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.
