The House of God

My thoughts on, “The classic novel of life and death in an American hospital.”

Recently, I’ve made a change in my career and life path, and with it, I’ve come into some time that I didn’t normally have. This has allowed me to catch up on all of the reading that has been stacking up on my bookshelf since I graduated from veterinary school.

This book was recommended to me by a peer in a group forum discussing burnout in the veterinary profession. I hadn't been heavily invested in reading this thread, but for some reason, the post about this book had caught my eye. So, when I did my last round of book acquisition I added it to the list. For less than $5 on Amazon, I was now the second (or perhaps third) owner of this book, but I had essentially no idea what it was about.

The story, it turns out, is about a medical doctor, Dr. Basch, going through his internship at the House of God Hospital — a fictional hospital based in Boston and associated with the Best Medical School — a fictional rendering of Harvard medical school. The book was published in 1978 and takes place around the time of the Watergate scandal and trials.

What I expected from the House of God was a story about American heroism taking place in a palace of medical experts and pageantry. A story that brings tears to your eyes in the final chapters as a team of excellent doctors brings your favorite character back from the brink of death, and then go on to their next case in the classic, “It’s all in a day’s work,” fashion. In essence, I expected a story to uplift and rejuvenate my excitement in medicine.

What I got instead was a deeply satirical and painfully honest view of the human medical progression from medical student to medical doctor. What the book actually is, is a spotlight on the flaws of medical education and an appeal to reevaluate the, “I did it, and so should you.” mentality. I got the tears in my eyes that I’d expected in the final chapters of the book, but for reasons I didn’t.

The internship year is and has always been seen as a right of passage in the medical community. In human medicine, it is the year after graduation from medical school, and it is essentially a necessity before going to your career medical field. Following an internship, you would generally enter a residency and then finally enter your preferred medical field, i.e. dermatology, radiology, internal medicine, etc as a practicing physician. Now there are variations to this, but this is the easiest way to consider it. Veterinary medicine is similar, about 70% of veterinarians graduating will pursue an internship (at least when I graduated in 2017). Veterinarians are not required to do an internship before entering general practice, however, which is what I did. Internships are generally a requirement if you desire to specialize in veterinary medicine.

Long regarded as a time of intense training and additional skill-building, the internship year is meant to give a new clinician (human-focused or otherwise) a huge chunk of experience in a variety of illnesses, disease presentations, and procedures to help build the pattern recognition and poise that’s required to be an excellent practitioner down the line. In exchange for this training, the intern will receive the protection of general oversight from a team of doctors that usually includes residents and attending or faculty doctors.

However, in exchange for this training, the new medical professional will give up about 50% of a full-time salary per year. Medical doctors average about $80,000 and veterinarians around $30,000 per year in their internship. Additionally, most internships have an extensive on-call and overnight commitment and can require shifts upwards of 24 hours at a time.

The House of God does an excellent job exploring the emotional, mental, and physical strain that an internship can cause especially to a developing new professional.

“‘Damn, Basch! NO BEEPER!’ ‘They can’t hurt me now…’”

As the year of internship finishes, Dr. Basch is finally free from the on-call shift, and the beeper so associated (remember this was published in 1978). The word, they, in this context, means so many different things to Dr. Basch at this stage. It references his bosses, his patients, and perhaps most of all himself. The time as an intern had shattered his archetypal perception of the medical doctor as the savior and the healer. The perception that he had was quickly destroyed as he witnessed death, betrayal, and suicide despite every and anything that he did.

He watched himself transformed from a bright, excitable student into a cynical and angry medical doctor. Though, with the help of those closest to him, we’re led to believe that there is still hope for him going forward.

What struck me the most about this book, was how similar the internship year still sounds. It is currently 2020 — that’s three decades since this was published. Still, medical doctors and veterinarians alike enter from school into a year of clinical practice where they will trade experience and immersion for loss of sleep, poor pay, and often unbearable mental strain.

Why do we do it?

I believe you could survey millions of doctors, veterinarians, and other healthcare professionals and receive billions of different answers. However, the answer is, of course, likely to be a combination of several things. I believe the book nails down the reason pretty well though. As Dr. Basch is told by his supervisor in their final meeting of his internship year.

“(We’d) invested too much by then”

By the time veterinarians and medical doctors have finished school, they have invested 8 years of their lives into higher education, and generally hundreds of thousands of dollars. Jumping outside of the time-honored track seems too risky, or lacking in prestige or honor. Furthermore, in many cases, the goal of becoming a doctor (or vet) has been with this individual since they were quite young. Quitting or changing paths now would seem only to be a betrayal to oneself.

Instead of seeking a better opportunity for yourself, it is easier to dig down and tough out another year. You’ve made it this far already, you may as well keep going. Additionally, you’ll be greeted by dozens of others who have already been through it and will cheerfully inform you that they made it through, so you can too.

In fields as closely scrutinized as human medical care it is reasonable to assume that change will come slowly. However, as mental health and work-life balance continue to press into the forefront of the minds of professionals, I hope that we see the gradual progression towards change continue and even gain steam. The biggest obstacle to this progression is the deeply ingrained feeling of tradition that exists in these fields. It is difficult to brainstorm new ways of progression when everybody that’s doing the brainstorming went through this process already.

Once new ideas surface, it then becomes imperative to get the youngest generation of professionals on board with it. So long as appropriate prestige is attached, the highly motivated veterinary and medical students will pursue it. In other words, a solution cannot be introduced as the second-best.

While I recognize that the stresses and the pressures of human medicine are different from veterinary medicine, I was shocked at how much I related to this book.

Suicide and mental illness are higher among veterinary health professionals compared to human health which has recently received national attention due to a 2018 study by Merck Animal Health. They have recently updated this with their 2020 study which can be found here. While I was fortunate to avoid conflict with anybody that I knew directly, I had classmates that actively went through divorces during our four years of school, classmates that had to call off engagements, and I will never forget the days (yes that’s plural) where our professors began class by informing us that a student in the program had chosen to end their own life.

Rule number VIII of the House of God: They can always hurt you more. Unfortunately for some, this rule doesn’t and won't prove true as young professionals pay, all across the United States and the world, the ultimate price.

In the book, the house ‘shrink’ introduces himself at the beginning of the internship and stresses the importance of seeking help. He is hushed and pushed aside by the medical chief to avoid “scaring” the new interns.

A positive takeaway from the book is that mental health has been slowly heading to the forefront of discussions. Even at the start of my career in veterinary school, it was made abundantly clear that there was help available almost everywhere I could look. It was even possible to speak with someone on the condition of anonymity.

This book was a very interesting and eye-opening read, and while much has changed since the time it was written, it still rings a bell of familiarity regarding medical education. I suggest if you do elect to read this in the future, it’s worth approaching it as a satirical piece. If you’re expecting to read an uplifting story of medical heroics, this isn’t it.