Man’s 4th Best Ho$pital


Leonard Zwelling

For internists of a certain age, there is a book more important than any textbook of medicine ever was or will be. The age includes those who trained at academic medical centers in the 1960s and 1970s. The book is The House of God by Samuel Shem (real name, Dr. Stephen J. Bergman). Why is this book so important?

Let me illustrate with a story. In 1976, when I was an intern at Duke Hospital, I was trying to convey to my father, a civilian (a non-doctor), what it was I did and what my world was like. After all, my parents had made many sacrifices to get me into that short white coat and white pair of pants (plus bow tie). When they had taken me to Duke as a freshman undergraduate in 1966, they had parked on the wrong side of campus and we walked through the medical center to get to the main quad. Right then I told them I would be a doctor there some day. Well, I was, but what did that mean? I owed them an explanation.

My parents’ view of doctoring came from two places. First, there were their own encounters with the medical system of the time of which they, unfortunately, had had quite a few. For the most part, they looked upon doctors from the point of view of living patients—grateful for the mysteries of healing. They also saw doctors as depicted on television, whether that was Marcus Welby or Ben Casey. None of this had any resemblance to what I was experiencing wading through blood and other body fluids on the public wards of Duke Hospital.

Then, in 1978, I read The House of God. I sent my father a copy.

“Dad,” I told him on the phone, “this is the truth.”

He read the book. He was shocked.

“This is real?” he inquired.

“Oh, yes,” I said. And it was.

The House of God may be a satire in the vein of M*A*S*H and Catch-22, but it does do for medicine what those books did for the military. It told the human truth of the war that was going on between patients and doctors—patients trying to die and doctors longing for sleep.

Dr. Shem, after forty years, has written a sequel to The House of God. It is called Man’s 4th Best Ho$pital and every letter of the title matters, for this book is not about the war between doctors and patients. It is about the war between doctors allied with patients against the administrative world that controls medicine in 2020. It focuses on the corrupting effect of money, the scourge that is the electronic medical record, and the infiltration by business people into American academic medicine. In the end, it also addresses what to do about fixing this broken system that is American health care.

I remember The House of God mirroring my experiences as a Duke house officer. The essence of the book is summed up on page 376, The Rules of The House of God. (There are 13). Some of the key ones are:

III. At a cardiac arrest, the first procedure is to take your own pulse.
VIII. They can always hurt you more.
XIII. The delivery of medical care is to do as much nothing as possible.

The important note is that all the rules of The House of God were about patient care. They instructed doctors on how best to treat patients.

Fast forward to the new book.

There are again 13 laws of Man’s 4th Best Hospital. Here are some:

V. It’s not just what we do; it’s what we do next.
VII. Without health care workers, there is no health care.
IX. Put the human back in medicine.

Everything has changed. What was once a patient-centered endeavor where fighting disease was the key has become a dehumanized profession centered on money and technology and how to use the latter (the electronic health record) to maximize the former.

Shem captures today’s medicine as well as he captured the world of academic medicine in 1978.

I cannot recommend the new book (or the old one) highly enough. They speak to lay people about what has happened to medicine in the ensuing 40 years. It is a sad commentary, but an accurate one. I only wish that Dr. Shem and I live long enough for him to write the third installment that describes a new system where patients and doctors band together to bring “the human back in medicine.”

Leonard Zwelling