Ode to the Fat Man

Here is a sweeping generalization: When doctors write for the lay public they tend towards tiresome self-flagellation.

Samuel Shem’s House of God is an exception; a refreshing read.

Perhaps he wrote for physicians so he wrote with such open face honesty.

In today’s politically correct world, Shem would have been castigated as an ageist for his brilliant acronym, GOMER (Get out of My Emergency Room), for peri-ninety year olds with advanced dementia who are skirting that narrow zone between St. Peter’s Gate and fractured ribs post-CPR.

Time for a pronouncement for medical students: There are two things you must do before starting your internship. Pass your USMLEs and read House of God.

I have read Shem’s classic twice. I remember the Rules of House of God more reliably than I recall the names of the carpal bones.

My first read was a few days in to my internship in elderly care medicine. The hospital was a rickety establishment in Britain’s National Health Service, not quite the Best Medical School that Shem described. But I seemed to share the same clinical experiences as Roy Basch, Shem’s Gomer-phobic protagonist.

There was a deluge of Gomers on New Year’s Eve; the old practice of granny dumping. I had to justify admission by finding nitrates in their urine for suspected urinary tract infection (grandson attending New Year’s bash still does not have an ICD code), or the vaguest T wave changes on EKG (unstable angina is a useful bet in a 90 year old).

If medical taxonomy could not be clinically justified there was always “acopia.”

Shem was remarkably prescient.

Take rule 13:
“The delivery of good medical care is to do as much nothing as possible.”  This was before physicians were inserting stents through rock hard femoral arteries to give patients an aggregate of two extra hours of survival.

Basch’s elderly patients would do the best precisely because his caring was the least aggressive. He would occasionally forget to prepare them with laxatives for a barium enema, saving them from dehydration and its cascade.

If Shem realized in the seventies that nothing was more futile than an investigation leading to a futile treatment, God knows what he would have written today.

The book is full of truisms that you are pleased to hear but glad someone else is saying them!

I still chuckle at rule 3: “At a cardiac arrest, the first procedure is to take your own pulse.” I recall my first cardiac arrest as an intern. I arrived at the wrong ward. Never before had I been so relieved to have been so lost!

When I re-read the book recently for a book club, I was struck by rule 10: “if you don’t take a temperature you can’t find a fever”. So much wisdom in that statement! The gateway to overdiagnosis and overtreatment is the mindless quest for more and more information, more measuring, more variables and more pseudo-fevers.

And then there is Rule 7: “Age + BUN = Lasix dose.” It’s still usually an approximation! Yes, you’ve heard that before–medicine is not an exact science.

House of God’s Jimmy Conway, possibly Shem’s and certainly my alter ego, was the unflappable minimalist, the Fat Man; the battle-hardened, defiantly pragmatic senior resident with uncommon level of common sense, who just seemed to know when not to get excited.

The Fat Man had a hypertrophied judgment, which came from lots of judging, lots of subtractive care – subtractive medicine.  Subtractive medicine is hard work. It is easier to intervene than not. Wisdom is hard work.

I do not know if the Fat Man ever existed. If he did he risks extinction. We are killing him with logic, rationality and long lists. He cannot fructify his judgment because he is afraid of being wrong.

He is afraid of errors of omission. He has internalized the limitations of medicine as his own personal failings. He confuses caution for compassion, compassion for intervention, intervention for treatment. He won’t stop unless evidence based medicine tells him to.

We have tamed the Fat Man–at a time when our healthcare needs him more than ever.

Saurabh Jha, MD (@RogueRad) is a radiologist in Philadelphia

5 replies »

  1. The Fat Man exists. I used to work with him and he was at my wedding. My dad and he worked with “Sam Shem” and they were colleagues x 30+ yrs!

  2. Vik, I think many doctors have a hidden Fat Man waiting to burst through the seams, like the rebellion of an adolescent!

    There is hope!

  3. This book was required reading for my entering physician assistant class at Hahnemann way back in 1980. My chief surgical resident was very good Fat Man in his own right.

    You are completely right, Saurabh, that we tamed the Fat Man. Even worse, we have sent him packing, much to our detriment. I’m afraid that barring a cataclysm, there’s no bringing him back.

  4. I love that book and it is still very true. Barack, Kathleen Sebelius and every member of Congress should be forced to read it.

    And don’t forget the “Electric Gomer Bed”