The Secret Language of Doctors

by Brian Goldman

  In July 1973, Stephen Bergman, then a 29-year-old just graduated from Harvard Medical School, began his internship in Boston at what was then called the Beth Israel Hospital. Five years later, writing under the pen name Samuel Shem, Bergman used his experience at Beth Israel as the basis for The House of God.

  The book was a blockbuster. The House of God has sold more than two million copies and has been published in thirty languages. The famed British medical journal The Lancet named The House of God one of the two most important American medical novels of the twentieth century.

  The novel follows Dr. Roy Basch during his year of internship at House of God, which stands in for Beth Israel Hospital (known today as Beth Israel Deaconess Medical Center). Like Bergman, Basch arrives on his first day completely unprepared for the responsibilities and long hours heaped upon him. A wise senior resident, an anti-hero named The Fat Man, befriends him.

  The Fat Man teaches Basch to keep his patients alive—and to survive internship—by deliberately disobeying the rules of so-called good patient care set by the hospital and the system in general. He teaches him instead to follow the thirteen subversive laws revealed during the course of the book. My favourite is Law No. 3: “At a cardiac arrest, the first procedure is to take your own pulse.” Cardiac arrest itself is a medical euphemism for heart stoppage, meaning the patient is clinically dead and in immediate need of resuscitative measures—cardiopulmonary resuscitation (CPR), inserting a breathing tube, defibrillating or shocking the heart, and administering medications to normalize the heart rhythm and raise the blood pressure.

  Nowadays, we call it a code—short for Code Blue, the near- universal designation for cardiac arrest. Residents on call carry arrest pagers; when a patient is found in cardiac arrest, a health-care worker or a bystander pushes a big red button (located on the wall near the patient’s bed and in patient bathrooms) that automatically pages the cardiac arrest team. Residents on call drop whatever they are doing and run to the patient’s bedside. (I remember running half a kilometre across the sprawling Sunnybrook Health Sciences Centre complex, up a staircase to the sixth floor and arriving at the bedside gasping for breath—only to find that the patient himself had pressed the arrest button, thinking it was the nurse call button!)

  By the time I read Bergman’s book around 1980, I had attended many cardiac arrests and had sometimes reached the patient’s bedside feeling so panicky that I wouldn’t remember what drugs to order and what voltage to use when shocking the heart. I took The Fat Man’s advice and often ran to the patient’s bedside with my finger on my own pulse.

  No sooner was the ink dry on Bergman’s book than residents and interns throughout North America began inventing laws of their own. Around that time, I recall a resident telling me, with a conspiratorial smile, a rather shocking adaptation for pediatrics of one of The Fat Man’s laws: “You can’t kill a Down’s,” he said. It was a direct steal of the First Law of The House of God: “GOMERs don’t die.” Down syndrome, also known as Trisomy 21, is caused by the presence of all or part of a third copy of chromosome 21. Down syndrome, named after John Langdon Down, the British doctor who was among the first to describe it, is recognizable by distinctive facial characteristics. It is associated with short stature and reduced cognitive abilities. It can also cause vision and hearing disorders, as well as congenital heart disease, underactive thyroid and certain forms of cancer. Like GOMERs, some kids with Down syndrome have many medical problems and require frequent admissions to hospital.

  What the resident was saying is that no matter what the doctor does, these kids keep getting sick but keep surviving, only to get sick again. I took it as a statement of grudging admiration for the durability of children with Down syndrome.

  You might find the awful phrase shocking, as I do today. In fairness, you have to remember that the resident used it in 1980. I suspect the doctor would cringe hearing those words from so long ago repeated in a book. But that’s not the point. The resident smiled while saying the words, as if emulating The Fat Man introducing me to the facts of medical life. And, as surprised and disturbed as I may have been to hear kids with Down syndrome spoken of in that way, I have to admit that I was glad to be let in on the joke—however distasteful.

  * * *

  Conversations like the one I had with that pediatric resident have played out in hospital elevators, bunkers, and on-call rooms and at nursing stations across North America and around the world ever since. Fat Men, and perhaps even Fat Women, were repeating the rules and the slang set forth by Stephen Bergman in The House of God—and making up many of their own. In 1999, Newsweek listed The House of God as “the novel to read about becoming a doctor.”

  The House of God has been so influential for several reasons. One can’t ignore the fact that Bergman wrote a great book. He had and still has an ear for language and an ability to write the way doctors talk. Bergman’s take on the culture of modern medicine at that time—including the hazing of interns and residents and the futility of medical care served up to frail seniors with dementia—sounded authentic, or at least plausible. Interns and residents could see themselves as Roy Basch or The Fat Man.

  For decades before Bergman wrote his book, interns and residents battled brutal schedules, sleep deprivation and emotional abuse. What made The House of God special was that Bergman was the first to say emphatically that the system was sick and that it was okay for interns and residents to rail against it.

  Bergman invented a secret language that helped Basch and his fellow interns cope with their fictional hospital of despair. In so doing, he validated the use of that secret language in everyday conversation in hospitals in the real world. As with a secret handshake, Bergman invited interns and residents to join an exclusive club. And join they did.

  More than thirty-five years have passed since The House of God was published. In researching The Secret Language of Doctors, I interviewed dozens of residents, attending physicians and surgeons, nurses and paramedics. Even today, the slang codified by Stephen Bergman is used, or at the very least known, by all of them.

  “Every medical student should read it,” said Dr. Todd Raine, a nine-year veteran of emergency medicine at St. Paul’s Hospital in Vancouver. “Not as a paragon of what medicine should be, although there are facets of it that I still think ring very true. Some of them—like ‘Do as little as humanly possible’—are very true these days, [when] we oversee a lot of stuff we don’t have to. Most of us can quote the rules, if not by number at least by knowing what they are.”

  From 2007 to 2012, Dr. Christian Jones did a residency in general surgery at the University of Kansas Medical Center in Kansas City, Kansas, becoming chief resident in his final year. Nobody’s claiming that The House of God is a textbook, or even factual, but it’s entertaining and teaches you a lot about the jadedness you’re going to see, in residency especially,” said Jones. “While that may not be something that a lot of people admit is there, it most certainly is. And I don’t personally see a problem with getting that first exposure from a book, rather than from being shocked when you start your residency.”

  What’s telling about the state of modern health care is the extent to which medical wannabes have not only embraced the secret language; they have embellished it. Dr. Christopher Kinsella is a resident in general surgery at Saint Louis University Hospital in St. Louis, Missouri, who blogs at scrubsisreal.com. Where he works, they don’t turf patients to a different department or team; they do a lateral. For the uninitiated, a lateral refers to a lateral pass—a term used in American and Canadian football as well as in rugby. The ball carrier—often but not always the quarterback—throws the ball not forward but to a teammate beside or behind him.

  “Let’s say there’s a patient I’m taking care of who is no longer interesting to me,” says Kinsella. “They don’t need surgery but they’re sick. The patient needs to be in a hospital, they need to be taken care of by someone, but
they don’t need to be taken care of by a surgeon. So we would try to lateral to another ward.”

  As in football, a patient lateral may be attempted by a doctor who has done all he or she can think of doing to help a patient who isn’t responding to treatment. Sometimes, it’s done to remove a difficult patient from the doctor’s list. “I’m done running with this ball,” says Kinsella. “I need to send this to someone else. They can run with the ball now.”

  Databases are filled with slang words and phrases that make up medical argot. A 1993 paper by Robert Coombs, Sangeeta Chopra, Debra Schenk and Elaine Yutan, published in the journal Social Science & Medicine, used what was described as a “sociolinguistic approach” to compile an impressive list of more than 300 slang terms culled from medical personnel and publications about hospital life. Sorry to say, the largest body of slang unearthed by the authors consists of highly unflattering descriptions of patients—especially patients regarded as difficult.

  The article defined toad as a “troublesome and demanding patient.” A blabber is a “patient who talks excessively.” A troll is a “patient who is a big pain in the neck; old, debilitated, and sometimes incontinent.” A Camille, named for the Alexandre Dumas heroine in La Dame aux Camélias who dies dramatically from tuberculosis in her lover’s arms, is a “patient who chronically feels about to die and is very vocal about it.”

  Health professionals love devising acronyms: type 2 diabetes is shortened to DM2, congestive heart failure into CHF, gastroesophageal reflux disease into GERD, and so forth. Coombs and his co-authors discovered that the playful desire to create acronyms carries over into slang. The article describes COP as an acronym for “crotchety old patient,” HOWDY as short for “hypertensive obese white diabetic yahoo,” and DIAL as short for “dumb in any language.” “Informal medical language, neither taught in the classroom nor recorded in textbooks, is no less dynamic in clinical settings,” Coombs and his colleagues wrote in 1993.

  In July 2011, Scrubs, which bills itself as “the leading lifestyle magazine for nurses,” published the Top 47 slang terms nurses use, along with suggested usages of the terms. Top of the list: PITA, an acronym for “pain in the ass.” Second on the list is BATS, short for “broke all to shit.”

  All of this medical slang exists in part because The House of God made it acceptable, even desirable.

  Even critics of medical slang—including Dr. Katherine Grichnik of the Duke University Hospital Medical Center—acknowledge the seminal role played by Stephen Bergman. “The House of God was a witty, interesting, amazing book that revealed some medical culture,” says Grichnik. “But at the same time I think he propagated a few stereotypes that are just patently false. Medical students read it and, all of a sudden, the meter is set. This is the way medicine is. This is how we should all behave and act—and that’s just not true.”

  * * *

  Why did Bergman invent and disseminate a secret language? “We were in a perfect storm of desperation,” he said. “The desperate invent slang because what else are you going to do? You’ve got to kind of laugh and get through it.” That rings true—especially if you go back to Victor Hugo’s definition of argot as “the language of misery.”

  Bergman’s internship at Beth Israel Hospital amounted to a form of poorly paid servitude. He worked 100-hour weeks and was on call every second night, which meant he had no life outside of work. “The patient load was large. We were incredibly alone with all that we were doing. And we were tired as hell because the hours were awful.”

  But that can’t be the whole story. After all, the hours residents work today aren’t nearly as brutal, yet medical slang lives on.

  Perhaps it’s the psychological abuse by senior physicians that tipped the scales—something Bergman said he experienced at Beth Israel. Bergman attributed this to the rigid hierarchical structure of hospital medicine in which attending physicians lord it over interns and residents. “Like all medical students, residents and other lower- downs, I have been humiliated many times,” said Bergman.

  But unlike The House of God’s Roy Basch, who had a kind mentor, Bergman had no one to teach him how to learn to survive in a hospital in which residents like him—not to mention his patients—were treated inhumanely. “We had nobody,” said Bergman. “There was no Fat Man, really. I invented that we had a dude.”

  Far from having a dude, Bergman recalled that the chief resident he served under was a bootlicker. “The chief resident was an absolute jerk. He had only one thing on his mind, which was to do nothing that would alienate the chief of staff, the other faculty and senior staff so he could get a job at the Beth Israel Hospital and buy his horse farm out in Sudbury [a tony enclave near Boston].”

  For Dr. Peter Kussin of Duke University Hospital, the slang found in The House of God brought validation, making it okay to infuse medical terminology with a bit of wit. Moreover, Kussin said, Bergman’s book provided him with the cover he needed to become a slangmeister himself in the 1980s, without incurring universal disapproval from his buttoned-down colleagues at Duke. “It’s good to know that I’m not so much of an anomaly because all the people of my era used slang and spoke slang,” said Kussin.

  That said, very few have tried to keep it alive as Kussin has. The internist has crisscrossed the United States giving speeches on the language doctors use to converse informally with one another. Had Bergman completed his residency in internal medicine and not become a psychiatrist, Kussin would be his rival as the modern slangmeister.

  Like Kussin, I see the current use of slang as a yearning to put back some wit and wordplay into a world of medicine that long ago replaced literature and poetry with a nearly exclusive emphasis on science—much to its detriment.

  * * *

  Then, as now, the laws of The House of God ran counter to the culture of established medicine as taught by Bergman’s mentors and mine. According to an article by Bergman (under his pen name Shem) published in 2012 in The Atlantic, his book left the medical establishment up in arms. “I was maligned and disliked,” wrote Bergman. “The book was censored by medical school deans, who often kept me from speaking at their schools. None of it really bothered me, though. I was secure in the understanding that all I had done was tell the truth about medical training.”

  As an intern, Bergman absorbed the culture of internal medicine at one of Harvard’s famed teaching hospitals and captured it in his book. But he was just passing through. Following his internship, Bergman did a residency in psychiatry at McLean Hospital in Belmont, Massachusetts. Until he retired from medicine to write full-time in 2005, Bergman had a private practice in psychiatry, with an interest in patients with addiction disorders, and was a professor of psychiatry at Harvard Medical School.

  Bergman says he never personally experienced the deep sense of humiliation from some quarters of medicine that he depicted in The House of God. “I don’t get much bothered by fear or humiliation if I know that what I did was authentic and deft,” he told me.

  But he says he did have just such an experience after he joined Harvard’s faculty as a psychiatrist. Years ago, Bergman said, he taught a course in which third-year students were supposed to be able to talk in small groups about difficult experi- ences they were having as they adjusted from lecture halls to working on hospital wards. “In a group meeting to review the first year of the course, I said I felt that what the students really needed was to talk in safety about their stressful and brutalizing experiences,” Bergman recalled. “At that point, a famous surgeon interrupted me and, in front of my colleagues, said: ‘What do you want to turn this into—a year-long psychiatric séance?’”

  The remark left Bergman speechless. In The House of God, a character named Potts becomes depressed and commits suicide and a second character suffers a psychotic break—something that actually happened to one of Bergman’s fellow interns at Beth Israel. Both were consequences of the psychological toll inflicted on
interns and residents of the 1970s. Bergman felt he was being mocked yet again for raising the issue with his fellow teachers. “I ended my association with teaching at Harvard Medical School,” he says.

  I wanted to know why Bergman the slangmeister thinks medical argot has thrived in the years since his book was published. “Slang makes a very good connection among all those who share it,” he said. “They invent slang, sometimes to distance themselves from patients, sometimes to just amuse themselves, sometimes to break the tension, sometimes to be on the same page, and sometimes to bond.”

  But it’s a bond and a language that can be as insulting to patients as it is jarring. And it’s not going away. Bergman may not have a building named after him, but he has a legacy of medical slang and an enduring impact on the culture of modern medicine much more lasting than bricks and mortar.

  3. Code Brown and Other Bodily Fluids

  Ask many people why they didn’t become doctors and they’ll say that they can’t stand the sight of blood. Who are they trying to kid? Try feces or vomit or pus so smelly it can make the sturdiest resident faint. How about maggots emerging from a patient’s orifices? Now you get what I mean.

  Think the health professions are all glory? A lot of the time they’re just plain gory.

  From early on in our training my colleagues and I get thrown into the proverbial deep end of an effluent pool. We must learn to overcome our own urge to hurl while somehow making it seem to you as if it’s just another day at the office.

  One of the ways we cope with our own sense of discomfort and even disgust is by trading stories laced with a liberal dose of medical slang. The most universal example is Code Brown.