Friday, November 11, 2016

Book Review: House of God

[ed. I had never heard of The House of God until this review, but it has its own Wikipedia page and anything Scott Alexander at SSC recommends is worth investigating. Despite its age, much of it still sounds relevant.]

I’m not a big fan of war movies. I liked the first few I watched. It was all downhill from there. They all seem so similar. The Part Where You Bond With Your Squadmates. The Part Where Your Gruff Sergeant Turns Out To Have A Heart After All. The Part Where Your Friend Dies But You Have To Keep Going Anyway. The Part That Consists Of A Stirring Speech.

The problem is that war is very different from everything else, but very much like itself.

When I lived in Japan, I had a black neighbor who would always get told that she looked like Condoleezza Rice. She looked nothing like Condoleezza Rice. But if you’re Japanese, and the set of people you recognize includes ten million other Japanese people plus Condoleezza, then maybe all black women blur together into a vague Condoleezza-shaped blob. That’s how I am with war movies. War is so far from my usual experience that the differences among war movies don’t even register.

Medical internship is also very different from everything else but very much like itself. I already had two examples of it: Scrubs and my own experience as a medical intern (I preferred Scrubs). So when every single personin the medical field told me to read Samuel Shem’s House of God, I deferred. I deferred throughout my own internship, I deferred for another two years of residency afterwards. And then for some reason I finally picked it up a couple of days ago.

This was a heck of a book.

On some level it was as predictable as I expected. It hit all of the Important Internship Tropes, like The Part Where Your Attendings Are Cruel, The Part Where Your Patient Dies Because Of Something You Did, The Part Where You Get Camaraderie With Other Interns, The Part Where You First Realize You Are Actually Slightly Competent At Like One Thing And It Is The Best Feeling In The Universe, The Part Where You Realize How Pointless 99% Of The Medical System Is, The Part Where You Have Sex With Hot Nurses, et cetera.

All I can say is that it was really well done. The whole thing had a touch of magical realism, which turns out to be exactly the right genre for a story about medicine. Real medicine is absolutely magical realist. It’s a series of bizarre occurrences just on the edge of plausibility happening to incredibly strange people for life-and-death stakes, day after day after day, all within the context of the weirdest and most byzantine bureaucracy known to humankind. (...)

The story revolves around an obvious author-insert character, Roy Basch MD, who starts his internship year at a hospital called the House of God (apparently a fictionalized version of Beth Israel Hospital in Boston). He goes in with expectations to provide useful medical care to people with serious diseases. Instead, he finds gomers:
“Gomer is an acronym: Get Out of My Emergency Room. It’s what you want to say when one’s sent in from the nursing home at three A.M.”

“I think that’s kind of crass,” said Potts. “Some of us don’t feel that way about old people.” 
“You think I don’t have a grandmother?” asked Fats indignantly. “I do, and she’s the cutest dearest, most wonderful old lady. Her matzoh balls float – you have to pin them down to eat them up. Under their force the soup levitates. We eat on ladders, scraping the food off the ceiling. I love…” The Fat Man had to stop, and dabbed the tears from his eyes, and then went on in a soft voice, “I love her very much.” 
I thought of my grandfather. I loved him too. 
“But gomers are not just dear old people,” said Fats. “Gomers are human beings who have lost what goes into being human beings. They want to die, and we will not let them. We’re cruel to the gomers, by saving them, and they’re cruel to us, by fighting tooth and nail against our trying to save them. They hurt us, we hurt them.” (...)
In the world of The House of God, the primary form of medical treatment is the TURF – the excuse to get a patient out of your care and on to somebody else’s. If the psychiatrist can’t stand a certain patient any longer, she finds some trivial abnormality in their bloodwork and TURFs to the medical floor. But she knows that if the medical doctor doesn’t want one of his patients, then he can interpret a trivial patient comment like “Being sick is so depressing” as suicidal ideation and TURF to psychiatry. At 3 AM on a Friday night, every patient is terrible, the urge to TURF is overwhelming, and a hospital starts to seem like a giant wheel uncoupled from the rest of the world, Psychiatry TURFING to Medicine TURFING to Surgery TURFING to Neurosurgery TURFING to Neurology TURFING back to Psychiatry again. Surely some treatment must get done somewhere? But where? It becomes a legend, The Place Where Treatment Happens, hidden in some far-off hospital wing accessible only to the pure-hearted. This sort of Kafkaesque picture is how medical care feels, and the genius of The House of God is that it accentuates the reality just a little bit until its fictional world is almost as magical-realist as the real one. (...)

In the world of The House of God, medical intervention can only make patients worse:
Anna O. had started out on Jo’s service in perfect electrolyte balance, with each organ system working as perfectly as an 1878 model could. This, to my mind, included the brain, for wasn’t dementia a fail-safe and soothing oblivion of the machine to its own decay?

From being on the verge of a TURF back to the Hebrew House for the Incurables, as Anna knocked around the House of God in the steaming weeks of August, getting a skull film here and an LP there, she got worse, much worse. Given the stress of the dementia work-up, every organ system crumpled: in a domino progression the injection of radioactive dye for her brain scan shut down her kidneys, and the dye study of her kidneys overloaded her heart, and the medication for her heart made her vomit, which altered her electrolyte balance in a life-threatening way, which increased her dementia and shut down her bowel, which made her eligible for the bowel run, the cleanout for which dehydrated her and really shut down her tormented kidneys, which led to infection, the need for dialysis, and big-time complications of these big-time diseases. She and I both became exhausted, and she became very sick. Like the Yellow Man, she went through a phase of convulsing like a hooked tuna, and then went through a phase that was even more awesome, lying in bed deathly still, perhaps dying. I felt sad, for by this time, I liked her. I didn’t know what to do. I began to spend a good deal of time sitting with Anna, thinking. 
The Fat Man was on call with me every third night as backup resident, and one night, searching for me to go to the ten o’clock meal, he found me with Anna, watching her trying to die. 
“What the hell are you doing?” he asked. 
I told him. 
“Anna was on her way back to the Hebrew House, what happened – wait, don’t tell me. Jo decided to go all-out on her dementia, right?” 
“Right. She looks like she’s going to die.” 
“The only way she’ll die is if you murder her by doing what Jo says.” 
“Yeah, but how can I do otherwise, with Jo breathing down my neck?” 
“Easy. Do nothing with Anna, and hide it from Jo.” 
“Hide it from Jo?” 
“Sure. Continue the work-up in purely imaginary terms, buff the chart with the imaginary results of the imaginary tests, Anna will recover to her demented state, the work-up will show no treatable cause for it, and everybody’s happy. Nothing to it.” 
“I’m not sure it’s ethical.” 
“Is it ethical to murder this sweet gomere with your work-up?” 
There was nothing I could say.”  (...)
House of God does a weird form of figure-ground inversion.

An example of what I mean, taken from politics: some people think of government as another name for the things we do together, like providing food to the hungry, or ensuring that old people have the health care they need. These people know that some politicians are corrupt, and sometimes the money actually goes to whoever’s best at demanding pork, and the regulations sometimes favor whichever giant corporation has the best lobbyists. But this is viewed as a weird disease of the body politic, something that can be abstracted away as noise in the system.

And then there are other people who think of government as a giant pork-distribution system, where obviously representatives and bureaucrats, incentivized in every way to support the forces that provide them with campaign funding and personal prestige, will take those incentives. Obviously they’ll use the government to crush their enemies. Sometimes this system also involves the hungry getting food and the elderly getting medical care, as an epiphenomenon of its pork-distribution role, but this isn’t particularly important and can be abstracted away as noise.

I think I can go back and forth between these two models when I need to, but it’s a weird switch of perspective, where the parts you view as noise in one model resolve into the essence of the other and vice versa.

And House of God does this to medicine.

Doctors use certain assumptions, like:

1. The patient wants to get better, but there are scientific limits that usually make this impossible
2. Medical treatment makes people healthier
3. Treatment is determined by medical need and expertise

But in House of God, the assumptions get inverted:

1. The patient wants to just die peacefully, but there are bureaucratic limits that usually make this impossible
2. Medical treatment makes people sicker
3. Treatment is determined by what will make doctors look good without having to do much work

Everybody knows that those first three assumptions aren’t always true. Yes, sometimes we prolong life in contravention of patients’ wishes. Sometimes people mistakenly receive unnecessary treatment that causes complications. And sometimes care suffers because of doctors’ scheduling issues. But it’s easy to abstract away to an ideal medicine based on benevolence and reason, and then view everything else as rare and unfortunate deviations from the norm.

House of God goes the whole way and does a full figure-ground inversion. The outliers become the norm; good care becomes the rare deviation. What’s horrifying is how convincing it is. Real medicine looks at least as much like the bizarro-world of House of God as it does the world of the popular imagination where doctors are always wise, diagnoses always correct, and patients always grateful.

by Scott Alexander, Slate Star Codex |  Read more:
Image: Amazon