Basch Unbound—The House of God and Fiction As Resistance at 40

THE ARTS AND MEDICINE Basch Unbound—The House of God and Fiction as Resistance at 40 Stephen Bergman, MD, DPhil here’s a saying you should read nonfiction for facts demic and clinical careers. The Fat Man—the senior resident and fiction for the truth. The novel The House of God who teaches Roy Basch (a thinly veiled version of me), the T is a true account of my internship experience at moral center of the novel, and ultimately its hero—is an ex- Beth Israel Hospital (the BI) in 1973-1974. The book has sold ception. A literary invention, he seemed to write himself, 3 million copies to date and his sausage fingers on my typewriter keys, so buoyant, so funny, counting, popular because so wise. A measure of the success of the character is that Related article of its authentic portrayal of I hear of Fat Man sightings all over the world, from Iowa to medicine and postgraduate Australia, to this day. Casual readers may be turned off by his training, its rowdy sex and greed and ambitions for the “Big Fortoona.”But those who stick Video bawdy comedy, and its char- with him learn it’s all a put-on, a way of using the language of acters’ (my friends’) attempt to stay human and honor our money, which now more than ever is coursing through health patients’ humanity in a dehumanizing year. care, to disarm his interns, create connections with and be- I previously described why I wrote it.1 I knew before tween them, and teach them what is important in patient- and medical school I wanted to be a writer, but I wanted to make self-care. The book’s reputation for sex, humor, and more sex a living and a difference. After 3 years at Oxford, my choice belies the fact that underlying it all is the Fat Man’s embodi- was Vietnam or Harvard Medical School. I chose Harvard ment of human connection and caring. and went on to Beth Israel In today’s era of identity politics the book might have Hospital to train in internal a mixed record. On the upside, we in The House knew that JAMA.COM + medicine. Having come of age #BlackLivesMatter. Chuck, who readers meet at intern in the civil rights era, I saw orientation as “a smooth black guy slouched down in his that organized resistance chair with his hand wearily shading his eyes,” was based on and social action could be an an African American intern who, with far fewer advantages, effective response to injus- had way more street smarts and was far more put together tice, and the injustice I saw than the rest of us privileged white kids. I’m proud of the during my internship, the scenes that reflected my admiration for the real man: Chuck Video The Making of The way private attendings made and Roy coming to understand each other through basket- House of God money at the expense of ball, and “in the face of all that faced us” at the beginning of patients and also the way pa- the year, kind of falling in love. Unfortunately the book tients were mistreated while we were expected to be com- remains in sync with today’s times. Black physicians are our plicit in the process, demanded a response. I and a core group close friends and colleagues, but there are too few to be of interns did what we could to protect ourselves and our pa- found in today’s health systems for anyone’s good. tients, using humor and alcohol, sometimes even on shift, to More challenging for some perhaps is the book’s gener- stay sane. Our antics disrupted the system and its higher-ups ally unflattering portrayal of women, leaving it open to criti- who increasingly wanted little to do with us but had few cism in the context of today’s #MeToo movement. Critics of disciplinary options because, in an era when private attend- the novel’s tarted-up nurses and rumpus call-room sex scenes, ings rounded on their patients but only we could write their almost all true, would do well to remember that Roy knows orders, they needed us to do the work. The experience was they’re unhealthy. The soul and spirit of the novel is Berry, my so brutal that I fled into a psychiatry residency at McLean character’s girlfriend (and in real life, now my wife), who an- Hospital, which gave me mornings to write. During that chors the novel’s beginning and end and is more thoughtful time, I brought together my House buddies who remained in and centered than most of the male characters. She calls us in- Boston to drink, smoke, look back, laugh at it all, and heal. The terns out on our indiscretions and pulls us back to our shared novel poured out of me using our shared stories as a way of humanity. Roy is kept afloat by her patience and wisdom. coming to terms with what we had been through (Video). Less politically, the book was a late entry into a literature On the 40th anniversary of the novel’s publication, there defined 15 to 20 years earlier by the likes of Philip Roth and may be a few things left unsaid worth putting on the record. Joseph Heller. Roth’s Portnoy’s Complaint and Heller’s Most of the principal characters in the novel—Hyper Catch-22, like House, were absurd and funny autobiographi- Hooper, The Runt, Eat My Dust Eddie, and Chuck—are based cal fiction that attacked pieties, subverted hierarchies, on my fellow interns, all of whom went on to successful aca- unveiled uncomfortable truths, and were reviled by cultural jama.com (Reprinted) JAMA Published online July 10, 2019 E1 © 2019 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 07/11/2019 The Arts and Medicine power brokers and taste makers of the time. (John Updike, rent political moment. I am more appalled now than in 1973 a friend, wrote that House was “the Catch-22 of medicine.”) by our national politics, by the way house staff are forced to Not unlike Roth, I was pilloried by establishment doctors for spend much of their time at computers, by the fact that pa- the book’s razor-sharp version of the truth, and beloved by tients have no idea that electronic health records are de- my generation for its honesty. Previous internship novels had signed to optimize billing and insurance payments rather than been of the heroic variety: “With my heart pounding, I sewed their care, and by the way nonphysician executives at the top in the valve.” House told the truth: “I’m so tired I wish this of hospital systems, having never been trained in patient care, old lady would die so I can get some sleep.” The book placed dictate the terms of the profession. second on physician-author Michael Honig’s 10 Best Satires Chekhov described the best of writers as those who con- list in Publishers Weekly (after Don Quixote).2 vey “life as it should be in addition to life as it is.”3 The im- Whatever the similarities, Roth, Heller, and their genera- pulse to resist, reform, and create a view of life as it should be tion didn’t influence my writing. Instead, I treasured Tolstoy still inspires my writing and has carried me through every- and the other Russian novelists (including 2 doctors, thing I've done. I'm trying to hand that fight over now to the Chekhov and Bulgakov), the Irish (Yeats, Joyce, Beckett, and younger generation, in my teaching at NYU Med, in public Flann O'Brien’s The Third Policeman, one of the funniest speaking, and in a forthcoming new sequel to House called books ever), and resistance novels (1984, The Tin Drum, Man’s 4th Best Hospital.4 I talk to anyone who will listen about Heart of Darkness, The Quiet American, To Kill a Mockingbird, the electronic health record and the takeover of medicine by and others). I jumped into writing House full of raw anger and money and the opportunities that exist to resist it. to my surprise, realized I could write funny. My editor “We doctors are the workers, I tell them. Without us, there’s brought me back from far-out versions, saying, “You are at no health care. your best writing one step off real.” I did 7 drafts, morphing it We have power and can shape the fate of medicine. into something readable. Tolstoy wrote 7 drafts of War and My generation is almost gone, we're out the door, so this Peace and only stopped when his editor wrote: “When will is your fight now, your life. you stop your infernal scribbling?!” What will you do with it?” Samuel Shem is a pseudonym; I wrote the book during my psychiatry residency and wanted a name my patients couldn’t Author Affiliation: NYU Medical School, New York, New York. recognize. The name has several sources. Shem the Penman Corresponding Author: Stephen Bergman, MD, DPhil, 75 Bellevue St, Newton, is one of the 2 sons of Finnegan in James Joyce’s Finnegans MA 02458 ([email protected]). Wake. “Shem” means name in Hebrew—I liked that play on Published Online: July 10, 2019. doi:10.1001/jama.2019.9499 words—and Baal Shem Tov (“Master of the Good Name”) was Conflict of Interest Disclosures: Dr Bergman reports receipt of royalties from a 17th-century mystic who transformed Judaism into a radi- books, plays, and other works.

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