Thirty years ago, Samuel Shem (a.k.a. Stephen Bergman, MD) wrote The House of God, his landmark satire of the internship year. For medical students and housestaff of the late 1970s and early ‘80s, this was a defining novel. Few internal medicine residents in my residency program had not read it.
Nowadays, however, current housestaff may have heard of The House of God, or might quote famous lines, but it is a rare resident who has actually read the book. The House of God is a non-politically correct tour de force that deals with complex medical and professional themes. Many of these issues, such as hospital safety, signouts, quality of life and work hours, retain their importance and vitality. The book also coined several terms that quickly became a standard part of the intern's vocabulary, some of which are still in use today (see for glossary).
Back in the day, The House of God offered a set of rules of engagement that were essential to an internship. The laws of The House of God, as espoused by the all-knowing fictional resident “The Fat Man,” were the key to survival for both interns and patients. Some of these rules might seem out of date, but with some minor rewriting and translation, they can still be useful to the modern hospitalist.
Laws of The House of God
The original rules of engagement and their meanings, with updated explanations:
#1. GOMERs don't die.
Original meaning: The patients who seem the most hopeless—who return to the ER again and again—are the ones who are repeatedly admitted to the inpatient service, with little chance for improvement.
Update: On its own, the human body can withstand a broad range of disease and destruction, but with the right cocktail of medications, oxygen and nutrition, life can be sustained beyond all reason. The American population is aging, and the system may not be ready for them. Palliative care can save many from needless suffering.
#2. GOMERs go to ground.
Original meaning: There are two heights from which patients can fall: the orthopedic and the neurosurgical height. Either way, it leads to a “turf.”
Update: Falls in the elderly, both in and out of the hospital, are dangerous and common. The problem is not just the bed set to the “orthopedic height”; it's the medications and lighting and urine-splattered floors and delirium. Admission for pneumonia is bad; admission for pneumonia complicated by a femur fracture is worse.
#3. At a cardiac arrest, the first procedure is to take your own pulse.
Original meaning: Don't panic!
Update: Don't panic!
#4. The patient is the one with the disease.
Original meaning: Yes, you're going to die someday. Get over it, and go treat your patients.
Update: Don't go too far in distancing yourself from the patient that you forget the patient is a person. One should try to keep a healthy perspective. When I'm a patient, I'd rather not be “the hip fracture with the UTI in 219a;” I'd prefer to maintain my own identity.
#5. Placement comes first.
Original meaning: The absolute first question should be: “How am I going to turf this patient?”
Update: When a patient gets admitted and it looks like he or she may need nursing home placement or another supportive environment, don't wait until Friday afternoon to start the process. Don't forget you need a three-day admit for the Medicare benefits to kick in.
#6. There is no body cavity that cannot be reached with a #14 needle and a good strong arm.
Original meaning: Don't be afraid to go for a biopsy.
Update: The interventional radiologist is your friend. From diagnostic tap to therapeutic decompression, imaged needle placement beats the blind poke.
#7. Age + BUN= Lasix dose.
Original meaning: Simple memory tricks make decision-making easy.′
Update: There is no shortage of peerreviewed, evidence-based, medical society-sponsored, comprehensive algorithms, some of which are actually quite good. Others lead us into a Kafka-esque labyrinth of arrows, text boxes and cross references from which we may never escape.
#8. They can always hurt you more.
Original meaning: They—that is, the patients—can always cause you more grief than they already have, so count your blessings.
Update: “They” can also include administrators, The Joint Commission, your insurance carrier, your patients' family and students. They will only hurt you if you let them, so keep your chin up and your head on straight.
#9. The only good admission is a dead admission.
Original meaning: A very cynical statement about being overworked.
Update: I have had a few dead admissions. They were alive when they left the emergency room, but something happened along the way. Other times, they arrived in their rooms and took a fast trip to the ICU. On the other hand, some arrived ready to leave—same-day admit and discharge. The ideal admit is probably somewhere between these poles.
#10. If you don't take a temperature, you can't find a fever.
Original meaning: Don't go looking for problems.
Update: If the consulting service comes by and tells you to get a “ceruloquat 1103a dimer level,” don't forget to order the mixing assay. And if you don't know what a test means, you probably should not order it.
#11. Show me a student from the “best medical school” (BMS) who only triples my work and I will kiss his feet.
Original meaning: Hard-working, eager medical students are a blessing and a curse.
Update: Foot-kissing is out, since it is definitely not politically correct to perform pedal osculation on your sub-I. In his speech entitled “The Hospital as College,” Osler said that students keep us sharp and up-to-date. With modern electronic record systems, there is only so much scut you can get them to do, and certainly not enough to bring them up to the level of “monkey.”
#12. If the radiology resident and the BMS both see a lesion on the chest X-ray, there can be no lesion there.
Original meaning: Beware the zealotry of newly minted residents and BMS's.
Update: Students hear too many S4s and not enough consultants. If a heart murmurs in a forest and nobody hears it, did you order an echo? Wait for the final report and review the film yourself.
#13. The delivery of medical care is to do as much nothing as possible.
Original meaning: Primum non nocere. Do no harm.
Update: Primum non nocere sans documentum. Do no harm without proper documentation.
The House of God glossary
Following are some key terms used in The House of God.
GOMER. GOMER stands for Get Out of My Emergency Room. It is a derogatory term used to characterize the most difficult and persistent of patients. Today, “GOMER” has been generally replaced by the more descriptive term “troll,” as in one who waits under a bridge to eat an unsuspecting intern. GOMER had some cognitive caché at the time because of the dimwitted television character Gomer Pyle from The Andy Griffith Show.
Turf. To transfer a patient to another service. Turfing a patient to another service is a respected skill in any resident. A patient might be turfed to home, to the nursing home, another service or even the morgue.
Wall. An emergency department doctor who does not admit, or a resident who can successfully turf to another service before a patient is admitted. The wall is the most respected house officer. This subspecies of emergency physician is increasingly rare, and faces extinction.
Sieve. A doctor with a low threshold for admission, no matter the cause. Dealing with sieves remains a problem for hospitalists. When the census is high, the inappropriate admission is the bane of one's existence, causing headaches, paperwork and consumption of resources.
Bounce. A term that's morphed into the more sporty “bounceback,” i.e. the dreaded readmission. It remains an unpleasant reality and a vital piece of medical jargon. Example: “We just got a really complex trainwreck from the ER; good thing it's a bounceback to the other service.”
LOL. Of all the terms used 30 years ago, the LOL in NAD (Little Old Lady in No Apparent Distress) has most thoroughly lost its meaning. If I were to write to my daughter about an LOL, all she would do is laugh out loud.