism and medicine at the Association of American Medical Colleges, the same organization, he says, “where medical school deans treated me and ‘The House of God’ with ridicule and derision when it first came out.”

At some of these events, “Dr. Shem” brings along a few colleagues who were the basis for the characters in the novel. Listening to them reminisce over coffee, it is clear how proud they are of being part of the novel and prouder still of the reforms in graduate medical education that came in its wake.

“The novel was an outcry for the humane treatment of interns so that our generation of doctors would not harden into the cold personas of our attending physicians, the people we were fighting against,” said Dr. David Heber, a professor of medicine at the University of California, Los Angeles, immortalized by Shem as a frenetic and sexually charged intern named “Hyper-Hooper.”

Another “House of God” alumnus, Dr. Robert Press, a Manhattan internist, worries that recent changes in resident duty hours have created a whole new set of medical problems. “I think the pendulum has swung too far in one direction, toward making the experience too soft,” he said. “The inmates are running the prison, and it’s a huge challenge.”

Dr. Richard Anderson, who appears in the novel as the motorcycle-riding “Eat My Dust Eddie” and is now the chief executive of a national physicians’ insurance company based in San Francisco, says “The House of God” remains so successful because it perfectly mirrors the stressful life of interns in a busy teaching hospital.

“We were crass, rude, outrageous to each other but not to our patients,” he said. “We valued 110 percent effort and devotion. That was the lesson we took. But it was a hard way to learn it.”

Howard Markel is a professor of pediatrics, psychiatry and the history of medicine at the University of Michigan.

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