Published in 1978, The House of God is a biting satirical novel that reveals the seamy—and sometimes darkly hilarious—underbelly of medicine and medical training. The book was both reviled and hailed when it came out. With more than 2 million copies sold, it has since become required reading for every generation of medical students and interns.
In the book’s introduction, no less than John Updike wrote that The House of God “does for medical training what Catch-22 did for the military life—displays it as a farce, a melee of blunderers laboring to murky purpose under corrupt and platitudinous superiors.” The Lancet called it “one of the two most important medical novels of the twentieth century.” MDLinx readers recently ranked it number one among the 10 most influential books for doctors.
Now, after more than 40 years, author Samuel Shem (the pen name for psychiatrist Stephen Bergman, MD, PhD) has written Man’s 4th Best Hospital, the long-awaited sequel to The House of God.
MDLinx talked with the author to discuss the sequel and how it reflects the state of healthcare today.
MDLinx: The House of God was published 40 years ago. Why did you decide to write a sequel, and why now?
Shem: I’ve always wanted to write a sequel, but I was out of medicine and hadn’t seen patients in a long time. But then, 5 years ago, I got a call out of the blue from NYU Medical School. And they asked, “Do you want to be a professor in medical humanities?” I said, “Why? What do you want me to teach?” And they said, “We want you to teach The House of God in the humanities program.” So, all of a sudden I was teaching it to medical students in a seminar, which meant I was also back in modern medicine after many years of not being in it.
First of all, I was excited and amazed at what medicine can do now. But second of all, I was appalled—I was appalled by two things: money and [computer] screens, which really means money and money. Doctors sit behind computer screens while “healthcare” squeezes every penny out of the system. So, I just caught fire, even at my age, and wrote it pretty fast.
MDLinx: The House of God reflects a time in the early 70s when people were listening to protest songs and standing up to authority. But we’re not living in those times anymore. So, how did you take the same characters and bring them into a contemporary era?
Shem: I knew I had to get to the core people from The House of God—Roy, Berry, the Fat Man, Hyper Hooper, Chuck, the Runt, etc—I had to get them all back together. But what were they going to do? At the beginning of the book, the Fat Man is rich and famous, and Man’s Best Hospital has fallen in the rankings to be nicknamed Man’s 4th Best Hospital, so [the administrators] are really scared. They bring in the Fat Man to do whatever he wants to try to save it. And the Fat Man says he wants to have a public clinic next to the hospital’s big skyscrapers—and this was really the touch of the muse on my shoulder telling me how it should go—he says he wants to show how “to put the human back in medicine,” which is mostly what the book is all about. So, with that, I was on my way.
MDLinx: In the book, the characters all quickly fall back into their jokes and their old feelings with each other. What was it like to bring back these characters again after so many years?
Shem: It was like meeting old friends, because the core group has stayed in touch.
MDLinx: Oh right. I forget these characters are based on real people.
Shem: Yeah, and you can actually see what it was like for everyone to get together again after all these years. At a symposium at NYU last December, we had a panel with the real-life Eat My Dust Eddie, Hyper Hooper, Chuck, the Runt, Berry, and Roy, and JAMA was there and they filmed everything. And from that, they made a half-hour documentary movie. Go to the home page at mans4thbesthospital.com, scroll down and there’s a typewriter there. Click on that and it’s a film called The Making of The House of God. It’s the six of us talking about everything that you wanted to know about our experience, and what it’s like now and all of that stuff. And the film is spectacular. It’s so funny and so touching—it’s so good that it was accepted into the South by Southwest film festival in March.
MDLinx: The characters go through a lot in this book. On one level, I enjoyed it as a good, funny story with these interesting characters. But on another level, the book takes on just about all the major problems with medicine right now: screens, money, physician burnout, physician suicide, lawyers and beancounters running hospitals instead of doctors, and even gun violence. It really talks about how healthcare today is broken—and needs fixing.
Shem: I felt it was my job, number one, to show the situation of modern medicine, and that means all the different problems with it. And then, number two, how to do something about it. I’m very interested in getting out there now and trying to use whatever credence I have to help in reforming healthcare because, as you know, we doctors are really not happy.
MDLinx: You’re not just writing about it. You’re trying to change it.
Shem: I’m a writer who writes in resistance to injustice, and how to show the power of connection in humanity and the danger of isolation. And I felt an obligation in writing this book to really get close to what the hell is going on in healthcare.
The House of God was for doctors because it was about the brutality of training. For Man’s 4th Best, I felt it was important to really address something that affects a lot of people. So, this book is for everybody—this is for doctors, nurses, patients, hospitals, the public, and the people who make policy. This is much broader. Let’s hope the sales will be broad too. [laughs]
MDLinx: There’s a scene toward the end of the book where the characters are all gathered together and talking about a number of important things, and one of those is the idea of forming a union. And not just a doctors’ union, but one that would also include nurses, physician assistants, and hospitals. Why doesn’t such a thing exist already?
Shem: That’s a very good question. We doctors, we just don’t get together. We’re too independent, you know? Medicine is still mostly a male-dominated culture, and men don’t work together as well as women do. But nurses—although there are many male nurses—nurses have one of the strongest unions in the United States, and they almost never lose. They almost never have to go out on strike. The threat is enough. So, what I realized is that nurses and doctors are on the same team here. And patients are on that team, too, and maybe even hospitals. And all of us are getting screwed by the moneyed interests in all the different ways that I talk about in the book. I think that it’s a very ripe situation now, especially for doctors and nurses, to really try to get together.
I also realized I had to put my money where my mouth is. So, I got to be friends with Theresa Brown, a wonderful nurse who’s also a writer, too. She wrote a great book, The Shift. And I asked her, “Why don’t you and I write an op-ed piece together for The New York Times?” So, we did it and they say they’re going to print it, and it’s all about this stuff—it’s about money and screens and how nurses and doctors are on the same page and we can we get together. I’m really happy about it. I don’t think I’ve ever seen an op-ed piece in The New York Times with a doctor and a nurse as co-writers.
MDLinx: That makes me think of another theme that came up in your book. I wonder if you could reconcile the way women were seen in The House of God and the way they appear in Man’s 4th Best Hospital?
Shem: The difference, as you noticed, is the portrait of women 40 years ago in The House of God was mostly that they were sex objects and not really accomplished in medicine. I got severely criticized for that (although I think Berry was a terrific character). My defense at the time was just reality—that’s the way it was. I didn’t invent it, but I had to write it. In Man’s 4th Best Hospital, I’m reflecting the way things are now. In the Fat Man’s clinic, the number of women comes into parity with men. And the heroes in this book are often women. There are some really strong women, and especially from the next generation when a medical student, Mo, comes to join their clinic.
MDLinx: Speaking of the Fat Man and his idealism, one of the lines he says caught my attention. He says to a toady resident, “I’m so idealistic, to you I sound cynical.” I felt that’s how the book started—a little cynical—but by the end I realized that, yeah, this book is idealistic. That one line seemed to capture everything.
Shem: As a writer, you don’t plan to write a line like that. It came out of God, out of the Divinity, you know, not me. What happens later in the book is that these people go through a kind of hell—I won’t reveal what it is—but they go through hell. Still, I always feel that I have to show the hope. And we’re living through it now, a kind of hell. I don’t know your politics—it doesn’t matter which side you’re on—but it seems really necessary, in terms of the fragmentation and hatred, to show a way.
And I really believe the solutions that the Fat Man gives at the end of the book are pretty good. The basic thing that he says at the end—I’ll spoil it for people—is that we doctors have to squeeze the money out of the machines. If machines were not used for billing but just for data and information transfer, doctors would be happy campers. We’d really be happy campers.
So, the Shem solution is: unhook the data function of the electronic medical record from the cash part of it. Then, instead of 8 hours a day in front of the screen, we’d have maybe 2. It would work. Look at the VA—they do it. By the way, these are good questions.
MDLinx: Thanks. So, why hasn’t The House of God been made into a movie?
Shem: Oh, bad question! Bad question.
MDLinx: Sorry. If that’s a bad question, we can skip it.
Shem: Yeah, the less said, the better. It was made into a movie, and it’s the worst movie ever made. You know how some movies are so bad, they’re funny? It’s way down below that. It’s lost in some archive somewhere. I don’t even have a copy. It was horrific. Yeah, the less said about it, the better.
MDLinx: OK, is there anything else you want to say?
Shem: Let’s just hope this book has an effect on the two most important issues in the coming election: healthcare and healthcare.
In an unprecedented move, JAMA published an excerpt from Man’s 4th Best Hospital in its November 2019 issue. Read it here.
Disclosure: This post includes uses affiliate links to Amazon products, allowing us to receive commission for purchases.