MEDICAL MATTERS Dr Muiris HoustonThis year marks the 25th anniversary of the release of The House of God, a unique book about the life of interns at a major US hospital. The House of God is the author's, Samuel Shem's, term for the big teaching hospital affiliated with BMS, the Best Medical School.
Probably best described as a medical Catch 22 - it does for the art of doctoring what Catch 22 did for war.
Funny in a morbid way, iconoclastic, bitter yet compassionate, it offers a good insight into the not-so-gentle aspects of healing. It is not a book for the genteel or faint hearted.
BMS is just one of many acronyms that pepper the book; they are a reminder of medicine's ability to hide suffering behind abbreviations for people, diseases and the many long-winded terms it has coined over the centuries.
The following is an exchange between Dr Potts, an intern on his first day and the Fat Man, a world weary resident (the US equivalent of a hospital registrar):
"What's a gomer?"
From outside the room came a high-pitched, insistent cry; "Go Avay, Go Avay, Go Avay..."
"Who's on call today?"...
"I am," said Potts.
"Good, cause that awful sound comes from a gomer. If I'm not mistaken, it's from one Ina Goober, whom I admitted six times last year. Gomer is an acronym. Get Out of My Emergency Room - it's what you want to say when one is sent in from the nursing home at 3 a.m."
"I think that's kind of crass," said Potts. "Some of us don't feel that way about old people."
"But gomers are not just dear, old people," said Fats. "Gomers are human beings who have lost what goes into being human beings. They want to die, and we will not let them, and they're cruel to us, by fighting tooth and nail against our trying to save then. They hurt us, we hurt them."
As one can gather, by being mildly over the top, the book offers insight into the darker recesses of the minds of stressed-out health professionals.
Dr Shem ends the book by outlining the Laws of the House of God:
Gomers don't die.
Gomers go to ground.
At a cardiac arrest, first take your own pulse.
The patient is the one with the disease.
Placement (to a nursing home) comes first.
The only good admission is a dead admission.
If you don't take a temperature, you cannot find a fever.
If the radiology resident and the best medical student both see a lesion on the chest x-ray, there can be no lesion there.
The delivery of medical care is to do as much nothing as possible.
I was prompted to reread The House of God as a result of a recent debate in Ireland, in the context of the crisis in our accident and emergency departments, about acute medical beds being occupied by patients who no longer require treatment but who are not fit to be discharged home.
At one point the debate crystallized around the need to find long term "step-down" beds for older people who could then be discharged from the acute hospital, thus freeing up a place for the many patients stuck in the accident and emergency bottleneck. One could see a situation where Rule 5 of The House of God would assume priority.
Perhaps there is an argument for this, as long as it is carried out in a sensitive and holistic manner. But I am concerned at one development over the last few weeks. The introduction of the term "bed blockers" to describe the people, who through no fault of their own, cannot be discharged. It has appeared in a headline in a national newspaper and I have heard it used by politicians when debating the issue.
It was the use of the denigrating term "bed blockers" to describe older people that prompted me to reach out to the bookshelf and take down my copy of The House of God. I have no problem with Samuel Shem using the artistic licence of a novel to introduce derogatory terms, such as Gomer, to describe patients.
However, I do have a difficulty with the introduction of "bed blockers" in the context of a real debate about real people.
The term is dehumanising, derogatory and I believe, potentially dangerous. By depersonalising these "nuisance" patients, are we entering the slippery slope of objectifying them? Could the next step be a diminution of their right to fair and equal treatment? Might it be the first move in devaluing such people, exposing then to inequality and inequity?
We are all getting older. No one wants to be labelled a Gomer or a "bed blocker". Lets stop the rot now and remove the term "bed blocker" from the healthcare debate.
Dr Muiris Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets he cannot answer individual queries.