The laws of The House of God and Man’s 4th Best Hospital

Forty-two years ago, when I had finally finished the seven revisions of my first novel, The House of God, my editor said, “Why don’t you add a glossary and a list of The Laws of the House of God.”  Writing the Laws, I hardly needed to refer to the text; they just flowed out. The Laws became common parlance, not only tacked up in on-call rooms but even, recently, listed on a T-shirt for sale. Medicine has changed drastically, but the House Laws are still here.

The Laws of The House of God (1978)

I. Gomers don’t die.

II. Gomers go to the ground.

III. At a cardiac arrest, the first procedure is to take your own pulse.

IV. The patient is the one with the disease.

V. Placement comes first.

VI. There is no body cavity that cannot be reached with a #14 needle and a good strong arm.

VII. Age + BUN = Lasix dose.

VIII. They can always hurt you more.

IX. The only good admission is a dead admission.

X. If you don’t take a temperature, you can’t find a fever.

XI. Show me a BMS who only triples my work, and I will kiss his feet.

XII. If the radiology resident and the BMS both see a lesion on the chest X-ray, there can be no lesion there.

XIII. The delivery of medical care is to do as much nothing as possible.

Most of the Laws are still pertinent, helping guide us docs when we are in tough spots: Laws III, V, VI, VII (the equation for “Lasix dose,” with no scientific explanation, works every time), VIII, IX, X, XI, XII.

But which are the non-pertinent Laws?

Laws I and II were joking names using humor for our own survival and bonding — never said within our patients’ hearing. Now they seem the height of cynical.  Yet like all else in The House, they were a fact of life — much like the women in the House, described almost exactly as they were. It was the culture of the 60s and 70s, the days of “Women’s Liberation.” All I did was write it down.

Law IV, “The patient is the one with the disease,” tells us to keep an emotional distance from our patients. It was thought to be a self-protective device. But in fact, it could be called “The Doctor’s Disease”: “You the patient are different, sick; I the doctor am well.” We distance ourselves behind white coats, and now in front of computers. What heals, in fact, is a good connection, mutual connection. See the Laws of Man’s 4th  Best Hospital below.

And a word about the useful and amazing Law XIII.  When I got to writing this last Law, I quickly typed out: “The delivery of medical care is to do nothing.”  And then I stopped, still. I felt the Muse tap me on the shoulder, whispering, “Hey, pal, that is too cynical!” In a flash, I typed: “The delivery of medical care is to do as much nothing as possible.”  It is, in fact,  the wisest Law of all.

The Laws of Man’s 4th Best Hospital

Two years ago, when I had finally finished the seven revisions of my seventh novel, Man’s 4th Best Hospital, the sequel to The House of God, my new editor said, “Why don’t you add a list of The Laws of Man’s 4th Best Hospital?  Roy G. Basch is again the narrator, his wife Berry, a psychologist and Buddhist teacher. They have a five-year-old daughter named Spring. The Fat Man is again the story’s hero.  Fats is creating a public outpatient clinic, leaning up against the massive Man’s 4th Best Hospital.  His mission? “To show how to put the human back into medicine.” Several former interns of The House join the team — Eat My Dust Eddie, Hyper Hooper, The Runt, Chuck — and an equal number of women doctors, including Berry. In The Fat Man’s Clinic, there is gender parity.

I. Learn your trade in the world.

II. Isolation is deadly; connection heals.

III. Connection comes first.

IV. Use the “we.”

V. It’s not just what we do; it’s what we do next.

VI. It’s not that we do what we think we can get: it’s what we dare to do together.

VII. Without health care workers, there’s no health care.

VIII. Squeeze the money out of the machines.

IX. Put the human back into medicine.

X. Stick together, no matter what.

Medicine has changed drastically since 1978.  Back then, what got me writing The House of God was catharsis and to deal with injustice — the brutality of medical training. Looking back, each of us interns was at the bottom of the hierarchy of the hospital and got isolated: first, we got isolated from each other; next, we each got isolated from our authentic experience of the system itself — we thought we were crazy, for thinking it was crazy.  Finally, the call hours kept us isolated from good connections with our loved ones outside. Some say that the novel helped the movement toward more humane hours in residencies.

For two years after the House, I did no public appearances — I was a purist.  One day I got a letter through my publisher: “I’m on call at night in a VA hospital in Tulsa, Oklahoma, and if it weren’t for your book, I’d kill myself.”  Hmm.  Maybe I can help.

I started to go out talking about the internship, about resisting injustice: the danger of isolation, and the healing power of good connection — mutual connection.

Six years ago, I joined New York University’s Grossman Medical School to teach The House in their medical humanities program. All of a sudden, I was back into modern medicine, with fresh eyes.  I saw the miracles that we docs can do. NYU is the most humane system I’ve seen. But medicine has changed. As Roy Basch writes, at the beginning of Man’s 4th: “I’m called to write this novel because it was a time when medicine could go one way or another, either toward a more humane system, or toward money and screens — which means money and money, since the machines are not just for data, but billing insurance.”  We doctors, nurses, and other health care workers are in pain and suffering. “Burnout,” or “moral injury,” or what I would just call “abuse,” is hellish. Inhumane.  Perhaps Man’s 4th, like The House, can help bring change.

And so medicine is a lot different, and Mans’ 4th Laws are different.

Law I means that your patient is never only your patient, but also a person in the world.  Not only family and friends, but poverty and racial injustice and equity and climate and where the water comes from and where the garbage goes?  All are relevant.

Laws II, III, IV, V point out that we have to shift from a vision that is self/other, or I/you. This is self-against other, the adversarial turf of lawyers.  It is an isolating and dangerous world view. The healthy view is in the “we,” which informs both “I” and “you.”  I call it: “The shift to the ‘we.’”

For instance, when we see a new patient, Law III: “Connection comes first.”  If you connect with him or her, you will find out everything. If you don’t connect, you won’t find out anything. Simply using the word “we” with a patient — “Let’s talk about what we are going to do” — prompts the patient to reply, “Well, maybe we can …”  The use of “we” say “there’s a relationship here.” And studies show that the main reason surgeons get sued is the patient saying, “I had no relationship with him.”

Law V: Nobody gets connection right all the time; we are always screwing it up.  The best doctors hold the “we” through the disconnect to a better connection.  Even saying “We are in a disconnect” is a connecting statement. It’s not just what we do; it’s what we do next.  In our offices and at home.

Laws VI, VII are asking us to be aware of the larger political space.  If we are going to get what we want in health care, we have to reach high and dare together.

Law VIII: “Squeeze the money out of the machines,” says the Fat Man, giving his team a lecture on ‘The six rackets of American health care: follow the money.”  His main “fix” is to free us from spending 60 percent of our time treating the screen, instead of treating the patient or ourselves. Obama created the screens for data.  All good.  But then the private insurance industry somehow put a cash value on each piece of data and jackpot!  Fats says we have to go back to using screens for data, not haggling for payment. The best model in America is the non-profit VA: every appendectomy in America is billed at about the same price. No more war across the screen. No 60 percent of our time clicking for cash.

Law IX: “Put the human back into medicine.” This is our goal.

Law X: “Stick together, no matter what.”  This is how we achieve it. In those pre-covid days, in a theatre, if an actor collapses, does a shout go out: “Is there an insurance executive in the house?”  No.  We doctors and nurses and others do the work.  If we just ally with each other — doctors, nurses, other health care workers, and patients, we can get a fair deal.  And we also get better health care for all.

With the pandemic, with so many health care workers risking so much and accomplishing real miracles of care, our national health care has been in the spotlight. In many ways — not the least in equity for all, and stresses in our health care jobs — we have seen a great need for improvement. I’ve lived through the 60s and 70s.  I’ve seen how change comes. Trust me. In this bad time is hope.  This is how change happens.

Samuel Shem is the author of the House of God and Man’s 4th Best Hospital. He can be reached at his self-titled site, Sam Shem.

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