Nick Hopkinson: Man’s 4th Best Hospital—a powerful reminder of the moral hazards that await if we don’t look out for each other

My copy of The House of God, Samuel Shem’s 1978 novel of medical training, disillusion, and resistance, has a quote from Cosmopolitan on the cover; a “bawdy cult classic—Catch-22 with stethoscopes.” Given the critical reception that Closing Time, Joseph Heller’s 30-year on sequel to Catch 22 received, is this a hostage to fortune for Shem’s latest follow up Man’s 4th Best Hospital, out now in paperback?

I read The House of God a few months after I’d qualified, taking cathartic comfort from the feeling that, however much I was struggling, the healthcare system I was entering in the early 90’s wasn’t as appalling as the one that nearly crushes Shem’s young protagonist/alter ego, Roy Basch. Although imperfect, the sense that we were doing what could be done for patients while also protecting them from futile interventions seemed to provide a reasonable framework to try to do good, or at least no harm. At the House of God, Basch’s patients endure an endless cycle of investigation, intervention and complication—all driven by a need to maximise billing. As Thatcherism bled the NHS dry, the medical care we could offer seemed constrained by a lack of money, rather than corrupted by its pursuit. 

The dark humour and one-line “Rules of the House of God” that leaven the story mirror the temptation towards cruelty produced by these dehumanising conditions; medicine without its proper purpose. It’s an insiders’ book, and perhaps one that only doctors (and maybe their partners) ought to read—Shem might as well be waving Goffman’s The Presentation of Self in Everyday Life when he has one of the characters say “you can’t use your inside jokes with the ones outside all this….they don’t need to see and they don’t want to.”  The audience don’t want to see backstage.

In Mount Misery (1997) Shem described Basch’s painful discovery that the practice of psychiatry is even more dehumanising than internal medicine. Man’s 4th Best is set in the present day although only a few years have passed for the characters. In a further post-modern twist, Basch is also now the author of a scandalous medical novel called the House of God, allowing Shem to indulge in a few authorial anecdotes (not least, that doctors always want to tell him about their experience of reading his book, as I’ve just done). The sprawling BUDDIES Corporation that has taken over Man’s Best Hospital, is bleeding it for cash and realizes that MBH can “no longer make any real money by honouring its mission of service to the sick poor” and must instead focus on ways to “make money off the healthy wealthy”. Having dipped in the rankings, Basch and colleagues from the House of God are reunited under the messianic Fat Man who has been charged with restoring it from 4th to 1st

The Fat Man’s project, to bring the human back to healthcare, runs up against a series of “rackets”—insurance, data miners, healthcare corporations, the pharmaceutical industry, all lined up to disempower healthcare workers and patients; “the fatal trickledown economics of “no care.” Basch’s improbably tolerant partner Berry is given a bit more agency this time, taking a key role in explaining Shem’s concepts of good practice and good living to the team; “connection”, “being there”, and using the “we.” It’s an expositional device to underline the ideas to the reader, but the healthcare workers all seem a bit more surprised by these insights than you would expect, especially as they presumably have read the House of God themselves. It’s not completely clear that Chuck, an African American doctor’s observation what, y’mean that there’s racial discrimination in American medicine? Damn!” is meant to be sarcastic.

Shem has described his themes as “The risk of isolation, and the healing power of good connection…a good connection is a mutual connection”. The biggest barrier the Fat Man’s team face is the computer screen—what is supposed to be a clinical support system is actually a billing and account system, sucking the user’s attention down profit-driven algorithms of coding and away from the person in front of them. A new member of the team is praised because she “embodied the single best quality of a great doc, being able to type while looking at the patient.” 

The book is fast-paced and funny—Shem takes aim at power dynamics, Freudian analysis, racial prejudice, Israeli militarism and male-pattern thinking, while advocating for universal healthcare, alcoholics anonymous, and acknowledging a debt to his Oxford mentor Denis Noble. It’s important to say that sexual politics has moved on quite a bit from the Watergate Summer when the original novel was set, or more pertinently in the 40 years since it was written. Although the need to achieve gender parity is highlighted throughout the book, it is striking that, Jo, the by-the-book House of God resident who insists on always doing the maximum for/to patients (breaching Law XIII: “the delivery of Medical care is to do as much nothing as possible”), and who is cruelly treated by the interns including our hero, is not given a shot at redemption this time. 

Shem’s warnings about the corrupting effect of the market on healthcare have largely gone unheeded these last 40 years, but his work remains a powerful reminder of the moral hazards that await in medicine if we don’t look out for each other and ourselves.

Nicholas S Hopkinson, Reader in Respiratory Medicine, National Heart and Lung Institute, Imperial College, London, medical director of the British Lung Foundation and Chair of ASH. @COPDdoc

Competing interests: none