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?"
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:
Law 14 : 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.
This, as more and more studies suggest, can lead -- hand in hand with the tyranny of algorithms and other "quality/efficiency/cost-containers" -- to more tests, more errors and medical mistakes, lower quality care, and higher costs to all.
Law 15 : Learn empathy. Put yourself in the other person's shoes, feelingly. When you find someone who shows empathy, follow, watch, and learn.
Law 16 : Speak up. If you see a wrong in the medical system, speak out and up. It is not only important to call attention the wrongs in the system, it is essential for your survival as a human being.
Law 17 : Learn your trade, in the world. Your patient is never only the patient, but the family, friends, community, history, the climate, where the water comes from and where the garbage goes. Your patient is the world.
Some have said that The House of God is cynical. And yet in rereading, it has a constant message that I was dimly conscious of in writing: being with the patient. In the words of the hero of the novel, the Fat Man, "I make them feel that 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." And as the narrator Roy Basch realized, "What these patients wanted was what anyone wanted: the hand in their hand, the sense that their doctor could care."
And so in 1974 I came away from The House of God aware of at least one thing: The essence of medical care, and life, is connection.
Fast forward 30 years.
I have published two more novels -- Fine and Mount Misery. Also, with my wife, co-wrote the play Bill W and Dr. Bob about the founding of Alcoholics Anonymous, and a nonfiction book We Have to Talk: Healing Dialogues Between Women and Men.
During this time, as they say, life happened. There were many life struggles, and walks through the suffering. Luckily, at the right times, I was accompanied by others.
From Mount Misery, and also from conducting gender dialogues all over the world while writing We Have to Talk, I learned the importance of shifting focus from a center on "I" or "You", to "We." As in, for physicians, "We've got all the information; let's talk about what we can." The patient will say, "I think maybe we should .. " Suddenly there is a concreteness in your approach to treatment, that you are in this together.
From Bill W. and Dr. Bob, I learned that, in Bill's words: "The only thing that can keep a drunk sober is telling his story to another drunk." Alone, an alcoholic cannot resist alcohol. The self alone -- self-will or self-discipline -- will not work. What works is asking for help from a non-self-centered perspective. AA is an astonishing mutual-help organization, because alcohol and drugs are diseases of isolation.
My latest novel, The Spirit of the Place, took me in a new direction. I had always wanted to go back to my small town on the Hudson River and join my old mentor, a family doctor, in practice. Life had taken me elsewhere, but the beauty of fiction is that you can do in a novel what you haven't in the world.
At a point toward the end of the novel, the fraught protagonist has to make a choice. He struggles with it until he hears a kind of voice in his head:
"Don't spread more suffering around. Whatever you do, don't spread more suffering around."
This is the culmination my learning so far. All of us will suffer -- it's not optional. Some will suffer more, some less. The issue isn't suffering, it's how we walk through it, and how we help others walk through it. 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.
This is where we health-care folks come in -- this is our job, to be with others in caring.
We doctors are privileged. In a culture that deals more and more with surface and sheen and falsity, we in our offices and house calls and surgeries are present with the deep, hard truth that comes out at crucial moments of our patients' lives. The great themes of fiction are love and death. Death is always a theme in medicine. So too, I would argue, in its many spirits, is love. And one of those spirits is resistance to inhumanity, and injustice. Love and death. How lucky we are.