Book Review
The House of God
N Engl J Med 1996; 335:1165-1166October 10, 1996
- Article
The House of God
By Samuel Shem. 382 pp., illustrated. New York, R. Marek, 1978. (Out of print.) ISBN: 0-399-90023-3Participation in a recent ethics symposium at our hospital required one to read The House of God. For most of us, it was not the first time we had read the novel, but rather a return to it after 15 years. It is worth revisiting The House of God because of the many changes in medicine during those 15 years.
One is struck early on by how much the book is outdated. The sycophantic attending physician who hospitalizes patients for extended testing, portrayed in the book as Dr. Putzel, has been all but eliminated by reimbursement based on diagnosis-related groups. Putzel represented a frustrating paradox. In the era of open-ended reimbursement based only on fee for service, the indiscriminate use of diagnostic studies during a protracted hospitalization generated substantial revenue for teaching hospitals, which considered the Putzels of their staff valuable assets. But medical students and house staff perceived them (often correctly) as doctors who not only increased their workload but also contradicted basic tenets of medicine. Physicians who trained during that era can easily understand the futility felt by the book's protagonist, Roy Basch.
The system of reimbursement based on diagnosis-related groups, which began in the early 1980s, turned the tables on physicians like Putzel. Fixed-scale reimbursement based on specific diagnoses became a problem for physicians who hospitalized patients for a long time and indiscriminately used multiple diagnostic studies, because the hospitals now lost money on them. The new economic forces selected against these kinds of physicians.
Another character in The House of God, Dr. Pinkus, a cardiologist, is comfortable with his diagnostic skills, but only if helped by the high-technology facilities of the intensive care unit. The care of patients in the medical intensive care unit is presented as a series of conditioned responses to objective data, with little thought to the individuality of patients.
Dr. Pinkus has trouble facing illness and death. By objectifying his patients, he avoids the discomfort of closely identifying with those who are critically ill or dying. Dr. Pinkus's self-absorption and preoccupation with running are other mechanisms that distance him from his patients.
Although the Putzels of medicine are now anachronisms, the depersonalized Pinkuses have become increasingly evident. The art of diagnosis is giving way to algorithms. Proper use of an algorithm will lead to a diagnosis, and outcomes data will choose the treatment. The sequence of responses a physician makes, from the patient's arrival at the hospital to the day of discharge, is now a “pathway.” Pathways are being developed and refined by physicians, unit managers, and administrators who are under pressure to deliver efficient, streamlined health care. The pathway may be a financial necessity, but the patient's individuality may be lost. The new system will create the sort of sterile, controlled environment in which Dr. Pinkus would feel quite comfortable.
Just as death and incurable disease promoted the depersonalization of patients in The House of God 15 years ago, the focus on length of stay, outcomes data, and costs tends to depersonalize today's patients.
Does this book offer any lessons for us today? Perhaps the answer is in the novel's one sympathetically portrayed physician, the Fat Man. “He's got a healthy way of dealing with this incredible situation. He uses compassion, humor. He can laugh.”
Rob Reid Hood, M.D.
St. Thomas Hospital, Nashville, TN 37205- Citing Articles (1)
Citing Articles
1
Delese Wear. (2002) The House of God. Academic Medicine 77:6, 496-501
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