Samuel Shem’s The House of God sets out to unveil obscured realities faced by doctors during residency. The satirical expose of life as an intern (or first year resident) at an elite academic teaching hospital toes the line between cynicism and bitterness, between black humor and anger. The work has achieved cult status among medical students and residents and is considered by some to be “required reading” for anyone thinking about becoming a doctor.

Reading The House of God is an exercise in shock and awe for some naïve and idealistic students: it will tear your rose-colored glasses from your face and smash them to bits underfoot. The work follows Roy Basch and a group of ‘terns through their first year of graduate medical education as they cling frantically to what remains of their sanity; horrified, jaded, and burned out, their idealism crumbles under the harsh realities of [then] modern medicine. The Laws of the House, nuggets of wisdom that spit in the face of their idealistic view of medicine, are dispensed periodically to the ‘terns by the Fat Man over the course of the year.

The Laws lay bare and explicit the disparities between what drives many young doctors to the medical profession and the realities of clinical practice. Law I: “Gomers don’t die” but the patients you think you can ‘help’ – the ones that have retained some semblance of what makes them human and inevitably the ones you like the most – will try their damndest to die on you. For all the advanced interventions of modern medicine, law XII dictates that “the delivery of medical care is to do as much nothing as possible”. The more you seem to intervene, the more complications arise and the more harm you seem to do, despite your best efforts. Much of what you learned in med school isn’t even practical in clinical practice: Age + BUN = Lasix dose.

The implications of the Laws of the House alone convey some of the broad themes of the work, but it is the manner in which Shem describes the systematic abuse, burnout, and disillusionment of the ‘terns that really hits home for so many young doctors. The rigid medical hierarchy rivals the military in terms of bureaucratic politicking, and downstream emotional abuse is rampant. The sleep-deprived ‘terns stagger onward, finding ways to cope with their disillusionment: the escapism is evident in the saucy hypersexualization of the hospital setting. Other ‘terns, like poor Potts, buckle completely in the pressure cooker.

Some criticisms of the book argue that it’s outdated. While it is old and both medicine and societal norms have moved on since its original publication, much has remained the same. The rigid hierarchy remains along with the attitudes of those within it. The incidence of gomers and gomeres has only risen. Patients have gotten more informed and less grateful, and new medical technology keeps them alive for longer – perhaps too long? Some things have changed completely though: health care reforms have been passed that address Shem’s commentary on certain styles of doctoring: specifically in the case of Putzel.

The book was written before the implementation of the 80-hour resident work week, but in many hospitals this current policy is more of a suggestion than a rule. I’ve done 80-hour weeks, but never in a work environment so intrinsically emotionally draining and simultaneously hostile to newbies. I could see myself becoming incensed at the politics of the medical hierarchy more than any other aspect of residency. But I’ve spent some time in pretty miserable jobs myself, so I’m undeterred by Shem’s downtrodden description of life as an intern.

I tend to think that a great deal of the misery stems from students’ warped preconceived notions of a doctor’s daily minutiae and a lack of awareness of the realities of clinical practice. And looking anecdotally at the broad demographics of medical students, a fair amount go from having little work experience to being thrown into the fire at 80+ hours per week in a hostile environment with significant responsibility over the health of people under their watch. They have the experience of third and fourth year of med school, but the level of responsibility and accountability drastically changes during residency. And that’s all a lot to take in.