GOMERs and GOMEREs

I just finished reading The House of God by Samuel Shem, MD. The House of God is a medical satire about a group of interns’ experience during their first year of residency. The book follows Dr. Roy Basch, a ‘red-hot’ medical doctor fresh out the the ‘Best Medical School’ and starting his residency at The House of God, a prestigious hospital in Boston affiliated with the Best Medical School (Harvard, I assume). The book was referred to me by a friend in medical school who said it’s the most popular medical novel written to date. Expecting to get some fresh insight into what life is like as an intern, I approached this book with anticipation and excitement. In fact, Mel would tell you I looked at every used-book store in Nepal hoping to find this book. My enthusiasm quickly turned to confusion and even distress as the author paints a very cynical picture of medical education. Roy and his fellow interns are tortured with being on call every third night (and at times every second night), working 100+ hour weeks, being tortured by GOMERs and LOL in NADs, and slowly realizing the idealized physician’s life they all desire is turning out to look more like a nightmare than a dream. As these young doctors become disillusioned they lose their humanness, break down (one jumping to his death from a hospital window), and at one time or another become despicable.

I want to focus on one of the terms this book introduces, the GOMER. This derogatory term is defined by The Fat Man to mean “Get Out of My Emergency Room, a human being who has lost—often through age—what goes into being a human being.” It describes elderly people suffering from diseases such as dementia, whom the interns must care for in unflattering ways such as disimpacting hard stools. They can’t die, and are constantly abused by the medical staff. For example, one the the rules in The House Of God is GOMERS GO TO GROUND, meaning they fall out of bed. The interns use this rule in order to TURF their GOMERs to ORTHO or NEURO by setting the hospital beds up at dangerous heights. The treatment of these people portrayed by this satire is disturbing.

During my undergraduate education, I worked part-time as a certified nursing aide at two different nursing homes. One man for whom I provided care (I will call him James) was a WWII veteran, learned Chinese, and taught Chinese literature at Brigham Young University. In his old age dementia had left him miserable. He relied on CNAs for everything, and many CNAs resented him. James’ dementia made him violent, especially at night and he would punch, kick, spit, and do anything he could to prevent the aides from helping him. I remember one aide who even resorted to hitting James back. She lost her job. Whenever James’ call light went off, the aides would do their best to ignore him, or try and persuade another aide to go see what he wanted. Shem would call James a GOMER.

I became a ‘go-to guy’ when it came to James’ care. James liked me. I think he started to like me the first summer I grew a beard. A gruff man himself, James would say “you and I need a shave” with the biggest grin on his face. I found that James was rarely resistant towards care if I sat down and talked with him for a few moments before attempting anything. An avid reader, James enjoyed showing me what he was reading, and I would occasionally show him what I was reading. I would sometimes greet him with a ‘nee hau’ or begin by throwing his boot, which he hated, across the room to which he would applaud. He loved to tell me about his travels, about his family, and other such things. While his mind was ill, his soul was not. One day when I was struggling with my faith, James bore his testimony to me of the Book of Mormon and of the Restoration. James’ testimony is one of the most powerful spiritual experiences I have had in my life. James became a dear friend of mine.

The purpose in sharing this is to help encourage better understanding. James was treated as less than human because of his dementia. I discovered that James is a beautiful person who enriched my life greatly. People yearn to feel loved and respected. Treating people like GOMERs or GOMEREs (the feminine version of GOMER) is not acceptable. A lot of people have inherited a tough situation in life. I think one of our duties as human beings is to help each other out and encourage better understanding. Let’s think again about how we and others treat people like James.

Leia Mais…

Doctors’ Diaries

I received wonderful news this week. I will be attending the University of Rochester School of Medicine and Dentistry in August as a first-year medical student! As Melanie and I research activities and sights in New York, where we are going to live, how we are going to pay for tuition, and other logistical necessities, I continue to find my mind wandering and worrying about what lies up ahead. In an effort to demystify my future I decided to watch a PBS NOVA special called Doctors’ Diaries. This program follows seven doctors starting from their first day of medical school at Harvard. The program does a fantastic job at showing the different students’ personalities, and allows the viewer to get a glimpse of what it takes to become a doctor and what being a doctor entails.

Some aspects of the documentary are disturbing. As an intern, talking about the stressfulness of being a physician, one doctor says he’s “become this person that [he] doesn’t particularly like.” Another says “I’m gradually just getting more and more tired.” Several of the doctors go through a divorce or two (or three). A wife describes the time her husband is able to give her as a “shell” of the man she married. I also watched an intern connect with her patient before heart surgery and then, after six hours in the OR, pronounce that patient dead. These are some of the things I fear.

One doctor says, “In my years of practice now I’ve seen all the range of extreme tragedy, extreme joy. I can’t think of anything that’s grounded me so much in my life as being a doctor.”

There are also many uplifting aspects to the documentary. My favorite aspect is the film subjects’ interaction with patients and other doctors. These students and interns genuinely care for the people they are helping. One doctor develops a way to get eyeglasses distributed to rural areas of China. It is refreshing to see genuine care provided by all the physicians documented since this type of care is the reason many (including myself) go into medicine to begin with.

“You’re going to be okay. We’re going to take care of you and you’re going to be alright.” Being able to say (and mean) this is what satisfies one physician in the documentary. “I wouldn’t trade that for the world.”

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The Save

Dan J. Schmidt

I started medical school thinking I wanted to be a family doctor--someone who could work in a small town and deal with whatever walked through the door. But in our third year, when we received our first taste of clinical medicine, I found my surgery and ER rotations exciting. I was at our state's major trauma center, and I loved it. Fixing things gives me a thrill--and the power to save a life is even more alluring.

Each "save" felt like a miraculous triumph. Take the nineteen-year-old visiting Australian, stabbed in a random street altercation, his blood pressure dropping as fluid accumulated around his heart. Right there in the ER, he had his chest split open and his right ventricle patched by the very cool chief surgery resident.

But after several weeks of 5 a.m. surgery rounds and every-third-night call, I started to feel a nagging sense of unmet need, both my own and the patients'. To me, it seemed that the specialized care we were giving was excellent but fractured: No one was responsible for the whole person.

It was 8 a.m. during my third week of the rotation. The third-year resident had led us medical students through our rounds, and there'd been time for some drug-rep doughnuts before we headed down to the ER. At the nursing station, we joined those who'd been on call the previous night and were sharing their war stories.

"You shoulda seen what we just got!" said one of the students.

A twenty-something guy had come in with a near-amputation. "He cut off his arm with a Skilsaw!" (the powerful circular saw used by professional carpenters and builders). "He's down in the OR now. Orthopedic surgery thinks they can reattach it."

After the descriptions of the bones, the x-rays, the blood loss, I asked one student, "Which arm?"

She frowned. She didn't know. I looked at the x-rays. It was the right.

I caught the gaze of a third-year surgery resident and asked, "Do you know how hard it is to run a Skilsaw left-handed?" (It's a lot harder than scissors. I knew: I'd spent a year building condos before I'd entered medical school.)

The resident nodded. This injury was no accident.

That evening I heard the orthopedic surgery team talking about how happy they were with their neurovascular and bone-plating work. It looked like the patient's hand would be saved. But they were aware of his psychiatric risks: He was being kept in restraints until they could get a "full psych eval."

The guy was in the post-operative ward; when I'd gone around to check on my patients, I'd seen him. Straight black hair. Intense gaze. Cold affect. Girlfriend sitting at the bedside, then leaving in tears.

The next morning, the psych team came by to evaluate him. They started him on an antidepressant, but thought that he was no risk to himself.

Coming back from lunch that afternoon, I heard stat pages overhead, calling the chief ortho resident to a "thrash" on the post-op ward. Hurrying down the hall, I saw a bed barreling towards me, pushed by three residents. A nurse knelt on top of the patient and his bloody sheets, pressing her hands hard against his arm as they steered the bed into the elevator.

"What happened?" I asked the senior resident.

"He pulled it off! All that work, and he just pulled it off!" he raged.

Before the elevator doors closed, I heard him say, "Damn if we're putting this back on again! He'll get what he wants!"

And off they went, back down to the OR.

I went to his room. There were fine blood spatters everywhere, and a big, dripping arc across the far wall. The Filipina housekeeper quietly mopped the burgundy-stained floor, shaking her head.

A technological success. A medical catastrophe.

We had treated this man's injury, reattached his limb, evaluated his psyche--but not one of us had tried to care for the whole human being. It seemed that our academic and specialized-care system had accomplished a wondrous feat of technological prowess, but didn't foster a focus that could actually heal the patient.

Standing amid the gory mess left by a man I didn't know--a man who seemingly wanted not to be whole--I realized that I wanted to treat the whole person.

So I decided to stick with family medicine and left trauma and surgery behind.

A save still thrills me, although in family medicine they are thankfully rare. I get to keep my eye on the big picture. And I'm rewarded by a constant stream of quieter saves--the type 2 diabetic patient who loses fifty pounds, the alcoholic who's been dry for a couple of years now, the young single mother who's learning to raise her infant well.

These triumphs, bloodless but still lifesaving, keep me going.


About the author:

After seventeen years of practicing full-spectrum family medicine, Dan Schmidt now covers small-town practices on the weekends. Married, and with four grown daughters, he also fixes old cars and remodels houses--yes, sometimes using a Skilsaw. "I find that writing eases my need for reflection." This is the first of Dan's stories to appear outside of his Web site.

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