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The Prodigal Doctor Returns

6.4.09

"O my God—this is the end of civilization as we know it."  Such was the reaction of a physician friend of Stephen Bergman '66, M.D. '73, on hearing that Bergman would be the principal speaker at this year's Class Day ceremonies at Harvard Medical School (HMS). The friend, fictionalized as "Eat My Dust Eddie" in Bergman's celebrated 1978 novel The House of God (published under the nom de plume Samuel Shem), was simply acknowledging the improbability of the choice.

The House of God, which has sold more than two million copies worldwide and continues to be popular with young doctors and others who work in healthcare, is a lacerating black comedy, a bruising exposé of the realities of medical internship. Bergman's own internship at Boston's Beth Israel Hospital, an HMS affiliate, was the basis for the novel, and the unblinking, uproarious narrative once made its author persona non grata in certain medical corridors. "Some say the novel is bitter," Bergman declared. "It was rewritten seven times, to get the bitterness out."   

All is forgiven now. Bergman spent decades on the HMS faculty, teaching young psychiatrists-in-training at McLean Hospital. (This led to a second medical novel, Mount Misery, on psychiatric training.) And Shem/Bergman's critique of medical training has, over the years, gained considerable traction in the field. Confronted on the afternoon of Commencement with the HMS class of 2009, the author reviewed some favorite passages and "laws" from The House of God, then offered the new graduates "four suggestions for how to stay human in medicine."

His first tip was, "Stay connected."  Bergman asserted that "Isolation is deadly; connection heals."  In large medical hierarchies like hospitals, he said, "...someone always has power over you, and you have power over someone else"; then he explained that in such "power-over" systems, the only true threat to the dominant group "is the quality of connection among the subordinate group.  So in your training, please remember: stick together." He added that the best predictor of our own happiness is "not Lipitor, but the quality of our relationships."

"When you're in trouble, do not withdraw," he continued. "The way to stay human is to move toward others. Lean into life, not away.  America places a terribly high value on the individual. But happiness is not an individual matter."

His second principle was "Speak up," an action that he called "essential to your survival as a human being." The third was "Learn empathy." Bergman called the increasing prevalence of women in medicine one of the most encouraging aspects of the field, noting that women composed less than 10 percent of his class, but more than 50 percent of the class of 2009. "Women are valued for being the carriers of caring in our culture," he said, "and bring particular qualities to being doctors—empathy, nurturance, emotion—which have often been seen as weaknesses. These are not weaknesses, but strengths." His final suggestion was "Learn your trade, in the world"—to remain aware that all patients, and all healthcare providers, are embedded in a worldly context of families and friendships, an environment and a culture.

The novelist/doctor also delivered the "bad news": "You are about to enter a disaster area: the healthcare 'industry.' " Bergman observed that "The issue is crystal-clear: the for-profit health-insurance industry spends 30 percent on administrative costs—over $300 billion a year; the government-run systems Medicare and the Veterans Administration spend 3 percent per year.  Coverage and satisfaction with for-profit is low; that for government systems is high." He then thundered, "Why in the world should healthcare be for profit?" to the biggest applause of the day.

The "Shem plan" of healthcare reform includes a universal-coverage federal system. "Anything less is just palliative, whistling past the graveyard of American healthcare," Bergman explained.  "The for-profit system can continue, for the wealthy."

Secondly, he advocated tort reform, to attenuate defensive medicine. Third, paying for all medical education, in return for service, including a crowd-pleasing proposal to forgive all student loans, "starting retroactively, from today."

To pay for reforms of this magnitude, it would be necessary to revise our priorities, Bergman asserted, noting that "A whole year's budget for the National Institute of Health is a few days' budget for the Department of Defense." Ambitious as his agenda sounded, Bergman reminded his listeners that "We are the workers." He asked,  "Has anyone ever heard, in a crowded theatre when someone collapses, the call go out: 'Is there an insurance executive in the house?' " Bergman shared a message of self-recognition and strength with the new doctors: "We do the work.  We have the power.  Without us, there's no healthcare."