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Brought to you by the students of the University of Cincinnati College of Medicine

 

 

By Mark Nicolas

 

The door swings open and a figure lumbers into the doorway.  I look up from what’s in my hands: a Newsweek article which has held neither my mind nor emotions captive.  I see broad shoulders and an ample gut outlined by the street light and door frame.  This man looks rather like me, or more appropriately, I look rather like him. It’s my father.  It has almost slipped my mind; we are supposed to have dinner tonight.  It is a rare evening: the final outcome of weeks of phone tag and conflicting obligations.  I’ve managed to stay pretty busy for only having a part-time summer job, but restlessness can do that.  I stand to greet him: a cursory hug, the routine hello.  I run upstairs to change into something more appropriate.  While I’m not sure where we’re going, I know I will inevitably be underdressed.  I hear him open the fridge, then the kitchen drawer. The clanking sound of steel knives and forks makes its way up the stairs and finally there is the hiss of a bottle opening.  He’s talking to me from the kitchen, drinking a beer, as I change into a pressed pair of slacks and a dress shirt. I contemplate a tie.

 

“I’ve ordered you a few books to read. I’m having them shipped here, should arrive in a few days.”  

 

“Yeah? Anything I’ll like?”

 

“I think so. They came in a bundle. Three of them.”

 

I think to myself, “This does not bode well.  The nature of some items is not conducive to bundling:  novels, paintings… lingerie.” Mmm, my mind is wandering. The grouping somehow lessens their worth – cheapens their cerebral significance.  Literature should be unique, separate, enticing and intriguing, coincidentally, not unlike lingerie.  The idea of a bundle strikes me suddenly as grotesque.

 

“Well what are they?”

 

“I’m not sure about the other two, but The House of God is the one I want you to read. It’s a classic. Every med student should read it.”

 

I meditate on the fact that this is something I’ll have to do if it will make him happy.  My father: the doctor.  I hesitate for a moment, “Nah, no tie.” I come down stairs and he finishes his beer. We go to dinner. I get a steak. It’s nice, but I’m underdressed.

 

A few days later a package arrives.  In it are three books, a bundle if you will, of medically-related literature: Complications, The Intern Blues and The House of God.  It’s a week until medical school is supposed to start. I’ve stopped my part-time job and it seems I have no choice but to read.  I entertain the idea that I should have made the Harry Potter books last longer…

 

What follows are some of my impressions regarding Samuel Shem’s novel, The House of God.

 

When I reflect back on our orientation week, one activity sticks out as peculiar among the rest.  Well, peculiar may be a strong term, but it was certainly different.  While much of what we did was either clerical (think immunization paperwork) or community building (the infamous scavenger hunt), none of it required much thought.  I suppose it was the intellectual calm before the academic storm.  However, I remember taking a survey which asked us to consider our various motivations that drove us to pursue medicine:  

 

Was it a calling?

Was it the money?

Was it your life’s purpose?  

 

 

I remember finding myself surprisingly confounded by the questions.  It was not because I had never considered my reasons before, but rather that I had not considered the multitude of other reasons out there.   I found myself thinking that there must be some commonality among our responses - a unifying theme.  Despite our varied backgrounds and interests, we all saw in medicine something that resonated with us, something that made us feel that traversing the long and steep road to physicianhood was worth it.  However, my line of reasoning brought me to one conclusion time and time again.  Ironically, the conclusion I arrived at was the exact ‘trite’ thing I was told should be left out of any admissions essay: the desire to help people is why we are here.  Why else would we all consent to trek this arduous path? After all, we’re presumably all pretty smart, at least smart enough to know that there are easier ways to make money.  

While that conclusion is certainly not ground breaking, it did make me consider The House of God and its ideas in a different and, perhaps, sadder light.  I have no desire to summarize in detail the plot of the book; it really is something you should read for yourself.  However, I will ruin nothing by telling you that it follows the lives of several young doctors embarking on their ‘intern year’ (first year) of residency as internists.  Author Samuel Shem chronicles their struggles, failures, sexual exploits and disillusionment with the medical system as they try to reconcile their previously held notions of medicine with the harsh reality which confronts them on a daily basis.  In one sense, their struggle is not unlike what we face in our own stage of development, feeling out what medicine is and what it will be to us.  But unlike us, with our nearly endless list of peers, faculty and advisers as guides, the one man that seems to provide the interns with even an inkling of hope is the Fat Man, a senior resident who teaches them the true rules of medicine. These rules are the ones you don’t learn from textbooks and are certainly not the rules you can recite in front of a patient.  Throughout the book, you glean that Shem has no love for the medical system that he sees it as not merely broken, but dangerous.  In some ways it could be read as a cautionary tale, especially since much of the novel seems to parallel events from Shem’s own life.  From this brief description, you can probably guess at this point that House of God isn’t necessarily an uplifting book, but neither is it wholly depressing.  On more than one occasion, I found myself feeling overjoyed (which was admittedly transient, I was desolate within the span of a few more pages).  In the end, however, I came away with some distinct impressions about medicine, impressions which I felt were already apparent in our education, fledgling as it may be.

 

In The House of God, Shem focuses a great deal of his attention on the futility of modern medicine.  Throughout the novel, he makes it abundantly clear that you never heal anyone.  You run the appropriate tests, you make the correct diagnoses and then you wait while your course of treatment fails to provide even a modicum of relief.  In his satirical view, Shem conveys that medical treatment is just as likely to cause problems as it is to alleviate any symptom of disease. So convinced is he in this belief that the Fat Man’s Rule 13 echoes this sentiment: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.  While comical on the surface, I find that its message holds some sad truth and actually speaks to the more accepted rules of medicine: First, do no needless harm.  When considered in the light of why we want to be doctors, this idea suddenly struck me as very sad.  We want so desperately to help people, to heal them, to make them whole and healthy, and yet we are often confronted by hopeless problems which are only accompanied by an absence of solutions.  I’m reminded of an offhand comment by Dr. Dell, our clinical skills director, one day after class.  While asking him about the extent of our physical exam, he began to relate it to his own practice, “When I heal, well, wait, I never heal anyone. I help their body to heal itself.”  With less than 20/20 hindsight, I’m ashamed to admit that I don’t remember how he finished that phrase, but I believe it’s only because I was so taken aback by how it had begun.  I was surprised to hear those words spoken outside of House of God’s satirical worldview.  Certainly the sentiments were different, but the similarity in content was unmistakable to me.  There are problems in medicine which will always be out of our ability to treat and that idea is very disheartening to me.

 

Admittedly, The House of God was published in 1978 and a lot has changed since then.  Incredible advances in oncology, surgical interventions and pharmaceuticals have greatly augmented doctors’ arsenals and better armed them to fight disease.  Furthermore, the recent changes in residents’ workloads have done wonders for their mental health. However, even with these changes, Shem’s model still works surprisingly (and depressingly) well.  In particular, I think of the multitude of genetic diseases which we have learned about in class.  The tests can be performed and the diagnoses made, but treatment often eludes us.  We are reduced to the role of hand-holders, mere shoulders to cry on.  While I certainly believe this is an incredibly important role we will fill, it leaves me feeling frustrated to think about that powerlessness.  Furthermore, I see this impotence as a problem compounded, or at least made more painful to witness, by the vast dichotomy which exists between our knowledge of disease and our ability to treat it.  We can know so much about which enzyme is defective due to a particular frameshift mutation and yet we are also entirely helpless to cure the 10 year-old boy with muscular dystrophy.  While we may be reluctant to accept this, I believe most doctors are cognizant of this reality.  

 

As an example, the inclusion of my father at the start of this narrative was not merely a literary tool to entice you to keep reading.  (Now if you’re still reading, I suppose it worked and my choice requires no further justification.)  However, there was another purpose.  It is often said that doctors make the worst patients because doctors hate to cede control to another.  However, from what I’ve seen, it has much to do with the fact that doctors simply refuse to seek treatment from the get-go.  Growing up in a medical family, I’ve seen plenty of doctors simply refuse to seek medical help.  My father is the prime example: with a torn rotator cuff, Dupuytren’s contractures and chronic back pain he just keeps truckin’ without seeking help, without finding relief.  It leads me to believe that there is, at least in some part, recognition on the part of physicians of the failures of medicine.  They see that, oftentimes, the best medicine is the tincture of time and a whole lot of nothing.  After all, there is a real risk that treatment might not exist, and even if it does, it may only make things worse.

 

I realize that this isn’t perhaps the happiest article, but take heart; all is not sadness and gloom.  While The House of God raises some serious points, it is, after all, hyperbole of fact, it is fiction.  Despite my tone, I do believe in the power of modern medicine.  I wouldn’t be here if I thought our endeavors were folly.  I think we will see incredible medical advances in our lifetimes.  I sincerely believe that our generation of physicians will continue to erode at the present futility in medicine.  We will, with the grace of modern science, further our ability to help people heal themselves.  However, while I trust in medicine, I don’t think any of us should trust in it to a fault.  If there is a message to be teased from Shem’s The House of God, it is that everything is within limits, everything has faults.  It remains our task then to discover those limits and, even as we work within them, seek to expand them.

A 1st Year's Reflections on "The House of God"

 

A review of the seminal satire on the trials and tribulations of life as a physician.

 

3/26/12

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