The House of God and what the television in the room said

Stephen Bergman (nee “Samuel Shem”) recently wrote about his experience living and later writing The House of God. Every medical student I knew when I was in training read The House of God. Nearly every student I’ve known since has read it. My parents read it.

Like Arrowsmith, which I read a few months ago on the advice of Jerry Brungardt, and which surprised me in how little medicine has changed in the last hundred years, The House of God still has things to say. My experience and the experience of hundreds of thousands of other interns and residents over the last four decades has so much in common. Like the protagonist of The House of God, I have hoped for a quick death of dying patients so that I could sleep. I’ve given a patient cab fare just so that his inability to leave the grounds didn’t interfere with his discharge (placement—determining where patients will go after leaving the hospital—is still a huge part of internal medicine residents’ daily work). I have said over and over, maybe especially in my current role as an independent consultant, some variation on the phrase “the delivery of good medical care is to do as much nothing as possible.”

So much of the vocabulary that interns and residents use today comes straight from the book: “Turf,” “Buff,” “GOMER,” and others.

There is one black character in the book. There are fewer black medical students now than when the book was written, even though black men appear to receive better care from black doctors. This is a tragedy.

Regrettably, we recently had a physician in Wichita take her own life, probably for many of the same reasons that intern Wayne Potts does in the novel. Events like this need to remind us that the book was intended as satire, not as a manual.

Now we know, as Bergman and every other person who has ever completed a residency probably suspected, that the process ages you. Telomeres, the little shoelace aglets that prevent damage to the ends of our chromosomes, shorten each time a cell replicates. When they get too short it is a signal to the cell to self-destruct. Over time, we lose about 25 base pairs per year on our telomeres, a part of normal aging. First-year medical residents? They lose about 140 base pairs. The ones who work more than 75 hours a week, which I suspect is the majority, lose ~700 base pairs, the equivalent of 28 years’ worth of normal telomere shortening.

Like Bergman I hated—hated—my intern year. My experience was different than his in many ways, but something he said about the outside world imposing itself on his experience as an intern really struck me. You don’t get much exposure to the outside world in your first year of residency. Even I, working in the first year to have enforced work-hour restrictions, often went days without seeing the sun (I was at a high latitude). But one place where the world consistently inserts itself into the hospital is on the TVs in the patient rooms. We constantly judged our patients for their poor taste in TV: courtroom reality TV like Judge Judy, daytime talk shows, baseball if you were really lucky (and I don’t even like baseball). But Bergman remembers Nixon press conferences on hospital TVs; he was an intern during Watergate.

Such a momentous televised event didn’t happen during my intern year, but rather during my third-year Internal Medicine clerkship. On September 11, 2001 my team was rounding at St. Francis Hospital in Wichita when distracted patients started peering around us at the thick tube TVs to see what had happened in New York and Washington, D.C. We paused on rounds when the second plane hit the World Trade Center. When it was announced a plane had hit the Pentagon, and another had crashed in Pennsylvania, my attending said, “We’re under attack.” Then she went back to flipping through a heavy navy blue paper chart.

Before long, patients started throwing around wild conspiracy theories. One patient told me he heard that a third plane flew into the base of one of the World Trade Center towers before it collapsed. Patients did not believe that a fire alone on the upper floors could cause collapse of the building. My now-wife, then-girlfriend, who was on her inpatient psychiatry clerkship, had a patient scramble up to her and say, “I told you this was going to happen!”

For the next year we watched news about 9/11 on hospital TVs as we delivered babies, interviewed patients, scrawled marginally legible hand-written notes, examined patients, did paperwork, and worried about residencies. Many of the patients I’d rounded on on September 11, 2001 would not live to see the 2003 invasion of Iraq. But my classmates and I experienced it the day of our residency match ceremony. We tipped beers at Tanner’s and The Cedar—both since closed—as we watched Shock and Awe rain down on Baghdad. We were happy we were where we were and not in Iraq. Some of my classmates ended up there after residency.

Modern-day Stephen Bergman says that “…patients have no idea that electronic health records are designed to optimize billing and insurance payments rather than their care, and by the way non-physician executives at the top of hospital systems, having never been trained in patient care, dictate the terms of the profession.” Could this be the theme of The House of God’s sequel, Man’s 4th Best Hospital, out soon?

Read some fiction. It's good for you.

Even though it's pretty easy for me to lose myself in a good book (the first one I remember this happening with was 4B Goes Wild, by Jamie Gilson), for much of my life I had the feeling that reading fiction was a waste of my time. I think this had to do with opportunity cost; I spent such a large chunk of my life as a pre-med, then a med student, then a post-grad trainee, so I just didn't feel like I had the time to read anything that I wouldn't eventually be tested on. I was so cynical, in fact, that I read The autobiography of Malcolm X just so I would have something to answer medical school interviewers' questions with. And sure enough, one of my interviewers asked me about the last book I read. I don't think the "mic drop" had been invented in the 1990s, but whatever the equivalent was, I performed it in that tiny room with my good-natured inquisitor. Even that level of cynicism was rewarded, though, as I came to appreciate Malcolm X and his movement in an empathic, layered way that would have been impossible without having read his book.

As my hard-core academic career transitioned into my current medical consulting gig, I found the time again to really dive into books. I even took an intro to writing class taught by the excellent Amy Parker. My new reading habit and my toe-dipping writing hobby aren't because of any delusion of grandeur. I don't expect to see myself on the best-seller list any time soon. They're my therapy. I guess that makes you, reader, my therapist. 

Every time I enter my local public library, a sign tells me that reading fiction increases empathy. I don't know, because I haven't asked anyone with the Wichita Public Library, but I suspect they're basing the assertion on a series of studies by Emanuele Castano and David Kidd in which they randomly assigned readers one of several types of material: literary fiction (like Louise Erdrich), genre fiction (like sci-fi or romance novels), non-fiction, or nothing at all. Once the readers were finished with their assigned excerpts, they took a test that was meant to measure their ability to "comprehend that other people hold beliefs and desires and that these may differ from one's own beliefs and desires," or what they call the Theory of Mind.

What they found was surprising. Reading non-fiction didn't do much for readers' ability to know and understand the emotions and thoughts of others; it was no better than not reading at all. (this bodes poorly for the Theory of Mind of the readers of this blog) But reading literary fiction markedly increased this ability in readers, moreso than even the genre fiction. The authors theorize that literary fiction, by focusing less on the whiz-bang of the story and more on the thoughts of and relationships between characters, forces the reader to "fill in the gaps" to understand their intentions and motivations. Then, they say, this "psychological awareness" may carry over into the readers' own real lives.

I think I have some experience with this. When I was in medical school, Dr. Gerard Brungardt assigned The Death of Ivan Ilyitch to all students rotating through the geriatrics clerkship at the University of Kansas. Given the results of Castano and Kidd's studies, it isn't hard to see why. If students are dealing with dying patients every day, surrounded by their families with their conflicts and hidden desires, it surely helps students to be exposed to literary fiction told from the perspective of a dying man.

The implications of this finding are potentially broad. Should politicians be encouraged to read literary fiction told from the perspective of someone who disagrees with them? Should burnt-out endocrinologists be encouraged to read literary fiction about people mad that their doctor won't increase their thyroid hormone dose? Maybe I'll never feel chronic fatigue syndrome, and maybe medicine won't ever come up with a way to treat it, but I could read, learn from, and relate to characters I meet in an appropriate work of fiction and then apply those lessons to patients, right?

So even though my interests are broad (some might say attention-deprived), I try to sprinkle some fiction in with my technical reading, long-form journalism, and self-help. I like to have two books going at a time, ideally one fiction and one non-fiction. I can't prove it with a Science magazine study, but I hope the fiction increases my Theory of Mind and the non-fiction gives me insight into some part of my life I might've otherwise left unexamined. Right now the fiction-life improvement diad consists of Catch-22 by Joseph Heller, a book I amazingly made it out of high school and college without having read, and Just write: the art of personal correspondence by Molly O'Shaughnessy, a meditation on letter-writing disguised as a how-to manual. 

And I'd love to see what Castano and Kidd's research would show about books on tape. I just finished The Black Lights by Thom Jones, read by Rachel Kushner: