Man’s 4th Best Hospital by Samuel Shem: A Review

| By Dr. Ronald Hoffman

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Man’s 4th Best Hospital by Samuel Shem: A Review

In the late 70s and early 80s I underwent my training in internal medicine at some of the busiest hospitals in New York City. The AIDS epidemic was raging. Poverty, urban decay and crime were taking their tolls. The prevailing ethic was that internship and residency were survival ordeals—a sort of “hazing” ritual to initiate new doctors, and to winnow out the weak.

I seldom slept when I was “on call” every third or fourth night. I’d have responsibility for 10-15 severely ill patients by day, 30 to 40 when I covered overnights. My responsibilities included lots of “scut” like drawing blood, moving patients to radiology, and putting in IV lines. There were many times when I felt like the wheels were coming off.

Amid this scenario arrived a revolutionary book, deemed illicit and underground at that time. It was so taboo that my professors condemned it and discouraged us from reading it. It was written by a young doctor who even adopted a pseudonym—Samuel Shem—to avoid repercussions to his medical career. That book was The House of God.

The House of God detailed the misadventures of a young intern at a fictional hospital modeled after Boston’s Beth Israel. The protagonist is an idealistic young intern, like me, beleaguered by the overwhelming demands of his first year as a doctor.

It’s a ludicrously cynical view of medicine, but its dark humor helped sustain me and my overworked colleagues through those challenging years.

Shem coined the term GOMER, which stands for Get Out of My Emergency Room, which designated the endless stream of elderly, chronically ill patients who flooded our services. Exhausted, we came to resent them as obstacles to our sleep, sitting down for a full meal, getting home for a brief break to see our families, or our ability to care meaningfully for salvageable younger patients.

The answer was TURFing, the art form of transferring burdensome patients to other specialties or hospitals. The more accomplished senior doctors who protected us by limiting our patient loads became affectionately known as “TURFmasters”.

The overwork and futility bred a kind of clinical nihilism which was best encapsulated by one of the House of God rules: “The delivery of good medical care is to do as much nothing as possible.” And, indeed, there was some truth to that. The strenuous exertions we performed on some patients not only depleted us, but often subjected patients to unnecessary peril.

Fast forward to 2019—41 years from the publication of The House of God—and Samuel Shem (his real name is Stephen Joseph Bergman and he’s a member of the faculty of the New York University School of Medicine at NYU Langone Medical Center) is at it again. His new book, Man’s 4th Best Hospital, is an updated indictment of the state of modern medicine.

Why the title? According to the book, it used to be Man’s Best Hospital (MBH—presumably a facsimile of Massachusetts General Hospital) but then:

“ . . . several years ago, MBH had been bought by BUDDIES, a corporate conglomerate of most of the BMS hospitals. Bought, and being crushed under, the deadweight of BUDDIES—a 73,000-weak bureaucracy—filled, oddly enough, with bureaucrats. None of them provided any health care. This 26-billion-dollar cost center, this corporate whale, was inserted into the health-care food chain between hospitals and insurance conglomerates—for no other reason than cash. It had succeeded in its mission: using its purchasing power against insurance, to get prices up. To monetize. To cost more. Never mind that in health care Value = Outcome/Cost. Who cared about ‘value’? It became the biggest health-care empire in imperial America.

And so a great hospital, its great doctors and other health-care workers, as well as its tens of thousands of patients—all of us became allies, as victims of BUDDIES. Being bled of cash by BUDDIES, MBH was soon deep in debt. BUDDIES realized that MBH could no longer make any real money by honoring its mission of service to the sick poor, and insisted it ‘reengineer’ its mission to make money off the healthy wealthy.”

Shem conjures up the original cast of characters of The House of God, now established medical specialists, many of whom are disillusioned with their careers, on an idealistic mission to restore Man’s 4th’s reputation for quality care.

“This is new, different. Here at Man’s 4th, we’re not trying to survive, but to humanize! Okay, okay—it’s grandiose, stupid. It’ll never work. Maybe not. But maybe yes.”

But they encounter obstacles.

“Screen logic. You’ll each be given an ‘I’-tablet containing all the information in medicine. You don’t have to remember anything. Just clickclickclick. Our interns do eight thousand clicks per twelve-hour shift—best in America. We did a survey of house staff: What’s the minimum percent on their shift they spend in front of screens? Eighty! Eighty percent of their time in my hospital they’re in front of screens. Eighty percent minimum . . . some say ninety percent. Minimum.”

Then there’s fragmented care. In the old days, doctors-in-training worked heroic shifts, averaging 120 hours or more per week. But in the wake of well-publicized tragedies like the Libby Zion case, work hours were limited. The unintended consequence: doctors became mere shift workers, constantly handing off their patients to relief personnel. Then, with the advent of “hospitalists”—Shem derisively calls them “nocturnalists”—house staff don’t bond with patients anymore. Thus, a frequent refrain: “Who’s my doctor?”

Treatment has become depersonalized: “In the past, way back before the screens, what was a good patient visit? Your doctor greeted you, sat, and talked with you—chief complaint, history—then asked you to undress behind a curtain for the physical. During this, he or she wrote up what was learned so far. Then the physical. While you were dressing, he did what is now strange: he paused. He sat there and did nothing, as much nothing as possible—except he: Considered. Mused. Sensed. Intuited. Put it all together. Came to a vision of what was wrong and how he might right it, and if not, how he could be with you in caring for you in your illness, no matter what. He integrated. When you returned, he faced you and said, ‘Let’s go over what I found and see what we can do about it.’ Screens prevent us doing that. Machines never pause.”

These and other abuses of modern medicine are satirically depicted in the pages of Man’s 4th Best Hospital.

Shem delivers a harsh final verdict: “And it’s not that your doctor wants to turn his or her back on you. It’s the health-care industry that has turned its back on both you and your doctor.”

Man’s 4th Best Hospital is admittedly a bit of a slog, with its staccato pacing and gonzo style. But as a historical document, it’s a sad commentary on how medicine—already stressed nearly to a breaking point in the 70s era of The House of God—has only further regressed to the brink of dysfunctionality today.


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