Medical Examiner

Man’s 4th Best Hospital Is No House of God

In his first novel, Samuel Shem made a surprising argument about what plagues the medical world. Are health care’s problems too familiar for a sequel?

The covers for Man's 4th Best Hospital and House of God.
Penguin Random House

Like many doctors, I read The House of God before becoming a doctor. Published in 1978, the novel provides a wild account of newly minted interns training at a prestigious academic hospital, told from the bewildered perspective of one such intern, Roy Basch. Through a series of garish encounters with heartless supervisors and disagreeable patients, Basch paints a radically unvarnished view of medicine from the inside. The novel’s absurdity carries with it the air of authenticity, rendering it an antidote to the humanistic platitudes of typical clinical narratives.

Despite heavy inflection by the context of the late 1970s, from outmoded sexual politics to the dissolution of the Nixon administration, The House of God has enjoyed perennial interest among successive generations of medical trainees. Empathy comes easy for the trainees at the heart of the picaresque, who deploy deadpan humor not only to survive the inhumanity that surrounds them, but also to organize it. They coin idiosyncratic lingo (e.g., GOMER, “Get Out of My Emergency Room,” referring to the ubiquitous sort of elderly inpatient who is forever unwell) and precepts (e.g., “gomers don’t die”) that seem far more applicable to their daily practice than traditional medical rhetoric.

I read The House of God as an undergraduate before I knew a thing about clinical work, but even then I could appreciate its basic transgressive function, the breach of norms surrounding medicine’s sanctified presentation to the public. Likely the novel’s author appreciated this, too: As a young physician aware of the professional stakes involved in his bitter send-up of the hospital enterprise, Stephen Bergman elected to publish the book under a pen name, Samuel Shem. As physician and historian Howard Markel wrote on the book’s 30th anniversary, its debut scandalized prominent reviewers within the health care community, which likely hastened its circulation through less powerful ranks of the clinical hierarchy.

Circulation, in turn, led to legitimacy. The decades following The House of God’s publication have seen a progressive focus on humanism in medicine, from administrative restrictions on trainee duty hours to curricular initiatives incorporating the arts into medical education. Bergman himself has benefited from this sea change, serving often as a visiting professor and commencement lecturer, feted for his early contrarianism that has since been fully metabolized by the medical mainstream.

Forty years later, Bergman (still writing under his more famous pen name) has published a new novel, billed as a sequel to The House of God in both its characters and its rebellious tradition. In Man’s 4th Best Hospital, Basch and his co-residents are now fully trained, mid-career physicians, recruited to work not at the House of God but another thinly disguised, Boston-based academic medical center—formerly Man’s Best Hospital, now fallen to fourth in the national rankings. In Shem’s telling, the reasons for this drop correspond to the major sins of contemporary American health care: administrative bloat, corporate greed, an inefficient electronic medical record. These sins also comprise the major targets of his heroes’ new crusade.

To some extent, this formula was bound to falter. In The House of God, the main characters’ appeal derives largely from their powerlessness; in Man’s 4th Best Hospital, their ascent to the top of the hierarchy is a far less sympathetic position for speaking truth to power. In The House of God, the central critique is forceful because it is narrow: The various degradations of hospital work are displayed vividly and repeatedly. In Man’s 4th Best Hospital, the critique is confusingly scattershot, ranging from the high-tech trappings of modern medicine to sprawling social trends like smartphones, guns, Western diets, gender disparities, environmental degradation, and American imperialism. These are big and disparate concerns, and Shem’s earnest attempt to engage all of them renders the whole polemic toothless.

In its writing, too, the sequel falls well below the standard set by its predecessor. Its flimsy plot is punctuated by long stretches of dialogue invoking dry statistics and obscure journal references. Characters swing in tone between saccharine psychobabble and the ramblings of old men trying to figure out how to use their computers. Admittedly, the infrastructural grievances of Man’s 4th Best Hospital are harder to dramatize than the interpersonal conflicts in The House of God, but Shem also seems much less interested in dramatizing them. There are occasional episodes of clinical slapstick in Man’s 4th Best Hospital that recall the joys of his first novel, but the moral ambiguity that once served as its engine has been replaced by overt signposting toward the moral high ground.

Similar criticisms of “sermonizing” were once leveled at Mount Misery, Shem’s first effort at revisiting Basch’s narrative, published just over 20 years ago. Mount Misery is mentioned in passing in Man’s 4th Best Hospital, but the former’s lukewarm reception in 1997 is presumably what led to the latter being publicized as a sequel rather than the third in a trilogy. The House of God is also mentioned by name multiple times in the new novel, under the conceit that Basch wrote it, with various fictional physicians commenting parenthetically on how much the book still means to them. This self-referencing feels like the sort of technique a more confident author would avoid.

Or perhaps it’s the confidence that is the problem. In his 30th anniversary commemoration of The House of God, Markel describes Bergman as enjoying a “victory walk” through a series of reverential discussions on the legacy of his work. Man’s 4th Best Hospital often reads as another victory lap. In style and content, it resembles not so much a novel as a commencement speech, rife with trite prescriptions for the future of medicine and anchored by nostalgic callbacks to Shem’s greatest hits of yesteryear.

There is an edge of sadness to this turn of events, not least because the new novel makes clear that Bergman still regards himself as a medical revolutionary. But his tirade against the electronic medical record is neither original nor particularly resonant. His analysis of our flawed insurance system has been done before, and more effectively, in newspaper op-eds and campaign stump speeches. Bergman’s distinctive transgressions as an anonymous trainee led unexpectedly to his legitimation as a professional celebrity. Now, in that capacity, his desire to transgress again corresponds with the professional inability to do so. His anti-technology, pro-empathy, social justice–oriented message echoes the most common refrains in medical humanism—passionate, for sure, but not especially interesting.

The House of God remains a landmark work of medical fiction, as notable for its stylistic freshness as for its ethical cage-rattling. Its legacy shouldn’t be affected much by Man’s 4th Best Hospital, mostly because the sequel reads as a pedagogical exercise rather than a literary one. Perhaps a work as plucky and paradigmatic as The House of God is simply impossible to replicate. All the same, it is depressing to see Shem and his protagonists wind their way headlong into the same sorts of banalities they once so effectively undermined.