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Living in the House of God

Ben_3Ben 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.

November 5, 2007 in Ben Bryner | Permalink


Ben, you forget the main point of the House of God: medicine becomes real when you realize that your happy Sesame Street Character medical school education has run directly into the brick wall of real patients.

We speak at very high levels at my medical school about how patients act--and having spent my fair share of time in emergency medicine, I can tell you there are very few patients that show up and act like the patients we get "taught" on. Medicine happens when reality meets people's dreams, and isn't always pretty, clear, or consistent with your education.

That's what the book is about. No, I'm not a BMS, but I'll do my best not to be one when I'm on my rounds.


Posted by: Jared | Nov 5, 2007 5:04:07 PM

Jared, yes, I agree, this is a major point of the book, and very well summarized too. I certainly don't claim to have thoroughly addressed the book in the blog post. I also think a main point of the book is even more directive than that, putting the various characters forward as examples of what to do and not to do. I think it's as much aimed at medical education as the formal "Sesame Street" curriculum you mention.

Posted by: ben | Nov 6, 2007 3:05:42 PM

Interesting post, as I just read the book for the first time last month. I saw it as more of an indictment on the medical education system and how it chewed/s up residents and spits them out-to make an over generalizing statement. I've not gone to med school. I've not done a residency, but I can say from an inside observers standpoint, it was frightenly on the mark. If you want to read something less caustic and less morose about becoming a physician, check out Sid Schwabs, "Cutting Remarks". It's vingettes and stories from his Med School and general surgery residency experiences in the same time frame (1970s) in San Francisco (& Viet Nam). It won't discourage you the way HOG could. I just read it after HOG. Whereas HOG is more detatched, CR is more personal and personable. I recommend it.

Posted by: gayCMEguy | Nov 7, 2007 11:18:37 AM

Dear Med student Bryner,
First of all, let me tell yopu how much i admire you and all med students...i know you may think that sounds dumb or strange, but it is the truth... i also envy you...
On to "The House of God"... l o v e d it!!! i was actually told by a physican not to read it, which only peaked my interest, of course. Loved "Fats", love the whole gang, was so sad about Potts and loved what several of the interns and two of the policeman decided to do in the end. Have you read the sequel? It is very good as well, maybe better. Somehow, H o G came up in a conversation with my son's meds psychiatrist, and i told him i too had read it and really enjoyed it...funny, he has not read the sequel...shall have to drop it off to him.

Thanks for your writings, you are excellent, i love anything to do with medicine,

Sincerely, tracy

Posted by: Tracy | Nov 9, 2007 7:26:32 AM

I agree with "gayCMEguy" - this is exactly what medical education is, and it is outdated, unhealthy for all involved, and it strips us of our humanity. It is a system badly in need of change.

Posted by: Lauren | Nov 13, 2007 3:43:03 PM

it's an interesting book perhaps precisely because it sheds the PC veil we are all so keen to wear these days around patients and hits an uncomfortable truth regarding the dichotomy between needing to act professional (the Saint-like healers our patients expect us to be) and just be human and performing a regular job to the best of our abilities!

Posted by: | Nov 14, 2007 12:13:40 PM

I liked the book and obviously it is quite popular. Someone borrowed my copy in first year and has never returned it :)

Our professional development tutor recommended it so it obviously has some educational merit.

Rule #3 is my favourite too

Posted by: Eboney | Nov 14, 2007 11:32:11 PM

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