The Rules of the House of God November 8, 2007
Posted by keepbreathing in Career Advice, asinine, hospital, medicine.trackback
Like so many other people in the field, I have read and partially memorized the epic novel “House of God” by Samuel Shem. In his novel, Shem (pen-name of a psychiatrist whose real name I’ve forgotten) explores the horrors that modern medicine brings on unwitting patients. His point overall isn’t that medicine is “bad;” it’s just that medicine is a good thing that is too often taken to ridiculous extremes for tenuous reasons. The game has changed a lot since Shem wrote the book, but a lot of what he is saying is still frighteningly valid.
Perhaps the most famous part of the novel is the Fat Man’s Rules of the House of God. The Fat Man, who is the only sane physician in the book, shares his rules with the protagonist in an effort to enlighten him. The rules are as follows:
(1) Gomers don’t die. The uninitiated might ask: what is a gomer? A “gomer” is an elderly person who, despite an enormous quantity of diseases and an astonishingly low quality of life, refuses to die. Gomer is an acronym for “Get Out of My ER.”
(2) Gomers go to ground. When admitted to the hospital, Gomers inevitably take a tumble from the bed to the floor, adding broken bones or head injuries to their laundry-list of problems. They like to do this shortly before discharge in order to insure a longer length of stay.
(3) At a cardiac arrest, the first procedure is to check your own pulse. This is better advice than you’d think.
(4) The patient is the one with the disease.
(5) Placement comes first. This means that the first consideration when dealing with a patient, especially a gomer, is: where should I put them? Ideally, Gomers will go to nursing homes. Interestingly, nursing homes are the only way to circumvent rule number one, as they are able to kill just about anybody.
(6) There is no body cavity that cannot be reached with a #14 needle and a good strong arm. A warning.
(7) Age + BUN = Lasix dose. A bit out-of-date, but still a decent rule of thumb for those elderly CHF patients.
( 
They can always hurt you more. Beware the patient, because whether it’s breaking your heart when you make the mistake of getting attached or flinging their HIV-infected blood in your face, they can always hurt you more.
(9) The only good admission is a dead admission. This sounds more cynical than it is. Elderly or frail patients who are admitted are likely to be the victims of some sort of medical misadventure, whether it’s the Pharmaceutical Death Spiral (drug A causes side effect B leading to drug C causing effect D ad infinitum) or simply the stay-extending actions of rule #2. And as for young admissions? A young person who is vital and full of life should make you worried: either they’re seeking drugs, or they’re actually sick and they’re going to die.
(10) If you don’t take a temperature you can’t find a fever. And sometimes you just don’t want to find the fever. This is really a corollary to rule 13.
(11) Show me a medical resident who only triples my work and I will kiss his feet. Medical residents may be intelligent and well-trained, but too many of them are in this for the wrong reasons. As such they will work you to the bone to show how smart and devoted they are. I have been the victim of residents before, and while I respect their achievements I sometimes question their motivations.
(12) If the radiology resident and the Best Medical Student both see a lesion on the chest x-ray, there can be no legion. This is a bit dated, since radiology nowadays seems to consist of rubberstamp reports that neither rule anything in nor rule anything out.
And my personal favorite rule:
(13) The delivery of good medical care is to do as much nothing as possible. This sounds counterintuitive, but speaking personally and professionally I believe that this is very frequently true. The more we intervene the more problems we cause, and while there are a lot of interventions that are definitely needed and indicated there are a LOT more interventions that are done for (a) legal reasons, or (b) because somebody wants to intervene. Speaking as a libertarian I’m generally against intervention anyway, but this rule really hits home a lot of the time.
I’m thinking of doing a series of small essays on each rule. Good idea? Bad idea? Anybody?
oooh yes
it’s all so very very true. . .
Great. Yes, it’s a good idea. Keep going.
Bloody GREAT-keep it up. Need any help, as I am “currently “a Victim” of Medical Misadventure, in surgery, AND in hospital-still on-going THREE YEARS later, I would be “oh so happy” to assist. Currently-having to “My own court case” Check out ALL/ANY hospital BEFORE any elective surgery, check “how many “bureau nurses” float in and out””’No consistency of “quality care” and above ALL check ALL meds/thru “google” before, you take a “single minor dose” When side affects (many and often) DONT TOUCH - despite what the “hospital/gp/or Dr TELL YOU< Dont persevere-quit immediately or you will BE DEAD (thanks to the monopoly) of pharmaceutical companies. The Do’s and Dont’s need your OWN judgment/or you will suffer the comsequences “often leading to EARLY death.If you need/wish to email: do so at Jilda@xtra.co.nz-I run “a support group
for “medical Misadvenure “Victims” in this country taken 30 cents of “every health dollar. Now you know where taxpayer money goes
Sincerely
Jill
I must read this book!
You are definitely my hero now.
I think it would be dead friggin’ brill to do an essay on each one.
Thank you!
As someone who is just getting started in the RT program, you blog is very insightful. Keep it up! Love it!
Love it, love it, love it–as usual. Totally on point and humorous in that oh-so-informative way.
Great post, would love to see those essays. A side note that you may find interesting…. another definition of a Gomer is a bull with his penis surgically redirected. He is used to heat check cows, and probably has the same poor quality of life because he’s surrounded by cows in heat and can’t do anything about it, no matter how hard he tries.
GO AVAY GO AVAY GO AVAY….
I just started rereading House of God this weekend, so your timing is absolutely fabulous. This book is my medical bible and it kept me sane in the early years. Or, sane enough, I guess.
For those who haven’t read it, you should certainly try to get hold of it as it’s only a couple of dollars for a good used copy on Amazon.
I’d love to see your essay(s) regarding the rules of the house! And I still wanna be Ina Goober when I grow up.
[...] homes, patient safety, respiratory therapy. trackback This is part one of my series exploring the Rules of the House of God. The Rules come from the novel House of God, by Samuel Shem. While some of the content of the novel [...]
[...] unindicated useless exam is more something than nothing. Incidentally this is a clear violation of Rule 13, which I will be essaying about at a later [...]
[...] in The Rules, gomers, respiratory therapy. trackback This is part two in my series on the Rules of the House of God. I am continuing this series out of a combination of boredom and a fascination with the cynicism in [...]
[...] complication, it would facilitate the patient’s eventual transfer to another facility (placement comes first,) it would probably reduce his ICU length of stay and it would greatly reduce the amount of time I [...]
[...] in Uncategorized. trackback Soon to come: the third part in my long-neglected series on the Rules of the House of God. Tonight (or maybe tomorrow): Rule [...]
I’m not sure if you intentionally or unintentionally corrupted House Rule #11, however, the original rule does not refer to medical residents increasing the work of respiratory therapists, but rather to “BMSs” or medical students in general increasing the workload of residents.
Ed, the “my” in “my work” refers to the Fat Man, the author of the rules.
First, my issue with the way you have written House Rule #11 is that in no way does it refer to medical residents increasing work. The original quote by Steve Bergman A.K.A. Samuel Shem is as follows:
“Show me a BMS who only triples my work and I will kiss his feet.” BMS stands for “Best Medical Student.”
Your interpretation of rule number 11 (copy and pasted from above) is: “Show me a medical resident who only triples my work and I will kiss his feet.”
I am merely pointing out that it is _not_ medical residents increasing work.
Furthermore, it’s unclear that this rule was even written by the Fat Man. If you read carefully, starting in Chapter 8, Roy begins to invent rules. Quote: “I heard myself create a new LAW - NUMBER NINE: THE ONLY GOOD ADMISSION IS A DEAD ADMISSION” In the same chapter, he creates “another new LAW - NUMBER TEN: iF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.” Thus, it would make sense if these two are new laws, they are no longer the Fat Man’s laws, but Roy’s. Unfortunately with Law #11 it is not as clear. Roy states that it is “very famous,” however, does not attribute it to anyone. Since he invented laws number 9 and 10, and this is clearly labelled law #11, we can safely conclude that this is of his invention as well.
I thought one of the rules (it was years ago I read the book) was something like your first goal for the day was to go home. Maybe it wasn’t one of the “official rules” but I was still pretty sure it was a primary goal that was put out there and that the earlier you did this, the more successful you were.
Can someone help my memory?
Thanks.
[...] house of god trackback It’s time for installment number four in my long-neglected series on The Rules of the House of God. Today’s rule: The Patient is the One with the [...]
[...] Fat Man??s rules of the house of God. the Fat Man, who is the only sane physician in the book, …http://keepbreathing.wordpress.com/2007/11/08/the-rules-of-the-house-of-god/Read “RE: Did Jesus Ever Claim to be God?” at Religion Forum…Zedekiah king over Judah and [...]