Just What Did The Doctor Order? Visit The House of God by Samuel Shem and Arrowsmith by Sinclair Lewis

In The House of God by Samuel Shem and Arrowsmith by Sinclair Lewis, the patient is American medicine.  Shem focuses upon the brutality of physician training.  Lewis describes a system afflicted by commercialism, ignorance, and self-promotion.

The House of God (1978) by Samuel Shem (a pseudonym for doctor-writer Stephen Bergman) satires the disheartening experience of interns at a major teaching hospital.  The hospital is a thinly disguised Beth Israel Hospital, an affiliate of Harvard Medical School.  Roy Basch and his fellow interns are caught between the hopelessness of treating GOMERS and the futility of caring for young patients.  Gomer is an acronym for “Get Out Of My Emergency Room.”  The term describes elderly, demented patients who perpetually bounce between nursing home and hospital in an endless cycle.  As described by the Fat Man, a resident who supervises Roy, “Gomers are human beings who have lost what goes into human beings.  They want to die, and we will not let them.”  The Fat Man insists that for Gomers less is more; heroic measures only increase the suffering of the Gomers.  However, the hospital philosophy is to “do everything for every patient forever.”  One of the Fat Man’s rules is that Gomers don’t die. Roy finds that the opposite is true about young patients; they are never saved.  The cancer treatments always fail, and Roy has been taught not to withhold any therapy no matter what the patient wants.  Meanwhile, private physicians subject LOL in NADS (Little Old Ladies in No Apparent Distress) to needless treatment. The ultimate goal is to BUFF and TURF— to polish the chart and transfer the patient to another unit. The endless hours of futility break the interns.  Roy loses himself in tawdry sex with nurses and becomes machinelike and numb. Other interns literally fall apart.  Roy cannot absorb the Fat Man’s humanism. “I make my patients feel like they’re still part of life, part of some grand nutty scheme instead of alone with their diseases.  With me, they still feel part of the human race,” the Fat Man states. A dying physician advises Roy that the aim is not necessarily to cure but to “be with the patient.”  However, as one of the interns asks, “How can we care for patients if’n nobody cares for us?”

Writing thirty years after the publication of The House of God, Shem acknowledged that the hopeless atmosphere he wrote about in The House of God had been mitigated by medical progress and alternative medicine.  I suspect that the ongoing and valuable conversation about quality of life and patient choice has also changed the experience for the better.  As a patient, I’ve opted on occasion for caring, compassionate doctors over mechanical physicians with weightier credentials.  Every relationship is or is supposed to be give-and-take. There is something to be said for a doctor who knows your name and asks about your kids.  It makes negative experiences just a little bit less negative.

At one point in The House of God, the Fat Man muses, “The whole pattern of medical education is backwards: by the time we realize that we are not going to be TV docs undressing ripe-titted beauties, but rather House docs disimpacting gomers, we’ve invested too much to quit….”  The Fat Man suggests bringing the medical students first into the House of God and allowing only ones with the stomach for medicine to start on the preclinical years.  This suggestion should be taken to heart by university career offices. It’s not just about finding a career; it’s about finding out about what being a doctor, lawyer, accountant or software developer means on a daily basis.  We watch TV doctors effectuate miraculous cures and TV lawyers unearthing reams of smoking guns.  I can tell you that smoking guns exist but it’s not the norm and that finding them can require tens of hours of drudgery, unpleasant interactions with opposing lawyers who have every motive to resist providing evidence, and repeated requests to the court to get someone to cooperate.  Plenty of folks like Roy and his friends experience career disillusionment because they make uninformed career decisions, sometimes influenced by media stereotypes.  University career offices need to open meaningful dialogues about careers.  When they don’t, they risk leading students down  unhappy paths.

Sinclair Lewis’s Arrowsmith (1925) traces the medical career of physician Martin Arrowsmith.  On the journey, Arrowsmith, like Roy Basch, discovers much cause for disillusionment, finding in the end that his true calling is medical research, an endeavor—truth-seeking– that can only be conducted outside the temptations of society, wealth, and even family.

The novel opens when Arrowsmith is in medical school.  Arrowsmith has a penchant for bacteriology and finds a mentor in Max Gottlieb, a noted researcher. For Gottlieb there is no god but science. As Gottlieb later insists, a “scientist is intensely religious—he is so religious that he will not accept quarter-truths, because they are an insult to his faith.” Gottlieb has disdain for practicing doctors who “want to snatch our science before it is tested and rush around hoping they heal people, and spoiling all the clues with their footsteps.” Arrowsmith, too, is troubled by the clinicians who dispense medication without proof of effectiveness and for whom tonsils and other spare body parts are cash cows, existing only so they can be removed by enterprising physicians. Arrowsmith sometimes describes clinicians as shopkeepers and peddlers.  Despite his regard for Gottlieb, Arrowsmith becomes a clinician because he needs to support his wife, Leora.

Arrowsmith opens a general practice in Leora’s home town of Wheatsylvania, North Dakota.  He finds the practice boring and repetitive and the townsfolk narrow and prejudiced.  The townsfolk, in turn, believe that Arrowsmith drinks and plays cards too much and attends church too little.  Arrowsmith comes to learn the tension between clinical medicine and medical research first hand when a little girl becomes ill.  Arrowsmith suspects diphtheria, but there’s no time to wait for pathological results before treatment.

Arrowsmith develops an interest in public health and takes on an assistant directorship of public health in Nautilus, Illinois, under the stewardship of Dr. Almus Pickerbaugh.  Lewis skewers Pickerbaugh. Pickerbaugh is a booster who relies upon showmanship and promotion, but knows nothing about science. “That health might be determined by temperature, heredity, profession, soil, natural immunity or by anything save health-department campaigns for increased washing and morality, was to him inconceivable.” Pickerbaugh avoids trying to correct the underlying conditions that endanger public health lest he antagonize power holders.  Naturally these qualifications catapult Pickerbaugh to Congress. Arrowsmith becomes acting director of public health.  And naturally when Arrowsmith tears down unsanitary tenements and halts production of contaminated milk he becomes exceedingly unpopular.

Briefly Arrowsmith works as a pathologist attached to a state of the art surgical practice in Chicago.  In his spare time, he conducts independent research.  However, once the doctors in the practice demand that he only pursue research projects that will promote the practice, Arrowsmith renews his relationship with Gottlieb and becomes a research scientist at the McGurk Institute, a noted research facility.

McGurk is also riddled by politics and commercialism.  Scientists jockey for political power within the Institute.  Administrators demand premature publication or insist that researchers devote more of their time to subjects that will gain more support for the Institute.  Arrowsmith seemingly comes upon a cure for plague and takes his research to the field to a remote island, where there’s been a plague outbreak.  Again, he’s caught in the tension between clinical and research medicine.  He’s instructed by Gottlieb to conduct a controlled experiment of the serum’s effectiveness rather than dispense it to everyone.  Arrowsmith initially abides by these instructions, but after Leora succumbs to plague, he distributes the serum to everyone.  The plague subsides possibly more from the concerted effort to exterminate rats than from Arrowsmith’s serum.  Nonetheless, Arrowsmith is hailed as a hero.  Although the quantitative analysis of Arrowsmith’s results proves inconclusive at best, the Institute’s administrator alters the conclusion.  Arrowsmith is again pressured to publish and to give up his own work in favor of projects the Institute believes will generate more prestige.

Arrowsmith is eventually offered the directorship of the Institute.  That offer would mean focusing on administration rather than the lab.   Arrowsmith’s new socialite wife, Joyce, demands that he accept the position. She also urges him to accompany her to dinners and golf and tennis games. Arrowsmith’s solution is to eliminate distraction altogether. He removes himself to the Vermont wilderness with a like-minded scientist, Terry Wickett, to form an independent laboratory in an almost monastic setting.  The novel ends with Martin pledged to continue his work and with that pledge comes the renewal of his understanding that success in the laboratory is not guaranteed.

Arrowsmith won the Pulitzer Prize for 1926, although Lewis declined the Pulitzer on the ground that awards cause authors to write to please “whatever code of Good Form may be popular at the moment.”  (It has also been speculated that Lewis was upset that two of his earlier novels, Main Street and Babbitt, had been passed over in favor of Edith Wharton’s Age of Innocence and Willa Cather’s One of OursMain Street had actually been recommended by the jury but the recommendation was rejected by the Trustees of Columbia University because Main Street failed the “wholesome” requirement for the prize.). Lewis did not turn down the Nobel Prize for Literature,  when he was recognized in 1930.  He was the first American to win it.

Lewis is a masterful satirist. The satire is enhanced because Arrowsmith himself is a flawed character: brusque, unpolished, self-absorbed, arrogant, and utterly without empathy. Lewis also committed himself to authenticity, collaborating with Dr. Paul de Kruif, a microbiologist who had worked at the Rockefeller Institute.  De Kruif received 25% of the royalties. De Kruif became a noted writer in his own right, with his best-known book, Microbe Hunters, selling millions of copies.  Microbe Hunters portrayed scientists from Pasteur to Koch as heroes and crusaders and inspired a generation of scientists.

Arrowsmith’s belief that he can only become a truth-seeker if he lives outside society is troubling.  Arrowsmith does not see the price tag–the abandonment of his young son—as too high.  Imagine if a female character made the same decision. Imagine if Gaugain had been a woman and had left her family to paint exotic subjects in Tahiti.  Science may be an exacting mistress and the unimaginable laboratory hours that scientists expend, with no assurance of results, deserve nothing but commendation.  But abandoning a child in a quest for self-fulfillment is selfish and merits its own circle in hell.

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4 thoughts on “Just What Did The Doctor Order? Visit The House of God by Samuel Shem and Arrowsmith by Sinclair Lewis

  1. First a comment about evidence-based medicine. This was the big hoo-hah when I was full-time university in the 90’s. Unfortunately, in my eyes, it was simply the forerunner of the medical algorithms of this century which has allowed physician-equivalents (non-MD health care providers=HCP) to choose from a preset package of evaluation and treatment, often missing nuances or hidden disease altogether. I prefer to say that patients deserve to have (by any appropriately trained HCP, even not an MD) a diagnosis based on the history, physical, and appropriate testing; that treatment should be based on that diagnosis and then modified according to response, allowing a modification or elimination of the original diagnosis.

    The themes in Arrowsmith are reminiscent of what happened to the physician in Middlemarch. I don’t fault Lewis if he used that as a source since Middlemarch is an exceptionally well-written “modern” novel.

    Ah, but HOUSE OF GOD, the source bible of those of us who trained in that era. It was exceptionally close to reality. And it speaks to the psychological breaking of the physician in training. Two years of med school sitting in classes eight hours a day and still bright eyed and bushy tailed. Then junior year of clinical rotations that develop your stamina but wear you down and start to figuratively open your eyes even when you can’t literally open your eyes. Senior year, fluff rotations (you learn a lot but you’re not up all night) and trying to get your footing for internship/residency. All the grinding has been modified since the Bell Commission of 1989 where the hours now are regulated and you have to leave in the middle of whatever you’re doing if you have exceeded your awake time. Of course, the all-night stamina building of those old days was rooted in and needed to build skills that you would need in triage and the battlefield. Unfortunately, patients and the course of their acute illness don’t fall into nice sleep cycle events.

    You quoted:
    “The whole pattern of medical education is backwards: by the time we realize that we are not going to be TV docs……..we’ve invested too much to quit….” A vignette from my life vis a vis doctors and lawyers. Was at a meeting of Women’s Physician Society meeting jointly with female lawyers and bankers. Talk at the table by the non-physicians was all about ditching law, writing a novel, opening a cooking school, anything else, met by the slack-jawed response of the physicians. When the lawyers were out in their first year of practice, we were in our fourth year of a 7 to 10 year slog of training: internship, residency, and fellowship. The financial investment (even then) was more than other professions but the time commitment was so much more. We could not think of doing anything other than medicine.

    Things are different now because of many changes in medicine, but emotional investment, time investment, and psychological breaking (yes, even now, but now more by the insurance system and patient expectations) continue to make the pursuit of a medical career in a class by itself. The problem now is that the best and the brightest are looking at clean financial & hi-tech (etc) jobs, so the world is going to be cared for by either burnt out physicians or evidence-based, algorithm-bound HCPs, not necessarily what is best for the patient.

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    1. I totally agree. After getting shuttled off to the PA because the physician is now performing cosmetic procedures which insurance doesn’t regulate–and having to wait a week for labs that reflected what I as the patient already knew, then getting medication that I was told the next day to toss because they had ordered the wrong drug, I believe the system is broken. Would love to discuss this more.

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