In 1978, the psychiatrist Stephen Bergman published the novel The House of God, written under the pen name Samuel Shem. Based on Bergmans experiences as an intern at Harvards Beth Israel hospital, the book rapidly became a staple of any medical residents required-reading list; to date, it has sold more than two million copies. A 2003 edition included an introduction by John Updike, who wrote that The House of God could probably not be written now, at least so unabashedly; its lavish use of freewheeling, multiethnic caricature would be inhibited by the current terms racist, sexist, and ageist. Its 70s sex is not safe.

For Updike, for those who made this argument before him, and for those who continue to make it today, a measure of freedom has been lost in a culture that requires writers to watch their words for unintended cruelty. An army of chiding librarians seems to have arisen, tsk-tsk-ing the poor writers bawdy, outrageous imagination. Updikes concern is embodied in the real phenomena of Twitter pile-ons and sensitivity readers, but it is also Foucauldian: the chiding librarian is within us, suppressing the writers creativity before it even makes it to the page. In the panopticon where every action can be seen, known, and embedded in a tweet, no actual chains are required. Ultimately, we control ourselves.

The House of God is not a great book, the literary critic Kathryn Montgomery has written, but it is an important book. Bergman claims that it shows how residents are dehumanized in the course of their sleepless, gruelling medical training, and in turn begin behaving cruelly or carelessly toward their patients. As the physician and poet Jack Coulehan has pointed out, however, Bergman undercuts his argument somewhat when his narrator, Roy Basch, refers to patients as a heifer and a hippo on his first day of work. If the narrators callous attitude toward patients is a product of the dehumanizing power of residency training, how did Basch get there so quickly? Coulehan argues that the novel does a disservice to medical-student readers, who internalize the message that clinical training is dehumanizing without sufficiently noticing that the group most dehumanized is patients. Others, such as the emergency physician Jay Baruch, argue that the novels descriptions of the disgust, shame, and horror that patient care sometimes evokes comprise a badly needed articulation of the lived experience of residents. The House of God likely contributed to some of the reforms in medical training that have come about since the nineteen-seventies, particularly in regard to long work hours that lead to sleep deprivation. The book is taught in medical schools and quoted by physicians; whether we realize it or not, we are quoting The House of God when we say, for example, The first procedure in any cardiac arrest is to take your own pulse.

More than forty years after its publication, many of the books episodes, such as the suicide of an intern, still feel contemporary. Other bits are frighteningly dated or always felt slanted, particularly the portrayal of women. The books nurses have none of the clinical insight or skill of actual nurses, but theyre eager to reveal their montes pubis for the interns. There is just one female physician, a frigid, universally loathed character named Jo. The last of the women is Roy Baschs partner, Berry, who is intelligent but inexplicably content to serve as a surrogate mother for Basch, while displaying no expectation that he might broaden her horizons in turn, or even refrain from copulating with nurses.

As sympathetic as I am to Updikes concerns about social control, and as nostalgic as I may be for the time when I wrote like a childblithe, mindless of consequence, the only audience in my mind an audience of people who already loved meI am no longer a child. These days, I write not only for my best friends but for general readers. Growing up involves coming to realize that others are as human as oneself, with inner lives at least as rich as ones own. The realization that others have inner lives is a developmental milestone that we humans are supposed to achieve around age four. But, as it turns out, many of us are still working on it, decades later. Or perhaps we gain the ability to imagine the lives of others around age four, but we may or may not put that ability into practice.

I look to literature to attune my mind to the inner lives of other people, and it is painful when a book falls so short of deeply imagining the other that it portrays some whole wings of the world as flat, airless, not truly worth inhabiting. It is ironic, in a sick way, when the art that ought to bring us closer accidentally insists that some of us are not really worth the effort. I read The House of God in medical school, as many of us do, and was left looking askance at my chosen field. Because the book is lionized so uncritically in my profession, I could only suspect that my future colleagues did not hold women in particularly high regard.

Bergman and his apologists (including many of my women colleagues in medicine) say that The House of God was simply a novel of its time. When asked about the novels sexism in a recent interview, Bergman replied, I was roundly criticized for the way women were seen in the book, then launched into an anecdote about a doctor and nurse having sex in an on-call room in the nineteen-seventies. Things have changed, Bergman added. The anecdote is telling, with its implication that feminist thinkers object to sex itself, rather than to the portrayal of women as sex objects. The accusation that women who display the capacity for critical thought must be frigid is a tired one, and one given full treatment in the character of Jothe only woman in House who occupies a position of authority, the lonely single woman whose supervision of Basch and her other male subordinates equates to lop[ping] a bit off his schlong daily by telling him what hed failed to do.

Other authors have managed to see women in health care as complex humans: Aleksandr Solzhenitsyn, in Cancer Ward; Michael Ondaatje, in The English Patient; Elizabeth Norman, in the beautiful and deeply researched We Band of Angels. As more women have trained as medical professionals, physician writers such as Danielle Ofri, Pauline Chen, the former Surgeon General Joycelyn Elders, and the Navajo surgeon Lori Arviso Alvord have told our stories in memoirs. Part of a books essential work is to bring readers deeply into the worlds of others, and thus it is fair to criticize authors who make no attempt to examine the worlds of whole categories of people. As Eudora Welty said of her stories and novels, What I do in writing of any character is to try to enter into the mind, heart, and skin of a human being who is not myself. Whether this happens to be a man or a woman, old or young, with skin black or white, the primary challenge lies in making the jump itself. It is the act of a writers imagination that I set most high. It is odd to blame the times, then, for a failure of imaginationthat freewheeling, unabashed thing that Updike prized.

The other defense of The House of God that I commonly hear is But its satire! And The House of God is wonderfully effective satire insofar as it points an accusatory finger at systems of power in medicine. But the spectacle of the male Harvard Medical School graduate satirizing women colleagues is painful; good satire deflates systems of power, not the people who toil and suffer in those systems.

Naturally, I turned to Mans 4th Best Hospital, the recent sequel to The House of God, with cautious curiosity. I wondered if a forty-year career as a psychiatrist could have acquainted Bergman with the notion that women have inner lives. The novels first sentenceExcept for her eyes, Berry is fully clotheddimmed my hopes only somewhat. Roy Basch is back, and his life in the years between the two books maps closely with Bergmans. Both men married a psychologist who believes that profound and fixed differences between genders not only exist but also can begin to be bridged by using the word we more frequently; both adopted a daughter from overseas; both became psychiatrists with a special focus on addiction medicine; both wrote a novel called The House of God.

In the first chapter, Basch and Berry are staying at their Costa Rican finca, and Basch requires stitches from a Tica physician. When she bent over to examine me, he describes, I could not help noticing that her purple blouse wasto use a line from The Houseunbuttoned down past Thursday, breasts cradled in the lace palms of a pink bra.... As she left... I noticed she was wearing tight bright pink pants and red high healsmake that heels. For Basch, this is familiar ground: sex and death. Especially in the Medical Intensive Care Unit, in the daily horror of lingering disease and death, the healthy sex with the nurses, orgasms crying out Were still alive and young! At the threat of disease and death, the sensual, the vitaland, yes, the hope.

Now, I happen to be a woman physician. I cant speak for the whole crowd of us, but I think that most of us do not wish for our breasts to be ogled while we stitcheven if it makes our septuagenarian patients feel sensual and vital.

Even if Baschs ogling of the doctor is nauseating, his point about the erotics of medicine has something true in it. All that death does make one wish to prove that one is alive oneself, and that life offers something more exalted than excretion and suffering. Sex is a high line to pleasure, and I have friends both male and female who did fornicate their ways around the cities of their internship. Mostly we were too tired for fornication, though, or we were in love with our spouses and sensible enough to be faithful to the ones who kept us fed and sane. There is an actual orgy in the call room in The House of God which, in retrospect, feels quaint. What intern has time for an orgy these days? You would get paged out of it within ten minutes.

(It occurs to me that I am a pediatrician, and it could just be that childrens hospitals are particularly undersexed. Perhaps, in adult hospitals, the loamy must of sex luffs up around bedpans and ventilators, and interns must splash through puddles of semen to get to their call-room beds. Ive no way to know!)

Although many of the characters, including the physicians, in Mans 4th Best Hospital are women, and, although Bergman has gotten beyond the trope of nurse as dumb mons, his depiction of gender is still old-fashioned. Men are strong and zany and ha-ha funny; women are sensitive and moral and wise, happy either to bed the men or to mother them. (Berry refers to Baschs moral education as her full-time job in the medical field.) In one memorable scene, a nurse named Molly allows Basch to come up to her apartment and fondle her remarkably caressable breasts and strangely long nipples, for old times sake, then does him the service of reminding him of his wifes existence, putting an end to the dalliance before penetration can occur. The virile Baschs formidable sex drive is thwarted, but later he is grateful and falls to his knees on the sidewalkthank goodness Berry never needs to know! Molly goes on to work alongside Berry when she, too, joins the clinic. There is minimal drama and no consequences for Bascha male fantasy fulfilled, even if there was no penetration.

The other aspects of Baschs privilege also go unexamined, and his flaunting of his privilege as a doctor and a wealthy person makes me, as a fellow-physician, cringe. At one point in Mans 4th Best, Basch develops an abnormal heart rhythm and has to go to the hospital. He calls a fellow-doctor en route, and that doctor promises to get a cardiologist to come in and care for Basch. Once at the hospital, Basch continues to lobby for special treatment:

I had learned that if Ior any of my familygo to a doctor, its helpful to say Im a doctor, and when they ask what kind, I tell them and then ask, Have you heard of the novel The House of God? Almost always they perk up and say, Oh, yeah, its my favorite book! Well, I wrote it. And then the word spreads throughout the [emergency ward] and we all get a lot of attention. Docs and nurses crowd the room, want to chat, almost always telling me where they were when theyd read my novel.

For anyone who has struggled to receive proper attention from physicians, this passage could be a little hard to take. It is also difficult to feel sympathy with the Basch family for their financial troubles, which condemn them to owning a vacation finca and also a large Boston-area estate and confine them only to the carriage house of the estate while they rent out the main house. Basch goes into an alcoholic tailspin from the stress of working extra shifts in order to afford their adopted daughters private preschool. (My 24,000 dollar city taxes would have paid for excellent public school, he explains. But wed tried it with Springit didnt work. She was terribly shy.)

I have many shortcomings as a human, and one of them is my failure to sympathize with the struggles of the wealthy to secure private-school spots for their children. I was so shy that my preschool teachers thought that I had a developmental disability, and I still managed to survive public school in rural Texas, where abstinence-only sex education ruled the day and where we dissected a single rat that we shared as a class. Now I am not only a doctor but also some kind of arbiter of taste, called upon by The New Yorker to review this book. All this unexpected glory, despite having shared the rat. Im sure that I was protected by old-fashioned white privilege in public school; I was urged to the front of the class. The parents who really have to worry about the fates of their children in public school rarely have the luxury of choice.

Nor should Updike have worried that the racist label would eliminate free-wheeling multiethnic caricature from Bergmans writing. House employed caricatures of black and Irish-American people, among others. Bergman portrays Navajo people as fully realized characters in Mans 4th Best, but a Latino physician character is still a racist parody whose Spanish is incorrect. Mia madre! he says, and Esta mucho discombobulay, and El segundo causa, and Merck Vioxx kill my madre!and it is unclear if this Spanish is deliberately incorrect or if it has simply been believed to be correct, in a country where literate Spanish speakers are abundant and could correct it.

Basch frequently nods to the struggles of the working class, or, as he refers to them, all the poor and middle-class patients Id seen who were only one illness away, in our nations piss-poor health-care system, from bankruptcy. And the explicit mission of the book is to make medicine humane again. (Boring!) The book advocates, in its way, for universal access to health care as a cure not only for physical suffering and injustices in the system but also for the misery of physicians. Given these explicit missions, Shems tone-deaf approach to the narrative effects of privilege-flaunting is unfortunate.

In recent months, since I finished residency and began working as an attending physician, my way has been smoothed by the grunt work and flattery of trainees. My residents mine the electronic medical record for data and compose my notes; my medical students actually laugh out loud at my jokes. I recognize the precarity of all this, the seductive notion that this deference is not a consequence of a pernicious hierarchy but rather a consequence of my own hard work, wisdom, and virtue. I hope always to deserve the respect of my team. I hope never to be the dupe making sexist jokes that arent funny, to whom nobody in the room is willing to tell the truth. I hope to remember that I am a wealthy person now, and hand-wringing about the cost of private preschool would render me as unsympathetic as a self-appointed advocate for the oppressed.

Perhaps forty years of deference explain why Shem, like Updike, writes as a child would, imagining an audience that will express only adoration. Perhaps it explains why Basch presumes that his book is everybodys favorite, and that the doctors and nurses in the E.R. are gathering round to admire him. Some of them undoubtedly are, but a good portion of them are just staring at a fascinating specimen. We medical folk are simple people, and a famous writer in the E.R., like a case of Sydenhams chorea or an interestingly shaped object lodged in a rectum, excites our general interest.

So what is enough to ask of an elder male writer in this era? I think we women want revenge; we want blood on the ceiling, as Patricia Lockwood gave us in her recent epic takedown of Updike, in the London Review of Books. But also, perhaps, we want the possibility of individual moral progress, particularly among powerful men who have used their power to demean us. We want to recognize that progress when it comes, even as we continue to deserve real justice. Even if I would not wish to be or know the women in Bergmans book, I recognize an effortful appreciation of women here. In medicine, we are only just beginning to reckon with our gender-based wage gap, our failure to promote women leaders, our utter indifference to the needs of working mothers, and the systematic harassment of women trainees. Led by groups like Times Up Healthcare, we are beginning to discuss these things. It is all too slow, and, on my more exhausted days, I wish for torches and pitchforks rather than just these words.

Jo, the only female resident in The House of God, is also the only resident from that book who does not reappear in Mans 4th Best Hospital; she doesnt even rate a mention. Her character was instructive to me when I first read The House of God, because she symbolized so precisely the implicit threats levied against women who seek a career in medicine: that, if we do this unfeminine work, we will become hard and cold. If we assume leadership positions, the men we supervise will see us as schlong-lopping harpies.These threats are powerful tools of social control, instructing women in medicine that we must contort ourselves somehow into sexually available playthings, even as we thread catheters into femoral arteries and stuff tubes down the throats of the dying. For refusing to be pretty or sexy or soft, Jo was hated.

I would have liked to see Jo return, to see the consequences of her treatment in The House of God explored many years later. I would like to know if we women in medicineparticularly those who have been harassed and demeaned and underpaidget to live full lives, after all. I would like to know if we ever get to be both women physicians and people, or if the two conditions are incompatible.

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The House of God, a Book as Sexist as It Was Influential, Gets a Sequel - The New Yorker