May 3, 2015

Reading "House of God"

On Saturday, I finished my rotation in the MICU and left around noon, trying not to run as I left the hospital on my way to a week of vacation. On Sunday, I boarded a bus for Boston and settled into my seat with that now classic book, House of God, on my phone. The first few hours on the bus flew by. I was completely engrossed; it was satisfying but also horrifying to read about things I had seen and felt as an intern written on the page with such honesty. In some ways, it's depressing that so much of what is written in House of God is still true today, forty-five years later. The terror of starting in the hospital, the overwhelming feeling of uselessness, the callousness that starts to creep in so that you can deal with patients that day after day have issues you cannot solve - all of these are the same now as they were then. 

It is so hard to convey the way that the medical hierarchy is so firmly entrenched, the way that each level firmly socializes the one below it into strict conforms of behavior. The resulting impulses - toward hedonism, toward fatalism, toward no longer having any f***s to give - and the resulting loss of humanity - the inability to have regular conversations, the inability to talk to anyone outside of medicine, the inability to follow the news - are isolating. The most horrifying arc in the story tells of the intern who beats himself up over an initial mistake that affects a patient's care, a mistake that gets thrown in his face repeatedly. When the patient dies, the intern is distraught, having blamed himself for six months or more, and throws himself off the roof of the hospital. 

While many aspects of medicine have changed - the interns' unrelenting call schedules are certainly different from ours, and the constant level of near-exhaustion that is described is almost never experienced now (a change for the better, I would argue) - the gradual loss of empathy in the interns is shocking and not surprising to anyone who has worked in the hospital. It is a necessary adaptation, one that Dr. Campbell warned about at my White Coat ceremony at the beginning of medical school. He warned us to "keep our white coats thin" around us, that our empathy would continue to help us connect with patients; he might have done us a better service to explain why it would be so tempting to let our coats shield us from the demands of our patients and our superiors. Sometimes, they are our only shield.

The laws of the House of God are the most telling. Some of them are perfect - still usable, still pearls! (*) - but some of them are reprehensible, showcasing the way that medicine can trod on your humanity when the work overtakes the pleasure of it (**)
1) Gomers don't die
*2) Gomers go to ground
*3) At a cardiac arrest, the first procedure is to take your own pulse
*4) The patient is the one with the disease
*5) Placement comes first
6) There is no body cavity that cannot be reached with a number-14 needle and a good strong arm
7) Age + BUN = Lasix dose
**8) They can always hurt you more
**9) The only good admission is a dead admission
**10) If you don't take a temperature, you can't find a fever
I've heard attendings say rule #3, and it's true: when anything goes wrong, even on L&D, the first thing is take a deep breath and clear your mind. Rule 2 is why so many patients have bed alarms and are listed as "fall risks." I've had an attending quote Rule #4 on MICU rounds. Rule 5 has been stated before as "discharge planning starts on admission." 

Other quotes stood out to me, truer than the Laws:
-"the worse the Private [attending], the better the bedside manner, and the higher the patient's regard."
-"The profession is a disease. It doesn't care what sex you are. It can trap us, any of us."
- on intern friendships and survival: "We were developing a code of caring, helping each other leave early, not fucking each other over, tolerating each other's nuttiness, and listening to each other's groans. Each life was being twisted, branded. We were sharing something big and murderous and grand. Sensing that, I felt close to tears. We were becoming doctors."
- "What sustains us is when we find a way to be compassionate, to love. And the most loving thing we do is to be with a patient, like you are being with me."
- "I'd thought of how his life had fluttered round me like a butterfly in dying autumn, chilled, beating against my lashes, frantic, calling me to still the birth of winter."
- "It had become an unwritten law among the terns: don't tell what you feel, 'cause if you show a crack, you'll shatter."

Luckily, I think medicine has slowly started to recognize the caustic erosion of this kind of internship on the soul of those who endure it. Duty hour changes, perhaps with the entry of more women into medicine, have forced the establishment to recognize the harmful effects of confronting mortality day in and day out, especially when physically exhausted. There is much more hullabaloo paid to the mental health of interns, with resources and emphasis placed on how we are adapting to our new roles and how we are coping with the stresses of medicine. No increase in meetings or educational sessions can take away all of these struggles; in some way, they are the crucible that forges us into true physicians. While empathy and close connection to patients makes for a beloved practitioner, the healthy physician must learn to distance herself from her patients. A short distance makes decisions more rational, more impartial, and better for the patient. Get too close, and you risk your sanity as each patient's tragedy becomes a part of you. 

Ultimately, the book ends with most of the interns having survived the year and moving on. At this point in the year, I, too find myself looking forward eagerly to July, with the arrival of new interns. No longer will I be the bottom of the medical totem pole. The chance to move up (however slightly) is intoxicating. Already, I've started to do what the interns in the book do at the end: they start to rationalize, to excuse. "It wasn't that bad!" is the dismissive cry of everyone about to finish intern year. The only way to feel okay about what happened is to deny what it was, to move on. In some ways, House of God still resonates because that drive is always there, in any difficult passage. The only way out is through - and so we continue. July 1st can't come fast enough.