The DO Book Club, Sept. 2021: The House of God

Welcome back to The DO Book Club!

For September, Marta Van Straten, DO, read The House of God by Samuel Shem.

If you’ve read this one, please share your thoughts in the comments below. And if you’d like to write a book review for a future month, please email rraymond@osteopathic.org.

Plot summary (Spoiler alert!)

Shakespearean plays are broadly categorized as comedies if they end with a wedding and as tragedies if they end with a funeral. The House of God, first published in 1978, is loosely based on the author’s internship four years prior. The author used a pseudonym, Samuel Shem, to remain anonymous. Despite not ending in either a wedding nor a funeral, The House of God is both hilarious and tragic.

The book begins with the main character, Roy G. Basch, on summer vacation following internship with his long-time girlfriend, Berry, a clinical psychologist. Roy is traumatized from the past year and his mind wanders. The very next chapter drops the reader directly at the orientation for Roy’s upcoming internship.

Here the reader meets a cast of characters so vivid, they are caricatures of the comic, the melancholy, the angry, the genius, or the stupid, among others. Foreshadowing occurs almost immediately, as the house staff psychiatrist warns the interns of suicide.

The House of God was written in the early 1970s, and it reflects the unfortunate attitudes of many in medicine at that time. Today’s readers will find the book’s casual sexism and racism reprehensible. Despite this major shortcoming, The House of God offers a candid look at medical training that many of us will relate to.

The book is also written extremely well and includes many memorable one-liners. One month into his internship, as Roy is learning how to care for the patients of the medicine ward, he is again amazed at how the practice of medicine was not what he envisioned. His mentor, the nameless Fat Man, star of the novel and second-year medicine resident, responds with “Trash your illusions and the world will beat a pathway to your door.”

The next few chapters slowly chronicle Roy’s first days and weeks on the medicine wards, face to face with the realities of practicing hospital medicine at the time. The duty hours are limitless, and the reimbursements for staff physicians from expensive workups are generous.

Medicine in America exhibits an inherent conflict, as it is a business. The financial interests of the medical establishment many times are in direct conflict with the best interests of the patient. In the novel, rarely are a patient’s wishes solicited, and even more rarely are they honored. The author speaks some truth about the business of medicine and controversies at the Veterans Administration. It appears mismanagement transcends generations and specialties. Poor leadership is a pervasive problem, the Fat Man notes when he speaks of his rotation at the VA.

Soon, the book picks up the pace and the weeks blur together as Roy’s entire academic year meanders through various sexual dalliances and fantasies. At first, the erotic accounts are entertaining, but quickly they become a distraction from the talented writing. When Roy’s self-destructive behavior or thoughts turn ridiculous, the author intervenes timely with a confrontation by Berry, one of the few voices of reason in Roy’s circle.

Roy and his co-interns grow in competence and quickly learn to compartmentalize and repress their traumatic experiences. Some methods are productive. Sadly, many interns implode with self-destructive behavior, including sexual relationships outside of commitment, alcohol abuse, withdrawal from social relationships, and the development of cynicism and emotional detachment from the patients entrusted in their care.

At times, this results in tragic consequences and deaths by suicide and even a mercy killing. Toward the end of his internship, once he completes his intensive care unit rotation, the book climaxes in Roy’s breakdown, where he finally confronts his experiences instead of repressing them. Roy rights his wrongs and attempts to repair his strained relationship with his mentor, the Fat Man.

Interesting tidbits for DOs

The House of God employed only allopathic physicians, and there is little mention of whole-person medicine. Roy is disappointed in the middle of his internship when he realizes he hasn’t healed any patient yet and that only one patient has entered remission.

In one of many enlightened pearls of wisdom, the Fat Man reminds Roy, “We cure ourselves, and that’s it.” Indeed, the body heals itself.

Roy finally humanizes his clinic patient when he asks about her children instead of her aching knees. He is surprised at her response and realizes to himself: “These people didn’t give a damn about their diseases or ‘cures’; what they wanted was what anyone wanted: the hand in their hand, the sense that their doctor could care.”

Takeaways

The novel chronicles the unreasonably rigorous work conditions that lead to so many medical trainees developing anxiety disorders and other mental health issues. The House of God is as much a cautionary tale for incoming interns as it is a fictional diary and somewhat compressed coming-of-age novel. Despite not being traditional theatre or classical literature like Shakespeare, if a literary canon existed for medicine, The House of God should be the first entry.

October’s book

For October, The DO Book Club will be reading The Emperor of All Maladies by Siddhartha Mukherjee. We encourage all who are interested to read along (this book club can be followed at any pace)! If you are unable to get out to a local library or bookstore, we recommend checking out eBook options.

As a reminder, if you read The House of God or any previous Book Club selection and want your reflections to be shared in future posts, or want to write your own book review for a future month, please leave a comment below or email rraymond@osteopathic.org.

Happy reading!

Related reading:

The DO Book Club, Aug. 2021: The Undying

The DO Book Club, July 2021: Mutual Rescue