The House Of God by Samuel Shem

GOMERs go to ground
but they never die.

This book is as old as I am. Not necessarily the copy I own (that was reprinted in the 1990s and I got hold of it through the amazing Free Books Carmarthen initiative that is keeping books from adding to landfills), but it was written in 1978, a good year for the world by all accounts*. Back then, it wrought much anger from the medical community in America, leading the author and psychiatrist Stephen Joseph Bergman to assume a pen name to avoid suffering the professional backlash - it didn't work, but then he says his patients didn't seem to care.

Told in flashback, from the sunlit terraces of a holiday in France where the narrator still feels the spectre of his internship haunt his every waking moment, it is a riotously, bawdily furious work. Dr Roy Basch is a mature** intern at The House of God, the best Jewish hospital in the city. He and other interns are grist for the hospital mill, often taking the worst cases and saddled with the care of the hospital's GOMERs - that stands for Get Out Of My Emergency Room, a reference to the old and infirm who clutter up the admissions and wards but ironically, never get so ill that they die. Basch's first senior resident is the iconoclastic Fat Man, whose teachings inspire Basch and his colleagues to great heights of patient care, again ironically by doing as little as possible in terms of actual care. By the end of the book, the Fat Man's list of LAWS of the House Of God reaches thirteen:

1. GOMERs don't die.
2. GOMERs go to ground.
3. At a cardiac arrest, the first procedure is to take your own pulse.
4. The patient is the one with the disease.
5. Placement comes first.
6. There is no body cavity that cannot be reached with a #14G needle and a good strong arm.
7. Age + BUN = Lasix dose.
8. They can always hurt you more.
9. The only good admission is a dead admission.
10. If you don't take a temperature, you can't find a fever.
11. Show me a BMS (Best Medical Student, a student at The Best Medical School) who only triples my work and I will kiss his feet.
12. If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.
13. The delivery of good medical care is to do as much nothing as possible.

By 'buffing' charts (skillfully and artistically altering patients' medical charts) and 'turfing' patients (getting patients placed in other wards, such as gastroenterology, G&O or, more worryingly, the morgue), Basch becomes the hospital's MVI - most valuable intern - but in the process finds himself de-humanised and callous. In one scene he puts out of his misery one terminal patient in excruciating pain on whom the other, fastidiously thorough senior resident is determined to try every medical procedure in the book (thus proving law 13), and he and his team become ragged, mentally and physically exhausted and demoralised by the demands of the job. In a particularly upsetting chapter, one intern commits suicide after a rookie error leads to the lingering death of a patient, a death which lasts the majority of the book and of which he is reminded every day until the end. Meanwhile, the interns take every opportunity to indulge their sexual appetites in a vain attempt to fuck away their problems and to reaffirm their humanity, with the contrary results.

It's no wonder the medical community were aghast when this was published, and one can see why Shem sought to protect his identity. Nowadays, Shem is more sanguine about its impact, feeling that it brought to light the pressures under which medical interns were routinely forced to work, citing one clinician who credits Shem's book with saving him from suicide. He's travelled the world since then speaking to audiences on a simple topic: "the danger of isolation, the healing power of good connection. And any good connection is mutual." He's also added four more laws:

1. Connection comes first.
2. Learn empathy.
3. Speak up.
4. Learn your trade, in the world.

Coming from a place similar to that of Joseph Heller's Catch-22, it's clear to see the impact the book has had on medical shows, in particular, satires like Bill Lawrence's excellent Zach-Braff-vehicle, Scrubs***. It's in turns hilarious and savage, slapstick and poignant, and the punchline is that all the residents (and amusingly both the policemen routinely on duty at the Emergency room) choose not to stay for a second year's residency but instead opt for the more emotionally connective and humane choice of psychiatry, leaving the hospital with a shortfall in workforce. It might disturb, but it also educates and amuses, greatly.

*By MY account...

**'Mature' meaning of relatively advanced years compared to his peers - any wisdom acquired from these additional years is not in evidence.

***Wikipedia has all the Scrubs references you need to know.

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