Living in the House of God

Ben Bryner -- One of the books that's more or less "required reading" for medical students is The House of God. Nobody ever formally assigned it, but it comes up often enough in conversation that it's just something a medical student needs to know. Written by a psychiatrist, it tells the story of a new internal medicine intern's struggle to get through the year. The hospital from which the book takes its title is a thinly-veiled version of one of the Harvard-affiliated hospitals in the 1970s. Even if you haven't read it, you've probably heard some of the terms from the book: Gomer, Turf, Zebras, etc. Also, the TV series "Scrubs" has been lazily copying-and-pasting entire characters and plot lines from the book into the show.

Some people find the book too cruel to patients. I don't think the book actually endorses cruelty or neglect of patients, but it's also a pretty bleak book. My main issue was that it reads like the winning entry in the "Write A Book That Sounds Exactly Like Catch-22, But About Something Besides War" contest. But never mind.

The device that moves the narrative along is the list of "Rules of the House of God," truisms dispensed throughout the book that guide intern life in the hospital. Some of them are very useful and deeply true, like #3: "At a cardiac arrest, the first procedure is to take your own pulse." Some of them are painful to hear, like #11: "Show me a [medical student] who only triples my work and I will kiss his feet." Ouch. (I do think I've gotten my ratio down to 2.5 on a few services, though.)

Whatever your opinion of the book (and reasonable people may differ on that), it's eerily accurate. One time I was assigned to bring a chest x-ray from an outside hospital down to radiology. This film was several months old, and we wanted a formal reading of that film to compare with one our patient had gotten that day. I gave the film to a radiology resident who told me it would take most of the day for one of the attendings to give us the formal reading. But he put the film up on a lightbox anyway and we looked at it. At the same time, we pointed to a spot in the left lung that looked kind of suspicious to us. Since neither of us had seen the new film and had plenty of other things to do, we just waited for the formal read. As it turned out, according to the attending radiologist, there was nothing concerning on the new film, and nothing on the old film either. I was surprised, and tried to track down the old film to take another look to see what had tricked me. But I got caught up in more pressing things and never found it.

A few days later, The House of God came up in conversation. We looked at the list of rules, and I was shocked to realize that we'd unwittingly played out one of the Rules of the House of God that I'd forgotten about, #12: "If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there." The book was terrifyingly real, all of a sudden. I felt like King Claudius watching Hamlet's play. Well, not really, since I didn't actually poison the old king. But I gained a whole new respect for the book. Not enough to change over to a career in psychiatry, as the book's protagonist does. Not enough to completely overlook the overtones of sexism and racism, or the ridiculous sex scenes that make the book hard to take seriously. And not enough to actually calculate my furosemide doses by age plus BUN (rule #7). But a new respect for the underlying truth of the book nonetheless.