James Belarde //

“Comedy is a tool of togetherness. It’s a way of putting your arm around someone, pointing at something, and saying, ‘Isn’t it funny that we do that?’ It’s a way of reaching out.” -Kate McKinnon

In 1978, Samuel Shem published The House of God, a scandalous novel centered around the lives of several first-year medical residents navigating their responsibilities as new doctors. Shem, pen-name of psychiatrist Dr. Stephen Bergman, drew heavily on his own experiences as a resident in developing his story. In doing so, he sought to address “the brutality and inhumanity of medical training and practice.”1 Often troubling to read with many problematic passages, the novel was nevertheless an important early portrayal of the dark side of the healthcare profession and its training of physicians, raising questions about medical education still discussed today.

To share his controversial message with a contemporary reading public that largely venerated the healthcare profession, Shem relied primarily on humor. But aside from its use as a literary device, the concept of humor is a major theme of the novel. Focusing on the role comedy plays in overcoming life’s difficulties, Shem presents it as a double-edged sword, one that can prove beneficial or harmful depending on the context.

The benefit of humor is apparent early in the novel. To push through the daily tragedies they face, the first-year residents, or “terns,” frequently joke with each other. Ridiculing the hospital system that complicates life for them and their patients alike, these inside jokes are started by the second-year resident mentoring them. Known as The Fat Man, his cynicism and distasteful jokes are initially disregarded by the terns, including the protagonist Roy Basch. But before long, they realize that The Fat Man’s jokes speak truth, and his seemingly unprofessional approach to healthcare often results in less torture for both patients and doctors.

The Fat Man also uses humor to connect with patients and ease their suffering. This surprises Roy, who asks The Fat Man why his patients love him when he’s so irreverent. The Fat Man answers, “That’s why: I’m straight with ‘em and I make ‘em laugh at themselves,” highlighting his use of humor before explaining more closely. “I make them feel like they’re still part of life, part of some grand nutty scheme instead of alone with their diseases… With me, they feel they’re still part of the human race.”2 Just as it brings solidarity to the suffering terns, humor unites physician and patient.

This contrasts sharply with an opinion The Fat Man holds later in the novel. Toward the middle of his torturous first year, Roy lashes out at those closest to him. When his girlfriend Barry comes to the hospital to familiarize herself with the environment causing him pain, Roy distresses her by sharing the terns’ cynical jokes. The Fat Man, though the originator of these jokes, wastes no time chastising him saying, “You can’t use our inside jokes with the ones outside all this, the ones like her.” Roy objects, retorting that they need to hear these things, but The Fat Man shouts over him. “’THEY DON’T!’ yelled Fats. ‘They don’t need to, and they don’t want to.’”3 In this instance, Roy’s humor is seen as harmful, an assault on the sensitivities of those outside the medical system, pushing the two groups further apart.

The novel thus shows two sides to humor: a beneficial one founded on creating a sense of togetherness among participants and a harmful one that diminishes these feelings of connection. But how does a joke acquire one quality over the other? How can the same jokes that provide solace to the suffering residents harm non-physicians? And most importantly, how is trying to share these inside jokes with those outside the system any different than Shem writing this darkly comic novel to reveal the inhumanity of medical training to a non-medical audience?

To suggest an answer to these questions, I’ll share an idea raised by the comedian Hannah Gadsby in her wonderful Netflix special, Nanette. In it, Gadsby points out that jokes are truncated stories. They begin with a buildup of tension that is immediately released in the middle by a punchline, creating laughter. Though this release of tension can help, it has the unfortunate side effect of prematurely cutting off a story’s structure of beginning, middle, and end. In one example, she jokes about her mother’s insensitive response to Gadsby’s coming out as a lesbian before noting that these jokes fail to communicate the supportive relationship she and her mother now have.4 With jokes, stories often don’t get a chance for the closure their endings provide, and this absence can be harmful.

Hannah Gadsby
Hannah Gadsby, Nanette, 2018.

Adapting this theory provides one possible explanation for the double-edged quality of humor in The House of God. The Fat Man uses jokes with his patients to ease tension and connect with them, but the story doesn’t end there. Rather, the patient-physician narrative he establishes with humor develops toward some closure. The patient is still heard. Similarly, the inside jokes used by the terns act as tension release valves along the ongoing story of physician training: a painful, shared narrative that doesn’t stop with their jokes. It continues as they grow, learn, and support each other to the end. But when these inside jokes are used with Barry, who isn’t living the same story toward the same end, it prematurely cuts off any understanding. Neither her experience nor Roy’s can be told. Instead of easing suffering, this type of joke-sharing, born from a desire to spread anger that Gadsby eschews in her stand-up performance, cannot hope to ease the tension it creates.

This, then, would seem to be the major difference between Roy sharing inside jokes with Barry in the novel and Shem revealing the same inside jokes with an outsider audience by writing the novel at all. Shem doesn’t throw out the potentially hurtful humor in a vacuum and expect his readers to sort it out on their own. He tells the full story of a painful year of training from beginning to end, with all the triumph, defeat, and shameful behavior intact. The jokes then become the tension-relieving moments readers require in a narrative fraught with terrible truths about an unhealthy medical education process in need of change. And in the face of rising mental illness rates among physicians and physicians-in-training, this change is still needed today. But before it can happen, these stories must be shared. Gadsby puts it perfectly near the end of Nanette. “Laughter is not our medicine. Stories hold our cure. Laughter is just the honey that sweetens the bitter medicine.”5



  1. Shem, Samuel. The House of God. Berkley, 2010, 375.
  2. Ibid, 183.
  3. Ibid, 253.
  4. Nanette. Performed by Hannah Gadsby. Directed by Jon Olb & Madeleine Parry, Netflix, 2018.
  5. Ibid.

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