The laws in the House of God

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I thought the most important stuff I would learn during my internship internal medicine would be of the medical kind. I was wrong. Maybe because the field did not agree with me, or because I did not agree with it? I don’t know, but the fact of the matter remains that an internist gave me the best tip I had been given in years, which I will now convey to you guys: read the book ‘The House of God’ by Samuel Shem.

Why? Well first off: everyone who matters (doctors) has read it, especially your supervisors. Not necessarily a good reason, but be honest, isn’t this the sole reason you started reading Harry Potter too? A nice boon off this is that you will suddenly understand (and suddenly constantly notice) inside jokes and even jargon directly derived from this book. The tv-show Scrubs for instance often references it - in the episode “My Student”, J.D. quotes the medical student rule, “A famous doctor once said, ‘Show me a med student that only triples my work, and I’ll kiss his feet.’”. Thirdly, the most important reason, because of the cool and insightful content of the book: the descriptions of the eternal laws that govern the workings in a hospital.

Thankfully, it is also an awesomely funny read, though slightly depressing (in a good way). Still not convinced? Hopefully, this introduction to the book, describing the essential laws and jargon, will. For you lazy readers out there: no worries, this intro will provide you the superficial knowledge to understand and exploit those inside jokes. High grades in the pocket! And why the hell would I write this in English? Because it should be, that’s why. I honestly believe the original language the book is written in adds to its quality, especially its humor.

Be warned though! Possible side effects of this article may include: extreme cynicism about the avail of your future profession, possibly leading to severe depression, alcoholism in males and chocolate induced obesity in women. Do not proceed if you are severely intolerant to any form of humor, especially that of a cynical or sarcastic kind.

Synopsis
First, let’s quickly discuss the setting of the book. The story revolves around Roy Basch, an intelligent but naive medical student who starts his internships at the internal medicine wards. The story is set in the US in the early ‘70s, so prepare for loads of sex, drugs and rock and roll. At this ward he starts working insane shifts and experiences god-awful things. Luckily he does all this with a charismatically insane resident called ‘the fat man’.

The cool thing for us: the book focuses on the hard, distasteful labour the interns must perform, the sometimes poor working conditions, their lack of sleep, their lack of time to spend with friends and family, and the emotional demands of the work. Think you will be saving lives? You are wrong. In short it revolves around our own lives as ‘coassistenten’ taken to the extreme. Still it’s recognisable enough. Now, finally: the laws!

The laws

1. GOMERS DON’T DIE.
What are GOMERs? GOMER stands for Get Out of My Emergency Room. These are demented old people with multiple medical issues who keep decompensating and are in a constant state of delirium. Funnily enough: these people require an enormous amount of medical care but never seem to die. They are meant to represent the perfect examples of futile medical care.

2. GOMERS GO TO GROUND.
As soon as you turn your back, these “people” will fall and probably break a hip.

3. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
An actual useful tip: there is no emergency situation in which it is not helpful to take a few seconds to make sure you stay calm and in adequate control of the situation.

4. THE PATIENT IS THE ONE WITH THE DISEASE.
So be nice and empathetic but at the end of the day you live your own life.

5. PLACEMENT COMES FIRST.
You will notice cardiologists and pulmonologists are experts at this one. ‘What the hell is this patient doing in my ward? Well yes, there is fluid in his lungs, but that doesn’t make it cardiology/pulmonology!’

6. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14G NEEDLE AND A GOOD STRONG ARM.
Pretty self explanatory and...ouch! In the book GOMERs prove to be the ideal practice objects for interns, let’s just leave it at that.

7. AGE + BUN = LASIX DOSE.
Who needs guidelines or the FTK ? In a decompensatio cordis case, just add the BUN (blood urea/natrium ratio) to the patient’s age and you know how much Lasix (brand name of loop diuretics) to give him.

8. THEY CAN ALWAYS HURT YOU MORE.
Yes, everyone in the hospital is out to get you and the only point at which you will have reached rock bottom is when you are literally splashed against it, following the jump from your hospitals rooftop. Other than that: it can always get worse.

9. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
The paperwork is a bitch though...

10. IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.
Something every patient in the primary care setting seems to understand, but doctors and nurses in the ward don’t. A law -I think rightfully- questioning the habit of routinely taking each patient’s temperature.

11. SHOW ME A MEDICAL STUDENT WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
We really are a pain in the ass sometimes.

12. IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
Is funny because it’s true!

13. THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.
The big theme the whole book is really about: to show how futile much of the care we provide is - at least in the seventies. Remember, this was before people even thought about things like euthanasia. The book shows some great examples of unnecessary and in most cases even harmful diagnostics and treatment. Sadly these examples are probably the only things that aren’t very exaggerated.

So I hope I have convinced you to pick up this book or at the very least helped you suck your way up to a higher grade: go forth and impress your attending! One last tip: this book is best enjoyed during your internships. As the icing on the cake, or in this case at the bottom, I explain some jargon below. Still excited to be a doctor?!

Some jargon to help you along

LOL in NAD: Little Old Lady in No Apparent Distress (or No Abnormality Detected). In other words: please go home and get well there, before staying in this hospital will kill you!

Zebra: we use this one a lot: a rare diagnosis that is very unlikely to cause a patient’s symptoms. “If you hear hoof beats, think horses, not zebras”. In Dutch also: witte raven.

To turf: the act of trying to get rid of your patient, and get them anywhere else in the network of care, directly associated with law 5. Sometimes even harming your patient to achieve this goal.

To bounce: the act of refusing a turf towards your own ward.

To buff the charts: the act of making a patient look well treated in his charts without actually providing any treatment, which often turns out to be the best treatment (law 13). This could also be referred to as fraud for the good of humanity.