The New Laws of the House of God

On a family vacation road trip last month, I read “Man’s Fourth Best Hospital” by Samuel Shem, the sequel to “The House of God.” Most physicians have read The House of God, including me back in college, which chronicles the grueling nature of residency training, with equal parts satire, dark humor, and poignant humanity. It was controversial at the time, and still is, but what I remembered most was the 13 Laws of the House of God. Many of them ring true, even to this day:

I. Gomers don’t die.
II. Gomers go to ground.
III. At a cardiac arrest, the first procedure is to take your own pulse.
IV. The patient is the one with the disease.
V. Placement comes first.
VI. There is no body cavity that cannot be reached with #14 needle and a good strong arm.
VII. Age + BUN = Lasix dose.
VIII. They can always hurt you more.
IX. The only good admission is a dead admission.
X. If you don’t take a temperature, you can’t find a fever.
XI. Show me a BMS (best medical student) who only triples my work and I will kiss his feet.
XII. If the radiology resident and the BMS both see a lesion on the chest X ray, there can be no lesion there.
XIII. The delivery of medical care is to do as much nothing as possible.

In his sequel, the author’s focus shifts from the inhumane nature of residency training to the inhumane nature of corporate medicine, including the proliferation of administrators, unrealistic productivity demands, the driving forces of patient satisfaction scores and billing, and the hostile takeover of our work day and work lives by the electronic medical record. It’s worth a read, especially if you despise the EMR; there were many laugh out loud moments.

The now older, wiser, and gentler protagonist Dr. Roy Basch also redefined the Laws of the House of God to include a more updated version:

I. Learn your trade in the world.
II. Isolation is deadly; connection heals.
III. Connection comes first.
IV. Use the “we.”
V. It’s not just what we do; it’s what we do next.
VI. It’s not that we do what we think we can get: it’s what we dare to do together.
VII. Without health care workers, there’s no health care.
VIII. Squeeze the money out of the machines.
IX. Put the human back into medicine.
X. Stick together, no matter what.

As a practicing primary care physician, Laws 3, 7, and 9 in particular resonated with me. Connection comes first should be the guiding principle of every patient interaction (or any interaction, really); achieving this in a 20 minute office visit is no small feat. Over the years, I have tried every approach, and I have found that an effective one is not turning to the computer at all. Or, pulling up the EMR only toward the end of the visit, to verify data or the plan we’ve discussed. In doing this, I will have to review the chart thoroughly before I enter the room, enter orders and medications after I exit the room, and complete the note some time after the visit. But thank goodness that in January of 2021, billing of outpatient visits changed to be able to include those components in the total time spent evaluating the patient–in other words, we are reimbursed for this important work and it doesn’t have to occur during face to face time with the patient. Instead of typing into the EMR, I am allowing the entire human interaction to proceed undisturbed, including verbal cues, eye contact, facial expression, body language. (Well, other than the fact we are both still wearing masks.)

Without health care workers there’s no health care: how true is that, and what really struck me is that this book was released right before the covid-19 pandemic. It is even more relevant today, when we witnessed first hand how important it was to have front line health care workers willing to risk potential exposure to this deadly virus to care for patients. And yet, the irony of that statement? In my group practice, every physician took a 10% pay cut for three months last summer due to “covid related financial losses.” As it turns out, if you cancel elective knee surgeries and other revenue-generating procedures, the bottom line impacts even primary care physicians and hospitalists, who are working 50 plus hour weeks this entire time. Still, it is my hope that scenes and stories from the front lines, the lessons learned from covid will include the true value of physicians and nurses; not just cogs in a wheel or part of a system, but the heart and soul of medicine.

Put the human back in medicine: this law is similar to #3, connection comes first, but I would argue this extends beyond just the doctor-patient interaction and to the healthcare system as a whole. Covid related reliance on technology had hugely negative impacts on this; even as I write this blog, there are entire clinics in our outpatient practice that are still 100% virtual. We all know–in part because of the experience in the public school system–that virtual interactions are simply not as effective as in person encounters, and yet, we have a long way to go. The same is true for interactions with my coworkers and colleagues; “working from home” has really eroded the connections between me and my nurse, or the doctors and their administrative support. The potential for collaboration and mentoring is greatly reduced when attending Grand Rounds and other conferences via Zoom. There are new faculty hired since the start of covid that I barely know, or wouldn’t even recognize if I passed by them in the hall, because they tend to turn their camera off during meetings. If we truly want to put human back in medicine, many of these virtual experiences–which are now more or less a convenience since we are all fully vaccinated–need to be replaced by in person encounters.

I found it interesting that reading this book, again written pre-pandemic, caused me to reframe or rethink the Laws and place them into the context of a post covid world. In my mind, this makes the new Laws seem all the more valid and relevant, since most would agree that covid was one gigantic stress test for our health system. As we start to emerge on the other side, we should think often of these Laws and how to prioritize change, system improvement, and innovation going forward.

I guess that could also be stated: “it’s not just what we do, it’s what we do next”, right?

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