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The House of God

Article in BMJ Clinical Research · January 2007

DOI: 10.1136/bmj.39084.673889.59 · Source: PubMed Central

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When doctor meets
dictator, p 100

views & REVIEWS

What’s wrong with the wards?

PERSONAL VIEW Katherine Teale

One of the more depressing moments in my friends about. And it’s these that make
week came when I overheard a conversation patients, especially elderly patients, dread
between two surgical trainees. “I’m covering being in hospital.
the ward today,” said one disgruntled Ironically, this is happening at a time
young man. “I always get the crap jobs.” when great emphasis is being placed on
His colleague was suitably sympathetic at communication skills. Hours are spent
this terrible misfortune. When I teach the teaching medical students this art, and our
medical students they seem fired up with problem based learning cases are packed
the desire to help people. When does this with “social cues.” Yet both doctors and
become limited to wanting to cut bits out nurses spend less time than ever actually
of people, send them back to the ward, and communicating with patients. Part of
forget about them? the problem, of course, is the change to
It’s not just the doctors’ problem. medical training—trainees, now working
The Royal College of Nursing recently shifts and covering many more wards,
warned that cuts in nursing jobs are have less time to spend with individual
putting patients’ lives at risk. Certainly patients. Many of the tasks that would
understaffing is a serious issue—but my have brought trainees into contact with
experience of many wards is that there patients (taking blood, performing
seems to be an invisible barrier between electrocardiograms) have now been
the nursing station and the patient areas. delegated to nurse practitioners. Similarly
Nurses only cross this to do a specific task, many of the tasks done by trained nurses is it appreciated by peers. No one ever
and then scurry back to the paperwork as (“turning” rounds, handing out meals) got a merit award for looking after their
quickly as possible. Recent figures show are now done, if they’re done at all, by patients well. In fact, it seems that the less
that three of the four commonest causes auxiliaries. The result often is that the only time you spend with patients, the more
of delayed discharge are associated with people whom the patients regularly see are likely you are to be rewarded. This is
inadequate care on the ward: pressure completely untrained—and all the valuable tragic, not only for the patients but also,
sores, healthcare acquired infections, and information about patients’ progress which in the present climate, for the future of the
medication errors. Although the news used to be gained has been lost, as have hospital. It’s madness to spend thousands
is full of stories about high technology the opportunities for patients to use these of pounds on fancy surgery if the patients
surgery and expensive new treatments, casual contacts with staff for reassurance are then allowed to develop avoidable
perhaps what we should all be focusing on and asking questions. complications.
is the poor care that patients often receive It’s easy to blame the nurses, but we The crisis on many wards is the result of
on the wards. doctors have to lack of trained staff, lack of continuity of
Friends and relatives who have been It’s easy to blame take our share care, and poor leadership, and it is directly
inpatients recently all have similar the nurses, but of responsibility. harming patients. Many of these changes
complaints—never seeing a nurse except we doctors have I’ve worked on are out of our control, yet they have created
when drugs were being handed out, no to take our share wards where care a problem that we must recognise and deal
one offering reassurance or information, of responsibility is excellent; the with. Doctors often complain that they feel
days going by without any contact with difference is mainly helpless in the face of NHS reforms; this is
senior medical staff, virtually having to beg good leadership, both from the nursing one area in which each and every one of us
for help moving up the bed or getting to hierarchy and from the consultants. If the can make a difference—simply by making
the toilet, repeated requests for analgesia. senior medical staff are rarely on the ward time on the ward a priority, reviewing
Two elderly relatives developed pressure seeing what goes on, if they don’t act as patients, guiding the trainees, and
sores after straightforward surgery, and role models for their trainees, and don’t supporting the nursing staff. If providing
one lost 6% of her body weight after a joint make themselves available to support the care on the ward continues to be the “crap”
replacement because of prolonged nausea nursing team then patient care suffers. job, the experience of those unfortunate
that was inadequately managed. It’s these Ward care is just as important as complex patients will continue to be lousy.
experiences, and not the skilful surgery, surgery—and can be just as difficult—but Katherine Teale is a consultant anaesthetist, Manchester
that patients remember and tell their unfortunately it is not so glamorous, nor [email protected]

BMJ | 13 jANUARY 2007 | Volume 334 97

 VIEWS & REVIEWS

Small beer or G and T

FROM THE I was “remedial,” an old fashioned term for dim. I music, and sports—are clearly dependent on schooling
had “special” lessons. These were a rough and exclu- and parental input, it will be the usual suspects, the
FRONTLINE
sively male affair involving joke telling, arm wrestling, middle class kids, that will make up the body of the
Des Spence ­conkers, crayons, and learning to spell swear words— G and Ts. Boys who struggle to learn to tie shoelaces,
invaluable life skills that I have used throughout my hold a crayon, and string a simple sentence together at
career. Unfortunately, at 10 my word blindness began primary school will be marginalised even further. Also
to lift. I had to leave my poor simpleton friends for those tedious parents who already believe that their
the nerd section of the class, but I never forgot them. offspring are “special” will threaten schools if their
Apparently we morons are no longer herded together children are not included on the G and T ­registers.
and separated because it erodes “self esteem” to be The single greatest worry, however, is that children
told that you are stupid at the age of 7. might come to believe that they are G and Ts. Think
Now the top 10% of primary school children are to of those already in medicine who believe themselves
be entered on to a register of the gifted and ­talented— anointed by a higher power, deluded and downright
“G and T.” All future doctors will of course go on to dangerous. I don’t think we need more of them.
the register as a matter of default. G and Ts will receive Perhaps it is time for a pre-emptive strike from the
extra lessons and focused education. But do we really child and adolescent psychiatric community against
think that currently teachers ignore bright kids? this divisive and “remedial” idea. Otherwise we will
The omnipresent experts predict that in less than see a whole generation unable to square the circle of
a decade G and Ts will win all the Olympic medals the mundanity and mediocrity of adulthood with their
and never again lose the Ashes, and that doctors will once venerated status as G and T children.
find the elixir of life. Our society will walk into a fairy I sometimes regret leaving the remedial dunces.
tale sunset. Or will we? Unfortunately, many of the Oddly, without the weight of expectation, many small
attributes in life that set you aside cannot be meas- beers ended up as successful, happy family people.
ured or clearly defined. And as the definable “gifts Des Spence is a general practitioner, Glasgow
and talents”—such as special ability at maths, reading, [email protected]

Serbian smoke gets in Belfast eyes

THE BIGGER It is almost impossible to get away The Serbian MPs asked how up in their own offices, while the
from cigarette smoke in Serbia. parliamentary committee structures staff in neighbouring ministries
PICTURE We have the third highest rates of worked and explained how they nearly all smoke like trains.
Mary Black smoking in Europe—31% of women were implementing Serbia’s own Things may be changing due to
and 40% of men. There are only poverty reduction strategy. And all an interesting legal precedent in
a few effectively smoke free areas in a smoke free environment. the Serbian parliament. Members
in buses, cinemas, theatres, and at Throughout the trip, the Serbs of the committee that passed
the top of remote mountains. Fags survived on cheap duty free Serbia’s recent anti-smoking
are as cheap as chips and people cigarettes; to smoke 40 a day legislation banning smoking in
smoke through meals, at meetings, of Belfast cigarettes would have all public buildings were spotted
in their offices, over coffee, and taken 30% of their weekly salaries. smoking in a parliamentary
around their children. Most of the delegation simply working group meeting. Health
Northern Ireland is a bit ahead; redistributed their dosage to inspectors have imposed fines. So
only around 24% of adults smoke. comply with smoking restrictions, far only one MP has paid up; the
All public buildings have been a few smoked less, and a couple others have yet to do so.
smoke free since 2004. Pubs, considered giving up. Tobacco will continue to kill
clubs, and restaurants will go Serbia has a long way to go on one in three people in Serbia for
smoke free in April 2007, when a tobacco control. Health minister Dr quite a time to come. But one day
total ban will come into force. Tomica Milosavljevic (who recently Serbian prime ministers will not
Last November, our delegation resigned) is a true believer and walk smiling down red carpets
of 13 members of the Serbian achieved some success in banning to open new tobacco factories
parliament plus five translators smoking in hospitals and areas lavish with praise for tobacco
and support staff hit the ground in under his jurisdiction, but doctors industry investment. And tobacco
Belfast running . . . and puffing—11 and nurses still smoke in their executives will be treated as the
were chain smokers. We were clinics and during coffee breaks. pariahs they really are.
there for the launch of Northern And he was unable to prevent staff Mary E Black is a public health physician,
Ireland’s poverty reduction strategy. in the Ministry of Health lighting Belgrade, Serbia [email protected]

98 BMJ | 13 jANUARY 2007 | Volume 334

 VIEWS & REVIEWS

MEDICAL CLASSICS
Not dead yet—and buried The House of God By Samuel Shem
First published 1978
Henry James once Prevented is full of
remarked that an BETWEEN lurid stories that Sex and death are all that matter, argues Philip Roth,
perhaps the greatest living writer in English. The early
excessive interest in THE LINES make the flesh
years that doctors spend in hospital thus provide rich
the works of Edgar creep: “In a small
Theodore Dalrymple material, as they are surrounded by death and obsessed
Allan Poe was the town in Prussia an by sex. The House of God is the most successful and
sign of a primitive undertaker, living literary of books describing the initiation of doctors and
sensibility: such as in the limits of the has sold over two million copies since it was published
Baudelaire’s, I sup­ cemetery, heard in 1978. Its bleakness, black humour, and brutishness
pose. I cannot but during the night the paved the way for television programmes like Cardiac
agree with James on cries proceeding Arrest, Green Wing, and Bodies.
The book tells the story of the intern year of Dr Roy
this point, and I might from within the
Basch in a hospital called the House of God, which
add that Poe’s prose grave in which a is based on Beth Israel Hospital in Boston. Basch’s
style seems to me person had been experiences are those of Shem (a pseudonym for
dense without depth buried on the previ­ psychiatrist Stephen Bergman, who was a Rhodes
and earnest without ous day. Not daring scholar and trained at Harvard). The year is filled
seriousness. to interfere without with exhaustion, error, despair, suicide, inhuman
One of Poe’s pre­ permission, he went senior doctors, and lots of soulless sex, all leavened
by humour—in other words, a typical “houseman’s
occupations was The narrator in Poe’s story to the police and
year,” as my generation calls it.
shared by many arranged a mechanism in reported the matter.
Everybody is now familiar with such material, but it
people of his time, the coffin in which he When, after a great wasn’t so in 1978. The public was fascinated, hence
namely premature proposed to be buried that deal of delay, the the sales. Older doctors hated the book, but young
burial. Throughout required formalities ones loved it. Looking back after 25 years, Shem
would release him on the
the 19th century, and were fulfilled and tells of a letter he received that said: “I’m alone on
even into the begin­ faintest movement permission granted call in a VA in Tulsa, Oklahoma, and if it weren’t for
ning of the 20th cen­ to open the grave, your book I’d kill myself.” Writing the book was for
Shem a way to survive and heal, and he captures
tury, books appeared about the danger it was found that the man had been
how the young doctors come together and make the
of precocious interment, with advice ­buried alive, but that he was now dead transition to doctors: “Each life was being twisted,
as to how to avoid it. There was even . . . he had skinned his hand and head branded. We were sharing something big and
a Society for the Prevention of Burial in his struggles . . . ” murderous and grand. We were becoming doctors.”
Before Death, which published many The narrator in Poe’s story arranged One factor that lifts the book to the status of a
books and pamphlets; it made much of a mechanism in the coffin in which classic is the energy, beauty, and insightfulness of
the fact that death was a difficult diag­ he proposed to be buried that would the writing, but another is the “Laws of the House
nosis, the subject of controversy among release him on the faintest movement. of God,” which entered medical parlance not only
in the US but in the UK. Law one is “GOMERS don’t
doctors. (Romeo and Juliet would not Tebb and Vellum describe the apparatus
die.” GOMER stands for “Get Out Of My Emergency
have been a tragedy without a mistaken invented by Count Karnice-Karnicki, Room” and is “a human being who has lost—often
diagnosis of death.) who had once witnessed the premature through age—what goes into being a human being.”
Indeed, the precautions against burial burial of a Belgian girl. A mechanism Rule nine is “the only good admission is a dead
alive taken by Poe’s narrator in the story in the coffin opened a tube to the outer admission.” The book is strongly ageist and sexist
“The Premature Burial” are precisely air and raised a flag above the ground if (just like medicine?), and the descriptions of taking
those recommended in Premature Burial the supposed corpse showed the slight­ sexual pleasure from examining a patient are more
and How It May Be Prevented, second edi­ est sign of life. And then there was the shocking in 2007 than they
must have seemed in 1978.
tion 1905, by William Tebb and Edward mortuary in Munich, a kind of purga­
The factor, however, that
Perry Vellum MD. Tebb was not a doctor, tory for corpses, in which the corpses’ finally makes the book a classic
but he was interested in such good causes fingers were attached for a few days to a is its deep understanding of
as the abolition of slavery and the avoid­ bell that rang in an apartment inhabited good medicine—including,
ance of premature burial, to which cause 24 hours a day by an attendant. for example, how avoiding
he gave the last years of his life. He was Was any of this necessary? Even an intervention is often
also the originator and propagator of the now, a person occasionally comes to better than intervening. This
idea that leprosy was caused by smallpox life at his own postmortem examina­ understanding is captured best
in the mysterious “Fat Man,”
vaccination, and wrote a lengthy treatise tion. Perhaps I was wiser than I knew
a resident who makes patients “feel like they’re
on this subject. Dr Vellum had been when, as an exhausted houseman, a still part of life, part of some grand nutty scheme
medical inspector of the US Army and nurse phoned me from the ward in the instead of alone with their diseases . . . still part of
became interested in the subject of pre­ middle of the night and said, “Doctor, I the human race.”
mature burial after he nearly drowned, think Mr Jones is dead.” “Well,” I said, Richard Smith, chief executive, UnitedHealth Europe
was given up for dead, and woke up just “if you’re right, he’ll still be dead in the This is a series of reviews of books, films, plays, television series, and
before his own interment. morning,” and went back to sleep. artworks that relate to the practice of medicine. To submit reviews of
medical classics, please email Trevor Jackson ([email protected]).
Premature Burial and How It May Be Theodore Dalrymple is a writer and retired doctor

BMJ | 13 jANUARY 2007 | Volume 334 99

 VIEWS & REVIEWS

review of the week

When doctor meets dictator

Where does a doctor’s responsibility as a civilian begin and his duty as a
doctor end? Chloe Veltman is impressed by a film that grapples with this
uncomfortable issue
The Last King of Scotland When a homely, Scottish general practitioner toasts his tion as a medical relief worker at an impoverished
UK release date: son’s graduation from medical school, he little expects village ­mission for the chance to live in luxury at the
12 January 2007 the heir to the family’s doctoring ­tradition to wind up ­president’s residence in Kampala.
On general US release administering care to sick ­children in a remote part During a reign of terror between 1971 and 1979,
Rating:
**** of Uganda. And he certainly doesn’t expect him to
­become ­complicit in the local despot’s killing spree.
Amin was responsible for more than 300 000 deaths.
Although the film blends fact with a fictional premise
But as soon as Nicholas Garrigan, The Last King of ­(Garrigan, for one, is a made up character loosely
Scotland’s adventurous, young protagonist, arrives in based on a real life British soldier who became Amin’s
Uganda to work as a physician, he finds that he is closest adviser) its ­understanding of human psychol-
smack bang in the middle of a military coup. ogy rings devastatingly true. As such, The Last King
It is this mixture of spirited gung ho and politi- of Scotland’s shock value owes more to Garrigan’s
cal naiveté that makes Garrigan a dictator’s medical unwillingness to confront the fact that his patient is a
delight. As director Kevin Macdonald demonstrates bloodthirsty tyrant than any of the film’s depictions of
in his taut screen adaptation of Giles Amin’s murderous stampedes.
Foden’s 1998 novel, the combination The doctor brings For as long as he can, Garrigan clings
can be lethal in a doctor thrust into the about his own to the tenets of the Hippocratic Oath,
limelight at a time of civic unrest. as if he believes it will somehow shield
downfall when his
When Garrigan (played by James him from having to face a greater reality
­McAvoy) first meets Ugandan autocrat Idi
thrill seeking nature beyond that of his patient’s petty medi-
Amin (Forest Whitaker) the two instantly leads him into an cal complaints. The havoc Amin wreaks
hit it off. Amin is as much impressed by adulterous tryst on his country flickers only faintly at the
Garrigan’s no nonsense approach to borders of Garrigan’s conscience as he
bandaging his sprained wrist as he is by the young dutifully gets up in the middle of the night to deal
man’s roots: as a fervent admirer of all things Scottish with the president’s many hypochondriac episodes.
(the real life Amin even went as far as to bestow the Bombs explode and government officials mysteriously
title of “King of Scotland” upon himself) the presi- go missing, but Garrigan remains coolly professional,
dent sees in Garrigan the ideal confidante. Meanwhile, dispensing tough medical advice where necessary, but
The odd couple: (from the doctor, susceptible to flattery and always on the trying not to get politically involved.
right) James McAvoy as lookout for an adventure, is easily won over by the Inevitably, Garrigan finds himself unable to ­untangle
Dr Garrigan and Forest affable African with the medal festooned chest. It isn’t medical affairs from those of state. From the start of
Whitaker as Amin long before Garrigan decides to abandon his posi- their relationship, Amin treats ­Garrigan as a close
adviser, broadening his job description with a wide
range of ­private and ­public responsibilities that include
driving the president to the airport and selecting an
architect to design a building for the upcoming Pan-
African Congress. But ­Garrigan’s professional crisis is
not all Amin’s fault. The doctor brings about his own
downfall when his thrill seeking nature leads him into
an adulterous tryst with one of the president’s wives.
It’s fascinating to see how the dictator and doctor
share some of the same fundamental personality traits.
The abuse of power isn’t just Amin’s; the grossly negli-
gent Garrigan could also be accused of the same thing.
If it weren’t for the fact that McAvoy and Whitaker
film four and DNA films limited

both imbue their characters with so much sympathy,

we wouldn’t care about either man’s fate. But the film
leaves us grappling with the uncomfortable issue of
where a doctor’s responsibility as a civilian begins,
and where his duty as a doctor ends.
Chloe Veltman is a freelance journalist, San Francisco
[email protected]

100 BMJ | 13 jANUARY 2007 | Volume 334

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