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Beyond the ‘House of God’ – how medicine hasn’t really changed at all

In 1978, as I neared the end of high school and readied myself for medical training, a book called House of God (HOG) was published by a doctor under the pseudonym Samuel Shem. By the time I read it as an intern eight years later it had become a cult classic among doctors.

Everyone I knew in my hospital read it, passing around the single copy we had, writing our names in the cover pages, along with that of the person next in line to get it. The response from each doctor among us was the same — we were thrilled someone had dared write down what it was really like to be a young doctor, to put down the hidden thoughts and conflicts, to dare challenge the status quo that takes from the best and brightest of young people, educates them to an ideal, and then confines them in a working environment where expectations can never be met. And where new careers are formed and moulded in an atmosphere of what can often be described as indifference at best, and at worst, professional neglect.

HOG is a satire along the lines of Catch 22, largely autobiographical, following in broad detail the career of psychiatrist Stephen Bergman. The contents are deservedly controversial, in that in it patients are objectified according to certain rules that go against conventional medical teaching. Modern patient advocates are likely to find much of the book offensive, as would conservative physicians who may believe the profession’s dirty laundry should not have been aired in public.

Nearly 35 years later, a group of doctors in the UK have been heavily taken to task for an offence that is trivial by comparison, in that they referred to delicate medical environments in similar terms on Twitter, using words like “birthing shed” for a labour ward, and “cabbage patch” for an intensive-care unit. Reaction has been just as polarised as the response to HOG, some supportive and other critical.

I’m the first to suggest doctors have to be very careful about what they post on social media and that there are boundaries that should not be crossed. But both HOG and modern social media lapses by doctors both allude to the same situation that appears unchanged nearly four decades apart, that the process of development of young doctors still takes place in a difficult and seemingly hostile environment, with reactionary consequences that at first glance are callous, insensitive, and unbecoming of a doctor, but are ubiquitous under the circumstances.

I recognise this situation too well. Nine months in a busy South African trauma unit during my surgical training had consequences more profound and long lasting on me than two years at war as a combat trained doctor. It was impossible not to objectify the results of a society in turmoil, where murder, violence, alcohol and crime seeped into one’s mind and under one’s skin. Ask my wife. She bears witness to the changes in me at that time.

I see no evidence that doctors’ lives have become easier since the days of HOG. If anything, resources are scarcer, workload has increased, the consequences of error are worse and patients have changed in a manner that should be welcomed, but still adds to the challenges of being a good doctor. And yet, venting or expression of frustration by doctors in public is clearly a no-no to many.

Is that necessarily a good thing? If those of us with a vested interest in high quality medical care — hopefully 100% of the population — are to hope for a better world of medical practice, it is important to know what doctors, and nurses, and patients, and all others involved in healthcare really feel. Otherwise policy makers and advocates will remain in the dark about the real grass-root issues.

HOG did us all a favour. It ratified the frustrations young doctors felt at the time. I see little evidence of change to date. Perhaps it would be good for HOG to be essential reading for all medical students, doctors, hospital administrators, bosses, patient advocates, everyone who cares, and who are willing to do what it takes to change the negative dynamics of modern healthcare.

For House of God is not the medical world we want to embrace. It is the medical world we want to avoid.