Two old doctor books that won't die
From the time it was published, critics of Samuel Shem’s The House of God have been either predicting its death or trying to explain away its stubborn popularity. There are a hundred reasons why it should not be popular. It dealt with issues that seemed timely in the 1970s but that should have disappeared by now. It is sexist, racist, classist, and narcissistic in ways that are universally offensive. And yet, doctors keep reading it. In fact, doctors are probably the only people who read it. It is like the dark humor of medicine, a book of dirty secrets. It also inspired the entire genre of medical television shows that promise to pull back the curtain and show us what doctors’ lives are really like.
John Berger’s A Fortunate Man is, in many ways, the opposite of House of God. It is set not in a high-tech academic medical center but in an impoverished rural community. The doctor-protagonist is mid-career. There is rarely a note of cynicism in the book. Instead, it offers the world-weary idealism of a doctor who sees every patient encounter as an opportunity for empathy, healing, and self-understanding.
House of God was both controversial and popular from the day it was published. Fortunate Man was out of print for many years, before being reissued and newly appreciated as an important exploration of the nature of medicine and the complex work that doctors do.
Both are coming of age stories. Both understand that, for doctors, coming-of-age does not take place in the teen years. Instead, it is the process of professionalization and is a life-long task that begins with medical training but then continues through years of practice. In House of God, the protagonist is just beginning to come to a mature understanding of the work that he wants to do. In Fortunate Man, the protagonist is in mid-career, and we see the struggles continue, we see his sense of his own helplessness grow. Not all doctors grow into an understanding of their own work, but the ongoing appeal of these books is that they show how necessary it is to continually seek such understanding.
Both hammer home the fact that, as doctors, we will fail much of the time. We miss diagnoses. We needlessly prolong pain and suffering. We ask catastrophically wrong questions. We aren’t available when needed. We are flawed. We sometimes find ways to cope with the feelings of helplessness and inadequacy that are inevitable parts of medical practice. And sometimes, like Sassall, we ultimately fail.
Many other books deal with these issues. None explore the psyches of the doctors as searchingly. They allow the reader to experience the doctor-protagonists in the same way that those doctors experience patients. We are frustrated by the protagonists. At times we don’t like them. Ultimately, though, we connect, empathize, feel their pain, and recognize that, within their personal limitations and working in unjust systems, they are trying their best.
The take home lessons are simple and profound. In House of God, a retired physician tells Basch, “What sustains us is when we find a way to be compassionate, to love. And the most loving thing we do is to be with a patient.” In Fortunate Man, the author explains that Sassall is a good doctor “because he meets the deep but unformulated expectation of the sick for a sense of fraternity. He recognizes them.”
The things that could have made these books seem dated have, instead, made them more relevant than ever. Medicine is becoming more and more dehumanized. Artificial intelligence promises to replace doctors with chatbots. Trusting relationships between doctors and patients are more difficult to achieve because or systems of care prevent continuity and undermine trust. Decisions about how far to go or when to stop trying to prolong life are more complex than ever. Health disparities are widening rather than narrowing. Patients need a trusted doctor more than ever.
These two books show how these issues have always been present and can never be solved by systems, only by individuals who confront the tragedies. William Carlos Williams wrote about similar things. Almost 100 years ago, he wrote, “We know the plane will crash, the train be derailed. And we know why. No one cares, no one can care. We get the news and discount it; we are quite right in doing so. It is trivial. But the hunted news I get from some obscure patient’s eyes is not trivial. It is profound.” Berger and Shem would agree.