Friday, November 27, 2015

New MDs, NPCs,and LOLs in NAD*

While I was a third-year medical student on my surgery rotation, attendings and residents asked me a couple of times whether I had ever read a certain satirical intern "memoir." I confessed that I had not but reported optimistically that it was lying on my bedside table, waiting to be read. Unsurprisingly, it did not get read while I was on surgery, studying for board exams, preparing residency applications, or gone on away rotations. Finally, when my only occupations were traveling for residency interviews, TAing the third-year pediatrics course, and thinking about preparing to start working on an article manuscript, did I find the time to crack the spine of a used copy of The House of God: The Classic Novel of Life and Death in an American Hospital, by Samuel Shem (aka Dr. Stephen Bergman, psychiatrist).

This fictionalized account of a year in the life of an intern at a large, ostensibly Jewish teaching hospital [Beth Israel in Boston, MA] is clever, raunchy, and irreverent. The House of God is populated with characters who are mostly two-dimensional stereotypes: sexy nurses, indecisive interns, blustering attending physicians. A few have more dimensions: the Fat Man, who is simultaneously optimistic and cynical (or is it realistic?); and the main character, Dr. Roy G. Basch, who struggles to understand life, love, and death. Above the narrative floats Roy's girlfriend, Berry, a clinical psychologist, who analyses Roy's friends and experiences. Berry's Freudian interjections of "Dissociation." and "Secondary narcissism." help Roy (and subsequent generations of interns) understand themselves and the system in which they're training. It is a system that not infrequently puts patients' welfare second to last, just in front of that of trainees. I admit it is a little disheartening to think that there are still--have always been! insists my historian-brain--pressures beyond the patient-healer dyad that negatively affect medical care, from attendings' pride to patients' lack of access to hospitals' scarce resources to pharmaceutical companies' greed.

Because I had just finished reading physician-historian Kenneth Ludmerer's history of the American residency system, I could easily place the narrative in the 1970s. Besides references to the Watergate scandal and the Rose Mary Reach, in the novel the House of God residents have minimal supervision, perform a lot of "scut work" (like starting IVs), manage cumbersome paper charts (if they can find them), and work long hours taking care of patients who stay in the hospital for weeks, sometimes months. In the 1980s, Diagnosis-Related Groups (DRGs) would change hospital reimbursement to reward short stays and rapid turn over. In the 1990s, electronic medical records (EMRs) would begin to store and transmit patient data. And in the 2000s, duty-hour regulations would change the structure of resident shifts and call schedules. Depending on whom you ask, there has been more or less improvement in the supervision of interns and residents.

Reaction to the book's publication in 1978 was swift: the lowest members of the medical hierarchy devoured it, while the highest members denounced it. Bergman started speaking on the subject "Staying Human in Health Care," talking about how to remain sane in a system that divides and conquers, that tries to convince the pawns that failure is their fault rather than a product of their environment. His solution is connection: between clinician and patient, between the patient and their context, between the clinician and his or her support network. The House of God has another, more profane legacy: it spawned (or popularized) informal medical lingo like LOLs (little old ladies) and gomers (Get Out of My Emergency Room). The GomerBlog now carries the torch of gallows humor for medical professionals, making fun of neurologists' unwillingness to accept a patient with a medical problem; orthopedists' terse patient notes; and the new ICD-10 billing codes.

Bergman wrote once that he's heard doctors often read this book (and the sequel, Mount Misery) three times: once in medical school, when they find it cynical; once in residency when then find it True; once later, when they understand it. One down, two to go.

*--MDs are Medical Doctors, NPCs are medical specialties with No Patient Contact (i.e. radiology, psychiatry), and LOLs in NAD are Little Old Ladies in No Apparent Distress. Unlike gomeres, they are not actually sick and just need someone to listen to them rather than prescribe yet another drug.

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