January Book Review!
Why to Re-Read a Book at Different Times in Your Career – The House of God
William J. Yost, MD FACP | Member of AIAMC Program Committee
It has been said that one of the signs of a great book is that the reader desires to pick it up and read it again. If that’s true, then one of the great books that I’ve read, and recommend to you, is House of God by Samuel Shem. In fact, I’ve read House of God three times – first as an impressionable young medical student, then as an exhausted and probably more jaded house officer, and then finally as a hopefully wiser senior attending physician. Each time I came away from this book with a different understanding.
House of God is the semi-autobiographical account of an overworked and undoubtedly emotionally exhausted intern at the Beth Israel Hospital in Boston in the 1960s. Rich in satire but grounded in a harsh reality, the author describes the daily events in a hospital training program at a time when duty hours were without any regulation, education was something that occurred through immersion in a busy training environment without apparent structure or intention, and wellness was never considered. In House of God, the protagonist, Dr. Roy Basch, finds himself suddenly immersed in the day-to-day bustle of an internal medicine inpatient service, an experience for which he has been poorly prepared despite attending the nation’s BMS, or “Best Medical School.”
Dr. Basch is taken under the wing of his Senior Resident, an enigmatic figure known only as “The Fat Man” who has concluded that the diagnostic tests and treatments provided to patients admitted to the hospital only do harm to his patients. Therefore, The Fat Man goes to great lengths to avoid ordering the tests and treatments intended upon admission, and, as a result, his patients thrive. Dr. Basch falls into line, and rapidly gains a reputation among the attending physicians for being one of the best interns in his class. The Fat Man also teaches young Dr. Basch the Laws of the House of God, rules that can essentially be distilled into a survival guide for an increasingly cynical and disillusioned Dr. Basch.
Throughout the internship, and a series of tragicomic interactions with patients, peers, and hospital staff, Dr. Basch becomes progressively more dehumanized and jaded, then depressed, and eventually ineffective. The reader experiences the suicide of a colleague through Basch’s eyes. At the end of the year, and through a dramatic performance, Basch undergoes catharsis, decides to remain in medicine, and becomes a Psychiatry resident – the result of contact with the one character in House of God, a Psychiatry resident named Cohen, who may well be the one truly sane person encountered in the hospital.
Reader’s Reflections at Different Career Phases:
When I first read this book as an idealistic third-year medical student, I came away thoroughly depressed and discouraged by it. Could this be what life was like in the profession I had chosen? I read it again as a resident in internal medicine while training in a large, prestigious academic center on the East coast – and to my surprise, found the book hilarious. Not surprising, perhaps, given what we now know about the progressive erosion in humanistic values and well-being that begins in medical school and continues to slide through residency. Finally, I read it again just a few years ago, and read it with different eyes: with deeper appreciation, empathy, and understanding of the impact that training that is not truly patient and learner-centered can have on the wellness of our trainees and our profession.
Samuel Shem is the pseudonym of Stephen Bergman, who did indeed become a psychiatrist. The book was published in 1978 and ignited controversy that has never really died away. Dr. Bergman, according to some reports, has remained persona non grata with some of his former Harvard classmates. It has been widely criticized for its depiction of women (the only woman in a position of authority is “lonely single woman”), physicians as wealthy and privileged, and other professions (nurses that have no clinical insight or skills).1
However, for me this is a powerfully written book that pulls the curtain aside on the trauma often inflicted upon trainees in what should be the most humane of professions, and while things have improved (physician education, sexism, interprofessional respect, wellbeing), I would still urge anyone in medical education to read this book once. Or perhaps twice to measure our progress.
Reference #1: Pearson R. “The House of God,” A Book as Sexist as it was Influential, Gets a Sequel" The New Yorker. December 25, 2019.
Brief Bio: Dr. Yost is Chief Academic Officer, DIO, and Senior Vice President of Medical Education and Research at UnityPoint Health-Des Moines where he provides direction and oversight of UME, GME and CME. As the DIO, he engages in clinical and educational research and teaches clinical medicine and principles of quality and patient safety. He is a long-time Iowan, getting his BS and DVM (Veterinary Medicine) at Iowa State University before deciding to get his human medicine degree (MD) at the University of Iowa. He completed his GME training in Internal Medicine at Walter Reed Army Medical Center, is a Fellow of the American College of Physicians and continues to practice general internal medicine.