Residential Space A creative outlet during residency, turned ongoing virtual soap box

Posted on Tuesday, October 18th, 2005 at 8:02 pm. About Books.

I’m finally reading “The House of God”

Previously posted on October 18, 2005 at: http://spaces.msn.com/members/jodidodds/Blog/cns!1p1a54g1PSNkhyBLLbfi4i8A!129.entry

Yes, I know – book titles are to be either underlined (MLA) or in italics (as in, when they are informally referenced in a newspaper article), but MSN is not allowing me to use either of these features in my title. C’est la vie. In any case, Samuel Shem’s novel, The House of God, is supposedly a must-read for anyone going into medicine. Most physicians, from what I understand, read it during their third or fourth year of medical school. A PA student, Adam Gedney, gave it to me at the end of my third year, and it sat on my shelf – until many of my fellow residents started quoting it at me.
 
Roy Basch is the “protagonist” in the book – a 31 year old man who has graduated from BMS (“Best Medical School” which is supposed to represent Harvard) and has landed a residency at the prestigious House of God Hospital (which is supposed to represent Beth Israel Deaconess in Boston). It’s astonishing to me, because much of what Shem relays in his writing, despite having written the book in the 1970s before residency work hour restrictions, I can totally relate to. I know how it feels to be so mentally and physically exhausted that small, seemingly unimportant things make one burst into tears. I know the smell of urine in the hospital and bowel preps. Despite being a book from “the old days,” I am also surprised by how familiar much of the terminology is – to “turf” someone to another service, a “LOL in NAD” (a little old lady in no apparent distress), and I am acquainted with the concept of throwing steroids at any patient about to die to see if it makes a difference at the last minute.
 
The House of God also outlines a set of rules that interns still reference in 2005. Here they are: 
  • Gomers (an acronym for “Get out of my emergency room” – these are old, demented people who will sit on a resident’s service for weeks awaiting placement in another facility) don’t die.
  • Gomers go to ground.
  • At a cardiac arrest, the first procedure is to take your own pulse.
  • The patient is the one with the disease.
  • Placement comes first.
  • There is no body cavity that cannot be reached with a #14 needle and a good strong arm.
  • Age + BUN = lasix dose.
  • They can always hurt you more.
  • The only good admission is a dead admission.
  • If you don’t take a temperature, you can’t find a fever.
  • Show me a BMS (Best Medical Student) who only triples my work and I will kiss his feet.
  • If the radiology resident and the BMS both see a lesion on the chest x-ray, there can be no lesion there.
  • The delivery of medical care is to do as much nothing as possible.

I don’t particularly agree that the only good admission is a dead admission – I think he just means that, at 5AM when he is exhausted and an “interesting case” arrives in the ER, at that point there is no such thing as a good admission, because it is preventing him from sleeping.

Many of the other rules are hilarious, and shockingly, quite true. Take #2 – “gomers go to ground.” My first week on an oncology service one of my colleagues was paged because a demented patient got out of bed, fell, and broke his hip. Since that time, I have had three of my own patients fall out of bed in the middle of the night, fortunately not breaking any bones or resulting in any cerebral bleeds. BUT, I am currently on night float, and I am constantly paged because older patients try to walk around and go straight to the ground. In The House of God they lower the beds to the ground and it saves them a lot of trouble. I have started doing this, and it works beautifully.

It may seem crass to claim, as a physician, that the proper way to practice medicine is to do as much nothing as possible, but I have seen how many consequences can arise from a patient undergoing unnecessary procedures and taking unnecessary medications. Often aggressively interveing results in more (and worse) problems than what the patient was initially admitted with. I am all about doing nothing when nothing is appropriate.

Age + BUN (blood urea nitrogen content) = Lasix (a diuretic, aka “water pill”) dose is a nice one, and because it’s not scientifically proven, most of us start with a low dose of lasix and work our way up. What is scary is that once I give a dose that exceeds the sum of a patient’s BUN and age people who I thought would never pee actually surprise me with some urine.

And placement…ahhh, yes, placement is oh so important. I would say at any point 30 to 50% of the patients on my internal medicine service have no acute medical issues, but are awaiting placement either at assisted living, a skilled nursing facility, a drug and alcohol rehab program, a homeless shelter, a transitional care unit, a psychiatric hospital…the list goes on and on AND ON AND ON… When patients hang out in hospitals without medical issues, it is inevitable that they will acquire them. They are surrounded by sick people. They end up with staph infections or C. difficile diarrhea or a hospital-acquired pneumonia. Again, it may sound insensitive to focus so much on placement in this novel, but I can atest to the importance of good, early placement.

One recurring theme in the book I cannot relate to is having sex with nurses in the call rooms. I can’t exactly relate to all of the sex that goes on between residents and attendings on Grey’s Anatomy or ER or Scrubs either though. Medicine has become a profession of both men and women and the work environments are more respectful. We are constantly reminded about sexual harrassment and what it means. Plus, I see more residents in marriages and long-term relationships, and with work hour restrictions we actually have time to spend with our significant others.

Anyway, this post is growing much too long, so I will close. I am on page 209 of The House of God and expect to see a demoralized, cynical Roy Basch at its conclusion, questioning his decision to enter medicine. I am very grateful for laws that enable residents to maintain semi-decent qualities-of-life during their training (she writes, typing at her hospital computer at 8PM, three hours before her shift ends). I do not expect to complete my intern year as a demoralized, dejected person, but rather as a physician with a year of experience, prepared to move on to what comes next.

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