An ongoing dialogue on HIV/AIDS, infectious diseases,
July 14th, 2019
The House of God Profiled Physician Burnout Long Before We Called It That — Should Aspiring Doctors Still Read It?
Cover of my original paperback, purchased in 1980!
Many consider the novel The House of God, written by Samuel Shem (pen name for Stephen Bergman), to be a must-read for any physician or soon-to-be physician. A fictionalized account of his internship year, the book details how the accumulated stress, fatigue, and powerlessness of being a first-year doctor inexorably accumulates during that year — with sometimes hilarious, and but also disastrous, results.
The survival strategies of the interns in the book under such circumstances are not pretty. Cynicism becomes the default attitude, an us-versus-them camaraderie that considers the “them” to be not only hospital administrators and older staff physicians — but painfully, the patients, too.
Other survival tactics fall into the “instant gratification” category — the book is packed with sex, and drinking (but especially sex) — which no doubt boosted its readership, and also (warning) makes re-reading it today somewhat cringe-worthy, I imagine especially for women.
This insider look delivered by The House of God was at first widely criticized by the medical establishment. However, over time, the book has become a canonical and widely praised real-world depiction of internship — many doctors I know have read it, and it even appears in the humanistic curricula of some medical schools.
I first read the book in college, a time when I was seriously considering medical school. I found it funny, and surprising — could young doctors really be having so much sex? — but also quite sad (one of the characters takes his own life). And the grotesque depiction of the patients, especially the elderly and infirm, made me very uncomfortable, an undoubtedly intentional goal of the author to show how depersonalizing the whole experience had been.
Frankly, it filled me with dread about the prospects of becoming a doctor.
Re-reading it later, some years after my own training, I saw the extreme perspective as a necessary cry for help — these interns clearly manifested all the characteristics we now commonly refer to as physician burnout.
I could also appreciate the clinical insights embedded in the famous “Laws of the House of God”— #3 is absolutely brilliant:
3. At a cardiac arrest, the first procedure is to take your own pulse.
So my re-read found nuggets that included a human side to doctoring — The Fat Man character is clearly a great clinician — albeit these are few and far between. It’s no wonder that the online reader reviews of this book are so disparate, with plenty of angry one-star reviews mixed in with the general praise.
So why is it in the news now? And why bring it up here?
JAMA this week published a thoughtful perspective on The House of God, plus a piece by Bergman himself. It’s not just to mark the 40th anniversary of its publication; Bergman plans to release a sequel in November. Entitled Man’s 4th Best Hospital, the book will attack the current focus of healthcare on money, and screens, in particular electronic medical records, targets deserving of satire.
From a “pre-review” by WBUR’s Carey Goldberg:
But more than 40 years on, author Samuel Shem trains the satirical sights of his sequel on two particular targets: screens and money. And he connects them, pointing out that the electronic medical record systems that drive many doctors (and patients) crazy are really fundamentally billing systems pretending to be care systems.
With one of his ultra-simple syllogisms, the Fat Man sums it up:
MONEY KILLS CARE
SCREENS MAKE MONEY
SCREENS KILL CARE
Sounds like it will be another cry for help, this time to get us back to connecting with our patients — to pull us away from our electronic billing (I mean medical) records, and to care for them. I look forward to reading it!
As for why here, on an ID blog, regular readers might have gathered over the years that I have an interest in baseball.
(Hey, understatement sometimes is amusing.)
The House of God reminds me in many ways of another book from that era, the baseball classic Ball Four, another insider look at an extreme work environment — this time playing professional baseball. (And also, for the record, Kitchen Confidential. But that’s a different post.)
And last week, as JAMA released its pieces on The House of God, we baseball fans learned that the author of Ball Four, Jim Bouton, had died.
Just like The House of God, it also appeared in the 1970s, and was similarly widely criticized on release by the establishment — this time, the baseball establishment, who preferred a more white-washed, athlete-as-hero illusion of the players. But despite their protestations, the book was a huge critical success, and is now celebrated as a heartfelt and accurate account of what it’s like to live through the grind of a not-so-successful baseball season.
Also like The House of God, the book is very funny, and the players resort to plenty of sex and drinking (but especially drinking this time) — ways to overcome the stress of incessant performance demands, contract disputes, and relentless travel in a sport where management can dispassionately trade you to another team or drop you to the minor leagues for any decline in productivity.
But Ball Four differs from The House of God in two critical ways. First, it’s an autobiographical account, not fiction — these are real people, and it’s Bouton’s voice we hear telling the story.
Second, and more importantly, the joys of playing the game come through strongly. The many problems Bouton has on that 1969 Seattle Pilots team notwithstanding, he clearly loves baseball and deeply respects the hard-work and talent it takes to succeed at this professional level.
A much-quoted line from Ball Four captures this love perfectly:
A ballplayer spends a good piece of his life gripping a baseball, and in the end it turns out that it was the other way around all the time.
There’s nothing like this in The House of God — no joy from patient care, or their gratitude, or how rewarding it can be to master medical information over the course of residency, and then pay it back by teaching medical students and interns. Sure, there’s camaraderie in the book, but much of it is soured by the brutal experiences they are living through.
One of my colleagues has suggested that people wait until after they complete residency before reading the book.
I think he’s right.
What do you think?
19 Responses to “The House of God Profiled Physician Burnout Long Before We Called It That — Should Aspiring Doctors Still Read It?”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
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I read the non fiction memoir of Robin Cook “The year of the intern” in1972 the year I did my internship at Harlem Hospital. I never read the House of God but if it was fictionized with a lot of sex I doubt it was worth reading. The true story of internship is more shocking and effective. I got burned out by the heroin epidemic, lack of support ( we did all the blood draw. Ran the abg’s ourselves, did sed rates ourselves on every new patient. Made up nitro prusside drips using the chemical crystals dissolved in saline foR hypertensive crisis and did our own acid fast smears for “red snappers”and took care of terminal patients withTB, cancer, pneumonia, malignant hypertension, stroke and alcoholism with as much compassion and expertise as we could muster. But it was still one of the best years of my life because of the people I worked with and the patients and struggle with their illness and human conditions that they so heroically tried to deal with. I was able to transfer to academic 3rd year medical residency at U of Minnesota and had a wonderful career as nephrologist at Cleveland ClinicAnd private practice with 3 year stint as clinical trials director for drug company. Before, during or after internship the true story- “The Year Of the Intern” is worth reading. Burnout is a problem with the system and can be fixed by doctors, nurses and progressive politicians if we work hard enough.
Yes, House of God was horribly cringeworthy to read as a woman. And it was especially disheartening to read as a woman pre-med. So, not to be blatantly self-promotional, but there are other female-driven books on the state of internship/residency–hopefully just as entertaining (even without the sex and misogyny). Check out Not Quite Dead!
I had read my copy of house of God while in medical school when the book first came out. I specifically remember as an intern running to a code on the sixth floor from the cafeteria. When I got there I was useless. I then remembered rule number three.
As interns we all had “a yellow man.” 35 years later I still remember mine.
To this day I do not take a “temperature” if I don’t want to know if the patient has a fever. What do I do with that information from the lab tests that I really don’t need.
It was and still is required reading.
Funny how I don’t remember the sex part of the book.
Ahh, but I think you missed the point in The House of God. The intern ended up choosing psychiatry at the end of the book to affirm his connection to patients and humanity in general. I thought then and still think that this book is an affirmation of medicine, that despite disease and filth and death that the connection to others is still the most important facet of life.
I recommend my students read House of God in 4th year. They have seen clinical care and how exhausted residents behave, but they have free time enough to regain some of their optimism, as well. Remains an amazingly prescient book that, while uncomfortable, should still be in the canon.
age + BUN DOES = lasix dose
Read it while interviewing for residency, looked for the fat man at each site.
Key message is torturing patients who can’t benefit while ignoring those in need.
Indicts capitalism in medicine, little has changed.
I read this book my 4th year of medical school. The sex ages terribly, the pervasive sexism ages terribly, and was a lovely reminder of how far we’ve come for those who think nothing’s changed.
I am so grateful I read it BEFORE residency. There is much about modern residency and burnout that is 1984-level gaslighting (see “resident wellness”). Knowing that someone else had seen it and seen through it made the whole experience less isolating. There is nothing that fosters a sense of connection more than affirming, “this is actually happening. I am not crazy”
Also, “Do as much nothing as you can” continues to be a guiding principle.
cringe-worthy doesn’t begin to describe the sexism in this book – although I did not really notice it the first time I read it!
I, like most docs in the 70’s read it and used the slang coined in the book….
But, in recent years, because of the burnout all around me, I decided to recall my own experiences in that era, which were much more positive.
The book is called The Spattered White Coat and I mainly wrote it to inspire med students and residents. http://spatteredwhitecoat.com/ . It’s about my experiences in the major Chicago teaching hospitals which were mainly urban inner city hospitals. It emphasizes the hard work, true, but it is not a whiny complaint, it is about the humanity and the emotional growth of a young doctor in the face of endless work and human tragedy.
The book is to remind us why we became doctors.
A “Catch-22” that spoke to a past generation of doctors in training. An enduring message for those favored few.
I remember reading the House of God, but I don’t remember the sex parts although I know that it did occur in residencies. When I was later an associate residency director, I know that sexual innuendo was an issue for some female residents. Later in practice, I remember how great that we thought the EMRs were going to be. Wrong! They have turned clinicians into clerks and depersonalized care. I agree with Fat Man’s new syllogism that Money Kills Care
I also struggle with the question, should we commend this book to trainees? So far I have mentioned it, but haven’t recommended it. Its legendary status stems from its hyperbole. Legends are true, except for their facts.
A more sexist mentality was rampant then, those post-60s, pre-HIV times. (BTW – Trump and Kavanaugh are alumni of those days; all men coming of age in the 1960s are). We have evolved socially and culturally on those issues, with more evolution needed still.
Re-reading the book this year, I was struck by the humanity shown by Berry, Roy’s wise and patient girlfriend: “The more the hurt, the more the fantasied need for defenses.” Interns either killed themselves, killed others, or went crazy. Roy Basch was a survivor, but only by leaving the madness of the House of God.
Training in medicine now is even harder than back then – more information, sicker patients, less introspection. Resisting burnout starts with caring for oneself (= knowing oneself), and extends to caring for those sharing the workplace.
The third contributor to burnout, the institutional contribution, is so big that it seems impossible to address – how do we engage patients (persons suffering illness and decline) when the System imagines a machine improving outcomes at acceptable costs (healthcare as commodity)?
We have to start somewhere. Can we take care of ourselves and each other? Can we accept our ultimate powerlessness, and still care? Or do we regard patients as parts and money (see AH Nusbaum, “The Finest Traditions of My Calling”)?
My very good college friend was an intern at Beth Israel ’69-’70. He has told me that much of the book is true but the author took his fellow Beth Israel interns (all men) then mixed and reinvented them into the fellow interns of the House of God.
In my career as a family physician I must have thought of the Fat Man’s rules of HoG thousands of times. Especially the first two. My own elderly Dad fell and broke his hip anyway.
Funny that I don’t remember the sex, but I surely remember the Fat Man’s rules! And this book made me realize that I wasn’t crazy in how internship was affecting me and those around me – I think of it as an essential read to help preserve our mental health as we went through residency. So I look forward to his next book, as the EMR made it an easy decision to retire a bit earlier than I might otherwise have done…
I read the book and since I knew the real-life models for the main characters, I have a somewhat different view. Forgetting the sex, I thought the perspective was cynical in the extreme as well as self-serving for the author who wound up doing a residency at a fancy psych hospital outside Boston.. In fact, “Jo” (as well as the Fat Man who I remember sitting behind a desk with his feet up) was my resident as well, and although not warm and cuddly, she took care of patients to the best of her ability with a thoroughness that was, at times, maddening to a tired intern. She didn’t miss much. I hope that the medical students and housestaff whom I teach have a different perspective on relating to patients, even the yellow ones.
Don’t throw the baby with the bath water! Who would prefer the old paper charts? Blame the for profit health care structure not computers
I tried to read ‘House of God’ my junior resident year because I anticipated relating to it. However, I found it like a James Bond movie- so sexist it was hard to appreciate what other messages might be coming through. Interesting to see the sexism is commented on by a disproportionate number of women vs men in this commentary, which makes me wonder why.
Maybe, we need an updated version without the unbearable sexism, because I’d like one and to be able to recommend one to my residents.
I did internship at Boston City Hospital 1995 and experienced an intern year which was the hardest year of my life- where patients died, and then you had to run to the next crisis,, where my one desire was to make a shadow because I entered and left the hospital without the sun., where transport had higher status than interns- if I was in the middle of an H&P and transport came to take the patient to radiology, they trumped me. Where nurses responded to the male interns but ignored my requests.
It was the tv show ‘Scrubs’ which I felt best represented internship. I survived the year due to great co-interns to whom I am forever grateful.
Paul,
Great blog as always!
I read the House of God during medical school in the mid-1980s. It seemed like everyone read it either during medical school residency.I don’t remember all the sex either, but I do remember The terminology and some of the rules. I Recall laughing at some parts. I remember being able to relate to grind and exhaustion due to the lack of sleep (with every third or Fourth night call during medical school and residency), but also to the incredible sense of camaraderie with my co-residents. It has been quite a while and I think it’s time to re-read it now that I’m at the other end of my career.