The Evolving House of God

I was fifteen when I first read “House of God”. This book, infamous amongst those either within or privy to medical circles, was written by psychiatrist Stephen Bergman under the pseudonym Samuel Shem. My father, a young psychiatrist himself, had read the book soon after it was first published. Recognizing a potential physician in his daughter, he handed me his copy of the book as a teenager and emphatically told me I should read it.

I find this rather strange: “House of God” (HoG) is not a happy book. For anyone who has not read it, it describes the intern year – aka the first year after graduation from medical school – through the lens of the protagonist, Roy Basch, a fresh-eyed graduate from the Best Medical School. While it starts as an enthusiastic description of the ups and downs of the survivals and deaths of the patients Dr. Basch comes across, it quickly spirals into black humor, taking the reader along with Dr. Basch into the depths of the depression he experiences. In the days of 100-hour work weeks, what he experiences is not atypical of the physician of his day. Lost and confused, he searches for an “out” and ultimately decides to switch from internal medicine to psychiatry. The character’s story is based on that of the author himself, as an intern at Beth Israel Hospital, affiliated with Harvard Medical School.

I have read the book four times in the past ten years. Twenty-five years old, I am now five months away from graduating from the BMS myself. As I’ve matured through high school, college, and medical school – and as I now prepare to take my first steps as an intern – I realize that my perspectives on the book – and on medicine – have evolved.

The first two times I read the book, during high school and college – I was in complete denial. The second half of the book did not seem to exist. Like a new mother forgets the excruciating pain of childbirth immediately after she hears her baby’s cry, so too did I seem to forget that the second half of the book was utterly depressing, demoralizing, and discouraging. I seemed to disregard the fact that the protagonist wanted to leave the field of medicine altogether. He barely manages to pull himself together; ultimately, he chooses a field where he won’t need to touch patients physically – and where (he hopes) his patients can’t touch him emotionally.  

Other medical students have stories similar to mine: I was told by multiple wizened physicians not to go into medicine. “It’s a terrible field,” “I’m not happy with my life,” “I work so many hours and barely make any money. It’s not the lucrative lifestyle people portray it to be” – these were all things I was told by those older and seemingly wiser than me. But, evidently akin to all of my medical student colleagues – I chose to ignore their advice. I’d be different. I didn’t care about making any money. I wanted to make a difference in medicine, and believed the idea of making a small difference in one person’s life was enough to satisfy me. That’d be enough to get me through the long hours – which I understood then to be the most arduous part of the practice of medicine.

As I look back, it’s obvious to me that the denial I was adamantly partaking in for the second half of HoG was analogous to the strategies I was utilizing in making my professional life choice. I ignored the prevalence of unhappiness in physicians in the same way as I disregarded the despondency Dr. Basch experiences in HoG. And in this rather naïve frame of mind, I excitedly leapt from undergrad to medical school.

As a first year medical student, we are in a sterile environment. We delve into textbooks and focus on memorizing the vast array of medical information in preparation for clinical work that starts in our third year of school. I read HoG once again during this year. Similarly to the previous times I had read the book, I felt as though I was getting a glimpse into a world of which I was not yet part. I could only imagine what being a doctor, taking care of patients, and being primarily responsible for patients’ lives was like. It seemed so noble. I imagined the pride I’d feel with the weight of such responsibility. I smiled at the humor, the jokes – even though I didn’t really understand them, and could not relate to them. However, I distinctly remember one difference with this third read: I was cognizant of that second half. And while I shook off the feeling of foreboding as to what lay ahead, I finished the book with a bitter taste in my mouth.

Cramming vast amounts of information is meant to prepare us for the clinical life of a physician. As third years, we are thrown into the pit of the wards. Suddenly we have to apply all of our knowledge to the care of patients. Because we are exposed to the major specialties of medicine, there is a lot that we don’t know. We find that two years’ worth of textbook knowledge doesn’t easily convert to clinical savvy.  We have to learn to work with all types of personalities as we change teams on an almost-weekly basis. We often work as many hours as the interns, except without pay and encumbered with the duty of returning home to study in lieu of sleeping. We do all of this, all while trying to impress our superiors who evaluate us and grade us, prevalently subjectively. We vie for the highest grades, which may affect our choice of specialty and our ability to train at the most prestigious residency programs. For these reasons, the third year of medical school is often considered the hardest of a physician’s training.

Being a fourth year medical student and now having completed all of my clinical responsibilities prior to graduating, I feel as though I battled through to the other side. I can take a breather on this plateau before I continue the steep ascent that will await me as an intern. And, I am writing this as I just finished reading HoG for the fourth time. It is rather astounding how the way I view the story is drastically different. I smile at the ridiculous situations that Dr. Basch finds himself in – because they are hyperboles of similar situations I have either partaken in or have witnessed. I laugh at all of the criticisms of medical students – because that was me! I was the BMS distraught over a lesion in an X-ray that everyone else dismissed. I’m sure that at one time or another I was the medical student that only made the lives of residents harder: spending five hours writing a note that they could complete in one, asking them to practice my fumbling oral presentations with me, nagging them with offers to help them when really they wanted to be left in peace to finish their work. I was the BMS that is caricaturized in the book.

One of the characters in the book is chronically terrified of contracting a deadly disease after a needle stick contaminated from one of his critically ill patients. It’s inevitable that almost all medical students will pass through several phases of hypochondriasis – first, when we learn about all of the diseases that could exist based on our textbooks; and second, when we see the unbearable magnitude of diseases that does exist in the patients we care for. We look at patients – especially the young, previously health ones – and debate amongst ourselves which disease we’d least like to get, and which we’d be most able to tolerate contracting. This is our morbid way of dealing with the constant background hum in our minds, the niggling fear that the sick person in front of us – that could be us, next. This exemplifies how the burden of knowledge about pathology is pathological in itself. Medical students are told at the initiation of school that the fear of disease is essentially inescapable; this forewarning is supposedly meant to prepare us. What I’ve realized with this fourth read is that it absolutely does not prepare us, and we as physicians do not yet have established mature psychological mechanisms to deal with this very human fear of death and disease. We’re expected to forge ahead, feigning immortality in light of tangible mortality.

But I think the starkest distinguishing factor between this time I read HoG and all of the other previous times is how the humor washes over me. The terrible jokes that the physicians make in the book about the patients, the diminutization of the patients into parodies of their diseases, the ridicule of the gomers and gomeres – I’ve heard all of those jokes made on the wards. I’ve laughed at the jokes. I’ve become desensitized to the horrible humor physicians use to protect themselves – and I know how awful those jokes are to an outsider, because I still remember being shocked at them throughout all of my other reads of the book. As I reflect on this, I feel ashamed that to keep myself functioning, human, I’ve dehumanized the patients for which I care.

There is a process to becoming a physician, and far more of the journey entails learning these aspects of medical culture – the so-called “hidden” curriculum – as compared to learning pathophysiology or pharmacology. I’m now indoctrinated into this medical culture. I’ve learnt of the mental canes that doctors use to support themselves as they are faced with the barrage of the sick, the dying, and the hopeless. And I too, have built my own crutches to assist me in coping with the psychological challenges of being in medicine. It is part of my shield: the one I use to pretend I can’t become sick, that I won’t die, and that humor is the best (the only?) remedy to deal with the incredible sadness I witness in the hospital.

This pathway has led me to being a doctor. I may be several months shy of the degree, and I don’t deny how much I still have to learn. But over the past three-and-a-half years, I’ve been molded into a physician. But I wonder as to the cost of the journey: as I’ve gained the knowledge, the mannerisms and coping strategies integral to being a doctor, what have I lost of myself along the way?

Unlike Dr. Basch, I no longer have to face the now-anachronistic and decidedly inhumane prospect of 100-hour work weeks or 30-hour calls of an intern. There’s been a shift in medical culture that now respects and appreciates that physicians need personal time and space to maintain their sanity and mental integrity – to take better care of themselves so that they, in turn, can provide improved care for their patients (although whether the former does lead to the latter has become controversial). Fundamental knowledge about disease has leaped forward. It is apparent that much of the House of God – and the practice and culture of medicine that it represents – has evolved. And yet, as I’ve read and re-read HoG alongside my own maturation into a physician, it’s clear that an incalculable amount has remained just as it was. While a fresh-colored paint-coat adorns the walls of the HoG, closer inspection reveals the cracks – the barely perceptible foundational faults – beneath the façade. And as I prepare to officially enter the HoG as a newly-minted M.D., I wonder whose responsibility it is to seek out the cracks that exist, just visible beneath the surface. Who will take the time to identify the source of these cracks? Time must reveal whether I will ever fill in my own cracks – or just continue to paint over them.