principleintopractice

A few months ago I did a two-week elective with our hospital’s Emergency Medical Services. Over those two weeks I saw all manner of medical “emergencies”.  Some were true emergencies, but plenty were BS calls where first responders and ambulances were called into action when what was really needed was an $8 taxi ride to the emergency room (or even better, $8 worth of broth and a couple days in bed to get over the flu, but I digress).

I met some wonderful first responders on this rotation. People that really want to help others and who obviously get a high from the adrenaline of being called to duty in an emergency.  As I saw bits of the recent Boston and Texas events unfold I imagined how the EMTs and medics I worked with would have jumped to duty in these situations.  Indeed, many of them did 11.5 years ago when they responded to the attacks on the World Trade Centers.  One of the women I worked with lost a friend who was responding that day.

Unlike the hospital environment, where people usually avoid any controversial conversations, I frequently found the topics of religion, politics, taxation, healthcare reform, and gun-control being discussed. The disagreement was sometimes vehement, and the conversations often heated, but there were never any hard feelings at the end of the day.

I worked with a number of EMTs and medics on my 2-week elective, but I bonded with one in particular. I think we had matching (or perhaps complementary) streaks of cynicism and optimism (yes, you can be both a cynic and an optimist. In my case, I think my cynicism protects my optimism from being snuffed out by reality).  He asked if I had read The House of God [1], by Samuel Shem, (the nom de plume of psychiatrist Stephen Bergman), and when I said I had not he insisted that I must.

I ordered the book right away, but like so many excellent book recommendations, it took me a while to get around to reading it.  I finally started a couple weeks ago, and quickly devoured the whole book.

The House of God is a satirical novel that portrays the life of a medical intern in the early 1970s.  A lot of things have changed for interns since this book was published- the most notable (for the sake of this novel) is work hour restrictions. Nonetheless, there is much about this novel that made me, even as a mere medical student, laugh, cringe, and nearly cry.  I have since recommended it to many other medical students and residents with the description that it is “brilliant, hilarious, and terrifying”.

The book is, of course, fiction, but it is, in essence, true.  It is as poignant today as when it was first published in 1978.

Some of the scenes are things that I can relate to, if not describe verbatim, from my experience as a third year medical student.  Some of the patients I have seen are the embodiment of the caricatures described in this novel. “The Yellow Man” with his failing liver, the (relatively rare) young patient who invariably has some condition we can not treat and who sadly dies, the (common) old patient that we can not treat effectively but that we can patch up well enough to carry on… These are patients I know, even though they are fictional.

I won’t write a review of the book- it is brilliant, and I think everyone involved in the medical community should read it. I find myself wondering what non-medical people think of the book… I suspect it would be hard to decipher satire from actuality- the line is definitely not clear, even for those who work in the medical community.

The House of God uses terms that are familiar to those who work in a hospital- and I’m not talking about words you find in a medical dictionary. The term “turfed” is when a patient is moved from one medical team to another (such as from a general team to a specialty team, or vice versa), a “bounce back” is a patient that your team treated who was then transferred to another team or discharged from the hospital, only to “bounce back” to your service.  The term “gomer” is one that I write with some reluctance.  It is a word that I have never heard uttered in the hospital, and have only heard in “humanism” lectures (in which it was made clear that no one should ever use the term), which describes “a human being who has lost-often through age-what goes into being a human being”.  The House of God is how this term first became well known, a term that is an abbreviation for “Get Out of My Emergency Room”.

The same author, again under his pen name, published a piece in 2002 in the Annals of Internal Medicine entitled “Fiction as resistance” [2], in which he describes using storytelling to illustrate, and retaliate against, the brutality and inhumanity of medical training and the practice of medicine. Fiction makes reality palatable.

In this article Shem writes about how he encourages people to resist the inhumanities of medicine. The keys, he believes, lie in (1) learning our trade and being aware of the world around us and our patients, (2) avoiding isolation, (3) speaking up, and (4) learning empathy. I am not sure how one learns empathy.  Sadly, some aspects of medical practice almost seem designed to dispatch it.

Just as I finished The House of God, my mother sent me a book for my upcoming birthday.  I’ve quickly read about half of On Call: A Doctor’s Days and Nights in Residency [3], written by Emily Transue, an internist on faculty at the University of Washington.

Reading these books in immediate succession is powerful.  One is satirical fiction while the other is reality, but if you changed the writing styles you could easily swap the real stories for the fiction.  Both write of the dehumanization that occurs during medical training, but Shem follows the adage “if you want to tell people the truth, make them laugh, otherwise they’ll kill you”.

Sometimes I think I’m too young, too “wet behind the ears”, to write about dehumanization in medicine.  I’m only a fourth year medical student, how much have I really seen.  Other times (well, most of the time), I worry that expressing my feelings, especially in writing especially on the internet, is just asking to have things I say come around and bite me at some point in the future…

Another part of me, however, thinks that medical students are best positioned to recognize dehumanization in medicine.  We are the least indoctrinated, the least hardened.  As students, we also know that there’s a lot we can’t do. The idea, of course, is that with training we will be able to fix people, heal people, make things better.  Sometimes we can; frequently we cannot.

As students, we know that we are fairly powerless in the management of a patient’s medical care.  This can be frustrating when you think there is something that could be done that might help a patient, but also leaves you in a position where you don’t feel like you’re personally failing a patient when there is little to be done (at least medically speaking).  When those with more medical clout, more medical ability, are faced with a situation where the best medicine we can offer will do little good, they sometimes have a hard time letting go.  As if saying “there are no more medical options we can try” or “this isn’t going to get any better” is admitting defeat.

Perhaps it is defeat. But maybe in this circumstance admitting defeat makes you better.  When you realize that you have exhausted your medical options, perhaps you can finally treat the person, not the disease.  It’s just a shame that we don’t always treat the person first.

1.            Shem, S., The House of God. 1978, New York, New York: Dell Publishing.

2.            Shem, S., Fiction as resistance. Ann Intern Med, 2002. 137(11): p. 934-7.

3.            Transue, E.R., On Call: A Doctor’s Days and Nights in Residency. 2005: St. Martin’s Griffin.

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