It has been many years since I first read ‘The House of God‘ by Samuel Shem, back before I even started medical school. It made me wonder what the hell I was getting myself into. This satirical novel opened the door for a world of medical satire, including TV shows like Cardiac Arrest and Scrubs. It introduced the world to dubious terms like ‘GOMER‘, popularized the diagnostic ‘zebra‘, and taught us the difference between the ‘O sign‘ and the ‘Q sign‘.
But a lot has changed in medicine since the 1970’s when Roy Basch was a fresh-faced intern and the Fat Man was his heroic resident. Is the book still relevant?
I think so.
For instance, the lessons learned from this excerpt on how not to diagnose amyloidosis are eternal:
Being an academic House affiliated with the BMS, the House of God had a Visit for each ward team: a member of the Privates or the Slurpers, who held teaching rounds every day. Our Visit was George Donowitz, a Private who’d been pretty good in the pre-penicillin era. The patient presented was a generally healthy young man who’d been admitted for routine tests of his renal function. My BMS, Levy, presented the case, and when Donowitz grilled him about diagnoses, the BMS, straight from the library of obscure diagnoses, said “amyloidosis.”
“Typical,” muttered the Fat Man as we gathered around the patient’s bed, “typical BMS. A BMS hears hoofbeats outside his window, the first thing he thinks of is a zebra. This guy’s uremic from his recurrent childhood infections that damaged his kidneys. Besides, there’s no treatment for amyloid, anyway.”
“Amyloid?” asked Donowitz. “Good thought. Let me show you a bedside test for amyloid. As you know, people with the disease bruise easily, very easily indeed.”
Donowitz reached down and twisted the skin on the patient’s forearm. Nothing happened. Puzzled, he said something about “sometimes you have to do it a bit harder” and took hold of the skin, wadded it up, and gave it a tremendous twist. The patient gave a yelp, leaped up off the mattress, and began to cry with pain. Donowitz looked down and found that he’d ripped a big chunk of flesh from the guy’s arm. Blood was squirting from the wound. Donowitz turned pale and didn’t know what to do. Embarrassed, he took the piece of flesh and tried to put it back, patting it down as if he could make it stay in place. Finally, mumbling, “I… I’m so sorry,” he ran out of the room. With a cool expertise the Fat Man put a gauze compression bandage on the wound. We left.
“So what did you learn?” asked Fats. “You learned that uremic skin is brittle, and that the House Privates stink. What else? What do we have to look out for in this poor bastard now?”
The BMSs ventured several zebras, and Fats told them to shut up. Potts and I went blank.
“Infection,” said Chuck. “In uremia you gotta watch for infection.”
“Exactly,” said Fats. “Bacteria City. We’ll culture for everything. If it hadn’t been for Donowitz that guy would be going home tomorrow. Now, if he lives, it’ll be weeks. And if he knew about this, it would be Malpractice City.”
At this thought the BMSs perked up again. The BMS now comprised a majority of minority groups, and “Social Medicine” was a hot ticket. The BMSs wanted to tell the patient so he could sue.
“It won’t work,” said Fats, ” ’cause the worse the Private, the better the bedside manner, and the higher the patient’s regard. If a doctor buys the TV illusion of ‘the doctor,’ so does the patient. How can the patient know which are the ‘Double O’Privates? No way.”
“‘Double O’?” I asked.
“Licensed to kill,” said Fats. “Time for lunch. We’ll see from the cultures where Donowitz last stuck his finger before trying to murder that poor uremic schlump.”
The Fat Man was right. Colorful and esoteric bacteria grew out of the wound, including one species that was native only to the rectum of the domestic duck. Fats got excited about this, wanting to publish “The Case of Duck’s Ass Donowitz.” The patient flirted with death but pulled through. He was discharged a month later, thinking it usual, even a necessary part of his successful course of treatment in the House, for the skin to have been ripped off his arm by his dear and glorious physician.
And, of course, where would we be without the Fatman’s now infamous ‘Laws of the House of God’:
- GOMERS DON’T DIE.
- GOMERS GO TO GROUND.
- AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
- THE PATIENT IS THE ONE WITH THE DISEASE.
- PLACEMENT COMES FIRST.
- THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14G NEEDLE AND A GOOD STRONG ARM.
- AGE + BUN = LASIX DOSE.
- THEY CAN ALWAYS HURT YOU MORE.
- THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
- IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.
- SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
- IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
- THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.
Although these laws are potent satire they do have a firm basis in reality. For instance, in this age of modern medicine, Law 13 has never been more relevant and Law 3 is a good reminder to keep your cool.
If you haven’t read the ‘The House of God‘, now’s the time. Just make sure you’re feeling happy and healthy and that you have a big grain of salt at the ready.
from the Fast Lane
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.