In 1978, Samuel Shem (the pen name of psychiatrist Stephen Bergman) published The House of God, a novel that made tidal waves in the popular discourse around the training of medical residents and students. Shem said he took the pseudonym because he had just begun his psychiatric practice and didn’t want his patients to know their therapist had written such an “irreverent” book. But it was no secret that Shem was exposing the degradations of resident physician life at Boston’s Beth Israel Hospital (now Beth Israel Deaconess), the main teaching hospital of Harvard Medical School, where Shem completed his internship.
As in House, Shem makes no effort to mask the target of his recent follow-up, titled Man’s 4th Best Hospital, after Massachusetts General Hospital, or “Man’s Greatest Hospital,” a moniker used by those in the biz to acknowledge the institution’s somewhat inflated self-regard. Man’s 4th follows Roy Basch, the now older and wised-up intern protagonist of House, as he and his colleagues face the challenges of practicing medicine in the 21st century: the rise of the electronic health record (EHR), the consolidation of health systems into massive monoliths, provider burnout, and, fundamentally, the insults and inequities of our for-profit health care system.
The House of God’s importance to the field’s recognition of its strange and often abusive culture cannot be overstated. The novel portrayed challenges faced during residency that were simply not spoken of at the time—depression, sex, abuse, and the dehumanizing toll of medical work. In one famous and shocking scene, one of Roy’s intern colleagues, believing his error in judgment led to the death of a patient, kills himself by jumping off the roof of the hospital. At the time, Shem’s book was the only one to depict these horrors with this degree of honesty. As a result, it has served as an admonitory guide for medical students and offered residents the relief of recognition of their miserable work conditions. Doctors still can’t put it down; it has been continuously in print since its initial publication, with over 2 million copies sold.
The 13 Laws of the House of God, the irreverent rules of Roy’s senior resident (the “Fat Man,” or “Fats”) for giving good patient care in residency, have achieved iconic status as well. Though many don’t know it, when doctors tell each other, “At a cardiac arrest, the first procedure is to take your own pulse,” they are quoting Shem. The novel also popularized the term “GOMER” in its first law (“GOMERs don’t die”)—an acronym for “get out of my emergency room,” referring to the stereotype of an elderly and difficult-to-treat patient, which unfortunately one may still hear bandied about the wards.
That terminal cynicism toward providers and patients alike is emblematic of the book’s overall sensibility. Though the novel engaged in bald-faced racism and sexism, most of the initial critiques focused on its raunchiness and brutal confrontation with the culture of medical training (though more recent appraisals have decried its bigotry). The world of doctors is, as a rule, an inward-facing, close-knit one, not often welcoming scrutiny, especially as dramatized in such brazen form by an insider. But in a 2012 piece in The Atlantic, Shem said the criticism didn’t bother him. “I was secure in the understanding that all I had done was tell the truth about medical training,” he wrote.
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But what truth did the book tell, exactly? To Shem’s credit, The House of God shined a spotlight on the deplorable work lives of medical trainees and likely contributed to reforms on maximum shift length and mandatory time off for residents. And as Shem and his defenders have claimed, it was a novel of its era. But he has never really acknowledged that he told only one story about one experience of medical training in a particular time and place that, yes, resonated with many but not with all—not, for instance, with women, whom he hypersexualized; people of color, whom he caricatured; or students training in a rural environment. Though Man’s 4th makes a half-hearted effort to portray members of these groups more fully, it still envelops them in a narrative dominated by the white old guard; their stories always play second fiddle, merely details in Roy’s. For writing by and about this supporting cast, we’ll need to rethink the sources and kinds of stories that get told about medical training, as well as whose experiences and what kinds of experiences take center stage.
If the female and minority characters of House were lazily and insultingly sketched, any readers expecting an improvement in the sequel will find themselves sorely disappointed. Man’s 4th features among its caricatures Italian mob types straight out of central casting and the Hispanic character of Humbo, Fats’s personal assistant cum valet, who speaks in wildly offensive Spanglish that I cannot believe escaped an editor’s strikeout. What’s more, every new character is described first in terms of physical appearance, the women in sexualized terms (a doctor who tends to Roy is “gorgeous,” and he “could not help noticing that her purple blouse was…‘unbuttoned down past Thursday’”) or in racialized terms, like another doctor with “lids slightly Asian, epicanthic fold of upper eyes, and higher nasal bridge.” Yikes.
Despite these offenses, the book ought to be judged, to some extent, by whether it succeeds in its project of decrying the worst faults of the health care industry and its adjacent ones. For this, Shem puts the EHR in the crosshairs, citing the toll in time and energy it takes on doctors’ lives. In aspersing the EHR, Shem isn’t wrong. Countless hours of physician time are lost to navigating hopelessly complex and tedious software programs created primarily for billing purposes, at a cost to patient care and doctor sanity. These programs badly need reform, guided by user experience. But where Shem blunders is in suggesting that the solution to this predicament is a return to paper charts, as the book’s doctors undertake, to widespread praise. Shem’s claim that the advent of the EHR has been bad for quality of care is simply unsupported by evidence other than his own displeasure. In point of fact, the EHR is more accurate, more secure, and more portable (meaning it can be shared among hospitals) than paper.
“Take away the screen, the human rushes back in,” says Fats, railing against that cutting-edge technology, the computer. Setting aside the hackneyed vagueness of this axiom, a call for humanity rings hollow from Shem’s mouth, in light of his newfound position against, say, shift work. What’s more, in Man’s Best, Shem seems to have abandoned, if not outright reversed, his prior call for merciful treatment of medical trainees, who are now more depressed, burned out, and suicidal than ever before. At one point, Fats asks a hospital administrator to offer residents on the wards (inpatient floors, notoriously brutal for trainees) the option of staying past their shift’s regulated end time—as though he were doing them a favor! Shem also advocates reimbursing doctors based on outcomes (i.e., giving hospitals more money for patients who recover better or more quickly), a debunked method of quality assurance that serves only to punish hospitals that treat low-income, high-risk patient populations.
The main dramatic tension of the novel inheres in Roy’s pitiful attempt to balance his work and home lives, which results in a revival of House’s MOR theme, or marriage on the rocks. The thing is, it isn’t entirely Roy’s fault that his marriage and psyche are in tatters. He works, like virtually all doctors in the US health care system, in an environment hostile to his integrity and personhood and to that of his patients. As with climate change, there’s no longer room for doubt: Those who know best agree that medical practice and training are in a crisis that sabotages the health of both patients and providers, as are many other labor industries.
At the heart of this ongoing emergency lies for-profit health care, which deprives Americans of necessary treatment and inflicts moral injury upon their caregivers. Health care organizations further exploit providers’ consciences to milk them for as much cheap and free labor as possible. But Shem paints physician burnout as a matter of personal agency and resilience rather than structural and systemic inequities. He prattles on about the importance of empathy and connection without managing to suggest one change-oriented palliative or solution to the various epidemics that plague modern medicine, like its critical failure to engage a diverse workforce and treat underserved populations equitably.
Just as unwell doctors cannot make well patients, an overwhelming wealthy, white physician community cannot (or at least has utterly failed to) treat black, transgender, undomiciled, and other neglected groups with parity and respect. If even privileged trainees suffer greatly at the hands of the current structure, the obstacles faced by relative outsiders can seem—and be—insurmountable. Grueling testing systems favor kids whose families can afford expensive schooling and preparatory courses, as well as the neurotypical test taker. Race, gender, age, and ability bias in matching and hiring plays a huge role in the success of trainees and has proved resistant to control measures. And hidden, exorbitant costs of travel, housing, and apparel accompany training and interviewing for medical school and residency spots, favoring well-off applicants.
The genres of fiction, memoir, and all those in between are ripe for more narratives by writers from underrepresented populations in medicine, particularly ones that foreground patient perspectives or follow unconventional paths. These have begun to emerge on social media and, to a lesser extent, in medical journals and mainstream publications, but an increase in their number and variety can only lay bare the systemic barriers to entry and advancement that hinder diversity in medical training. The struggles detailed by the Shems of the world were and are dire; they’re just not the only ones worthy of telling.
One way to introduce different kinds of stories to the literature of medical training and practice would be to incorporate the concept of failure. Here I don’t mean failure as a genuine misjudgment or falling short but rather as an instance in which one’s humanity makes itself known and refuses to appease neoliberal cultural paradigms of “success”: professional achievement, financial gain, the acquisition of credentials and their concomitant influence. The notion likely perturbs the type of people who choose medical training, necessarily exemplars of intellect and achievement. But it’s in the interstices of failure that we learn and grow. This is not to suggest, by any means, that writers from underrepresented groups shouldn’t celebrate their successes; this, too, is a critical part of asserting power and selfhood. But we should also enumerate other, less commonly lauded types of success. Not the rare diagnosis but the moment of connection with a patient. Not the survival of 24-hour shift but persistence in a racist field trying to knock you down or the chance to advocate for a child from an underserved background.
Instead of stories that glorify the perfect knowledge and abilities of our caregivers, we need ones that communicate just how hard it is to be a doctor, both globally and individually—how those who heal us routinely fail to heal themselves. If there is one commendation to be paid The House of God, it’s that it affirmed the universality of failure among our healers, people in a demanding profession, working under arduous conditions, to do the impossible: stave off the end that comes for us all.
