March 2019


Part IV: The House of God, revisited

by J.C. Noreika, MD, MBA

J.C. Noreika, MD, MBA

In this final installment of the series on burnout, Sal Mangione, MD, shares insights for negotiating medicine’s rapidly evolving technologic and socioeconomic terrain

Published in 1978, the pseudonymous Samuel Shem’s The House of God would not see print today. That’s not to say that it shouldn’t be read. Racist, sexist, ageist, hilariously and unapologetically incorrect, this classic sends up healthcare as Joseph Heller’s Catch-22 did the military and Ken Kesey’s One Flew Over the Cuckoo’s Nest mental hospitals.
Untangling the crisis of physician burnout, the series’ final installment is prescriptive; some may reject it as disconnected from reality. But as clinician, educator, author, and media contributor Sal Mangione, MD, observes, “no one is happy, not doctors, patients, payers, or governments.” Below, quotes from The House of God introduce points for discussion.

“[B]ring to the grisly fun of hospital care a residue of their initial dedication.”
—John Updike, introduction to The House of God

Medical students are idealistic. Studying dehumanization inherent in clinical training and practice, Dr. Tait Shanafelt, a pioneer in the field, found that empathy isn’t lacking; it becomes suppressed. Dr. Mangione adds that practitioners, once perceived secular priests, suffer the eradication of meaning in their work. He cites Luke Fildes’ painting The Doctor (; search “The Doctor”) as art illustrating the essence of being a physician. Compassionate presence is often all we can offer.

“People expect perfect health. Most of the things that go wrong with their bodies we can’t do much about.”
—Fat Man to Roy Basch

The healthcare industry subsidizes the sham of perfect appearance, vision, and function. Even with advances in bioscience and technology, cures remain elusive and people die. There is enormous money in this. But the pursuit of money can intensify the risk of burnout. Although studies show physicians are motivated more by autonomy, mastery of skills, and a sense of purpose, the dollar’s tyranny can’t be ignored1.

“We ran smack into the conflict between the received wisdom of the medical system and the call of the human heart.”
—Stephen Bergman, afterword

Dr. Mangione is a polymathic film buff and witness to the zeitgeist. Hollywood’s portrayal of doctors has devolved over the last half-century. He references William Hurt’s 1991 portrayal of a pompous narcissist who learns empathy only after being diagnosed with cancer. Today, doctors are often portrayed as churlish technicians or “self-absorbed jerks with potential.” We must counteract this and other media fiction.

“What sustains us is when we find a way to be compassionate, to love. And the most loving thing we do is to be with a patient, like you being with me.”
—the dying Dr. Sanders to Roy

Technology finds itself at cross-purposes with compassion. It is seductively efficient but can isolate. Patient portals can’t replace an unhurried face-to-face exchange between physician and patient. Texts and emails won’t supplant personal touch when confronting blindness, morbidity, and death. “We slip into thinking that always being connected is going to make us less lonely. But we are at risk because it is actually the reverse.” A physician’s undivided attention is the bedrock of a mutually meaningful patient encounter.

“When you leave a patient’s room, make sure both of you feel better.” —Samuel Shem

Dr. Mangione advises that physicians revisit their job descriptions. Who am I? What do I do? What am I best at? How can I serve? What is the best use of my time? How can I remain competent? How can I make a difference? How can I best take care of myself? How do I want to be remembered?

“How can we care for patients if’n nobody cares for us?”
—Chuck to the Leggo

If modern medicine dehumanizes and isolates, care of oneself is crucial to counterbalance its lethal potential. Dr. Mangione recalls Epicurus’s advice to pursue cultivation, friendship, and independence beyond one’s employment. Leonard Woolf’s exhortation “just connect” is its currency.

“Sharing the experience is what will get all the rest of you through.”
—Berry to Roy

Collegiality has suffered. Connections fostered in doctors’ dressing and dining rooms, curbside consults on hospital floors, and at happy hours before medical society meetings have been lost. If anachronistic, the mutual support and understanding they promoted must be reinvented. They are anodynes to burnout.
Should you genuinely care about this? Must you be your patient’s friend? Do they really want this touchy-feely stuff? They only want to be cured, right? How’s that working out for you?
In his 2010 epilogue, Bergman prescribes doctors stay connected to one another, speak up as a group, learn empathy, and use competency as a complement to compassion. Dr. Mangione adds, to find meaning, come home to what first attracted you to medicine. Me? Reread the Russian writers, especially Chekhov. That brilliant doctor embraced empathy and compassion as humanity’s antidote to life’s corruption and inevitable tragedy.


1. Wenzel RP. RVU medicine, technology and physician loneliness. N Engl J Med. 2019;380:305–307.

Editors’ note: Dr. Noreika has practiced ophthalmology since 1981 and has been a member of ASCRS for more than 35 years. He wishes to thank Sal Mangione, MD, Thomas Jefferson University, for his assistance.

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