What I've learned from speaking out against the brutality of medical training, in advocacy of quality connection -- and four additional "laws" for good doctors
For better or worse, except in real danger, I don't seem to run on fear. Guilt, yes; fear, no.
It's a good thing, because my book The House of God enraged many among the older generation of doctors. I was maligned and disliked. The book was censored by medical school deans, who often kept me from speaking at their schools. None of it really bothered me, though. I was secure in the understanding that all I had done was tell the truth about medical training.
I took this pseudonym because I was just starting my psychiatric practice and wanted to protect my patients from knowing that their therapist had written such an irreverent novel. (They all found out, and didn't care -- but "Shem" had arrived, and refused to depart.) I also felt that real writers had no place in going out and publicizing their novels. I refused all invitations. And then one day I got a letter forwarded from my publisher, which included the line:
"I'm on call in a V.A. Hospital in Tulsa, and if weren't for your book I'd kill myself."
I realized that I could be helpful to doctors who were going through the brutality of training. And so I began what has turned out to be a 35-year odyssey of speaking out, around the world, about resisting the inhumanity of medical training. The title of my talk is almost always the same: "Staying Human in Health Care."
The theme of my speaking out is simple: the danger of isolation, the healing power of good connection. And any good connection is mutual.
I base a lot of my talks on what I've learned from The House of God. About how I've come to see it, and all my novels,
as a "fiction of resistance," a way of resisting the injustices of a system.
It wasn't until years into my journey that I realized the importance of the fact that I and my fellow interns were products of the 1960s. We grew up in that unique lost period of American history -- beginning with FDR and ending with Reagan -- when we learned that if we saw an injustice, and got together and took action, we could bring about change. During my college years, we helped put the Civil Rights laws on the books and ended the Vietnam War. When we entered our internships we were a generation idealistic young docs. We soon were caught in the clash between the received wisdom of the medical system, and the call of the human heart. Our patients, and we, were being treated inhumanely. As Chuck the intern put it:
"How can we care for our patients, man, if nobody cares for us?"
If we decide to walk through suffering alone -- "stand tall, draw a line in the sand, tough it out" -- we will suffer more, and spread more suffering around.
And so we took action. The novel can be read as a model of nonviolent resistance. Big hospitals, like all large hierarchies, are "power-over" systems. The pressure comes down on the ones at the bottom, and they become isolated. Not only do they get isolated from each other, but each gets isolated from his or her authentic experience of the system itself. You start to think "I'm crazy," instead of "This is crazy." In The House one of the interns does go crazy, and another commits suicide.
The crucial question is how to find mutuality -- or "power-with" -- in a "power-over" system. Historically, the only threat to the dominant group -- whether of race, gender, class, sexual preference, ethnicity -- is the quality of the connection among the subordinate group.
In The House of God there were 13 "Laws." I would now add these four:
: Connection comes first. This applies not only in medicine, but in any of your significant relationships. If you are connected, you can talk about anything, and deal with anything; if you're not connected, you can't talk about anything, or deal with
anything. Isolation is deadly, connection heals.
One of the worries in how the new generation of doctors practice medicine is their use of computers. If you have a laptop or smart phone between you and your patient, you are much less likely to create a
good, mutual connection. You will miss the subtle signs of the history, of the person. With a screen between you, there is no chance for mutuality, and
the connection has qualities of distance, coolness, rank, authority, and even disinterest. The "smart" digital appendages can make you, in human-connection
terms, a "dumb" doctor.