The house of God

by Samuel Shem

  Feeling hopeless, I said, "I can't see it."

  "I know. It's clear that it's not for you."

  "Well, then, what is?"

  "You think I know? Big deal. Fly high. Have a blast, Basch. Great minds?like ours?can't be just one thing."

  "Yeah, but I've got to decide soon," I said, feeling lost, cast out alone after so many programmed years. "I don't know what to do."

  "Do? Well, in Brooklyn we always did this," said Fats, and reached out and hooked my pinkie in his. "Linking pinkies."

  "Linking pinkies?"

  "Sure. That's what we did in Brooklyn whenever we didn't know what to do."

  A joke? No, his face was serious, sincere. I felt his fat pinkie hugging mine. Suddenly I knew what he meant. It was perfect, a magical moment. A tingling current of feeling zinged through me. He'd sensed my emptiness, and he'd responded. His touch meant I wasn't alone. He and I were connected. I squeezed back. It was love. No matter what, Fats and I would be friends.

  Laughing, I said, "You know,' for a fat kid, you don't sweat much."

  "Right. Life's tough, but even a fat kid can fast on Yom Kippur."

  Berry and I were laughing over the lead article in Doctor's Wife, a tribute to a terrific doctor's wife who; "becoming aware of the depth charges in a doctor's' dinner" such as her terrific doctor hubby getting called out on an emergency case that might keep him away: until his food gets cold, had learned "a foolproof operation to keep roast beef deliciously rare for hours," namely, wrapping it in aluminum foil and warming it on a hot plate. I told Berry about my top?bunk posture and asked if she thought it was another regression

  "No, I think it's integration, working out what to do with yourself. Now that you know you can be doctor, you've got the option of discarding medicine and moving on. What are you thinking of doing?"

  "Going on vacation to France with you. Maybe to taking a year off."

  "But what are you going to tell the Leggo about July?"

  "I don't know. I hated this. The whole year sucked."

  "Not true. Fats, the policemen, your buddies?you liked them. And you liked listening to your patients in the Clinic, right?"

  "As long as I didn't have to do anything medical, it was fun."

  "In the E.W., you were fascinated by the psych resident, Cohen." Tantalizingly she asked, "Why not become a psychiatrist?"

  "Me?" I said, surprised. "A shrink?"

  "You." Looking me squarely in the eyes, she said, "Being with people was all that kept you going this year, Roy. And 'being with' is the essence of psychiatry."

  CLICK. In my head, CLICK. I asked her to repeat what she'd said.

  " 'Being with' is the essence of psychiatry. You've always perched yourself at a slight angle to the universe. Psychiatry might be perfect for you."

  Being with. CLICK. Dr. Sanders, dying, telling me that what doctors did was to "be with" patients. "You mean 'being with' patients?"

  "I mean being with," she said. "Even being with your family."

  Family? My grandfather, TURFED to rot in a home, never again to be with anyone: my father?

  . . There is nothing more comforting during illness than a loved one to be with you and a good physician can serve that role .

  "You're saying that psychiatry really offers something to patients? That it's different from medicine in that you can cure?"

  "Sometimes. If you catch a life early, yes."

  "So the big thing is that you can offer something to patients?" '

  "No. You can offer something to yourself."

  Stunned, I asked her: "What can you offer to yourself?"

  "Growth. Instead of forgetting, you'd try to remember. Instead of defensive, obsessive superficiality, you'd try to become open, looser, deep. You'd create. Your only tool as a therapist is who you are and who you might become."

  It was hard for me to think. Somehow, in the chaos, something was clearing. I might become someone I might not despise? Escape being strapped into the rocker of past, culling my memories for trinkets? Be rid of my avoiding, my exploding, my contempt? Trembling, I asked her if there was anything I could start to read.

  "Freud. Start with Mourning and Melancholia. In it Freud says, 'The shadow of the lost object falls across the ego.' You've been under that shadow for a solid Year."

  "What shadow?"

  "You. The shadow of yourself:"

  My lacuna of humanity, my Berry. How I'd grown to love her, my accepting, caring, clear?sighted soft one, during this abrasive year.

  "I love you," I said. "I lived through this nightmare because you were with me."

  "Yes, partly. And you're right: this internship has been like the stuff of dreams, like the overpowering nightmares of childhood: aggression, fear of retaliation, and then the resolution, where you don't win, you live. It's the straight Oedipal theme: mother, father, child."

  . . Hope you are finishing up well and glad to be finished with your experience. Could not understand your premise that now you can handle all medical problems and there is so much to know. I am very worried over the worldwide economic situation meaning the inability of the brains of the world to solve inflation and the monetary crisis and it is not even worth having money the bank. I don't know what mother told you but I know it was basic and true. I know you care for us as a son and that will never change. Distance and circumstance have interfered with our keeping close, and that is inevitable in this day and age. Would love to play golf with my son number one again and that is just a hope. Mom really has such a short controlled swing and it is a picture. My passion for the game is unlimited and I do enjoy it . . .

  24

  Disillusioned, not wanting to go on as House residents but not knowing what to do, we needed help. We turned to Fats. At the ten?o'clock meal, we asked him what we should do.

  "About what?"

  "About what specialty to go into on July the first."

  "Do what's always done nowadays," said Fats, "do a colloquium. Never fails."

  "What on?" asked Eddie, his eyes a bit dull, tranquilized.

  "On 'How to Choose a Specialty,' what else?"

  "Who the hell's gonna run it?" asked the Runt.

  "Who?" asked Fats. smiling. "Me. The star of the bowel run of the stars."

  Word spread rapidly. On the day, from all over the House of God, terns and BMSs appeared. Even Gilheeny and Quick were there. The crowded room hushed, and the Fat Man began: "The whole pattern of medical education is backwards: by the time we realize we're not going to be TV docs undressing ripe-titted beauties, but rather House docs disimpacting gomers, we've invested too much to quit, and we wind up like you poor slobs: stuck. The sequence of training should be reversed: on day one, bring the puking BMSs right into the House of God and rub their noses in Olive O.: turn off potential surgeons with her humps, potential internal?medicine red?hots with her numbers incompatible with life and her inability to be cured or dead; even potential gynecologists will take one look at the terrain of their future speciality and transfer into dentistry. And then?and only then?let the ones who still have the stomach for it start on the preclinical years."

  It was brilliant, as expected. But how did it help us now?

  "But that doesn't help you now, 'cause now you've invested, and now you're trapped. So? So there are many different specialties you could choose. Most of them involve the same close contact you've had with patients all this year?touching, being tortured, killing yourself with night call. These are the 'PC?Patient Care' specialties. PC specialties will not be considered, here. The masochists may leave."

  No one left.

  "I myself am going into a PC specialty, Gastroenterology. I have my reasons. I am a very special case. Where I'm headed, GI is what's best for me. A rare gift, eh? Right. But the NPC?No Patient Care specialties number six and only six: Rays, Gas, Path, Derm, Ophthalmology, and Psychiatry."

  The Fat Man listed these six on the blackboard and told us he would list, with our suggestions, the advantages and disadvantages of e
ach. "Game theory," he called it. This chart would "optimize" our specialty choice.

  "First," said Fats, "is Rays. Advantages of Radiology?"

  "Money," said Chuck. "Big money."

  "Exactly," said Fats, "a veritable fortoona. Other advantages?"

  Aside from the assumed "No Patient Care," no, no one could think of any other advantages, and Fats asked for disadvantages.

  "Gomers," I said. "You do bowel runs on gomers.

  "Narcolepsy," said Hooper, "you're always in the dark."

  "Gonads," said the Runt. "X rays can fry your sperm. Your first kid comes out with one eye, two teeth, and eight fingers to a hand.

  "Terrific!" said Fats, writing them down. "Men, we're on our way!"

  We proceeded to construct a table of the NPC Specialties:

  SPECIALTY ADVANTAGES DISADVANTAGES

  RAYS Money (100K/annum) Gomers.

  Dark offices, narcolepsy.

  Damaged gonads; 8?fingered progeny.

  Barium enemas and bowel runs.

  GAS Money (100K/annum) Gomers.

  Boredom punctured by panic.

  Astronomical malpractice premiums.

  Noxious gases, producing bizarre personalities.

  Contempt, daily, of surgeons.

  PATH No live bodies. Gomers (rare).

  Low malpractice Dead bodies.

  premiums Smell of dead bodies and formalin

  Basement office.

  Contempt, daily, of all but other pathologists.

  Depression.

  DERM Money (100K/ annum) Gomers.

  Travel to sunny conventions Contagion.

  Naked skin attraction Naked skin repulsion

  OPHTHAL? Astronomical money Gomers

  MOLOGY (millions/annum) Astronomical maplpractice premiums

  Opportunity, daily, to Surgical internship required

  torment GAS. Occasional patient care

  PSYCHI? NO GOMERS! Hourly wage.

  ATRY Never touch bodies Hard on lumbar spine.

  except in sex-surrogate Multiple accusations from rightwingers,

  Voyeurism, perversion, cf. 'communist,' 'queer,' 'pervert.'.

  eroticism, autoeroticism,

  polyeroticism.

  Easy on feet.

  Long lunch hours.

  Cure?alleged-many others

  By the end of the Fat Man's colloquium, the remarkable had happened: on paper, Psychiatry was the clear winner.

  On the canoe trip, Psychiatry loomed even larger. Chuck had organized this final intern outing, and one bright, sweet?breezed summer day we signed out to the House residents, loaded the beer, and headed for the shore, into the foothills of the marshland to the tidal river, winding through the grasses to the sea. As we paddled lazily downriver, Berry and I found ourselves in a race with the two policemen for last. Gilheeny, a great red?feathered mallard in the bow, continued to curse his rudderman, Quick, as their listing canoe smacked first one bank and then the other. And yet what could have been better than drifting along, drinking cool beer, listening behind us for the deep carmine baritone of the redhead and the insistent tenor of his mate crooning "a lament from the Emerald Isle"?

  We stopped on an island for a picnic. In a pine grove dappled with shadow, we found ourselves drawn to Berry. She listened to our discontent; she agreed that the year had been a horror:

  "It's been inhuman," she said. "No wonder doctors are so distant in the face of the most poignant human dramas. The tragedy isn't the crassness, but the lack of depth. Most people have some human reaction to their daily work, but doctors don't. It's an incredible paradox that being a doctor is so degrading and yet is so valued by society. In any community, the most respected group are doctors."

  "You mean the whole thing's a deception?" asked the Runt.

  "An unconscious one, a terrific repression that makes doctors really believe that they are omnipotent healers. If you hear yourselves saying, 'Well, this year wasn't really that bad,' you're repressing, to put the next group through it."

  "Well, then, my clever woman," said Gilheeny, "why is it that these fine young men do this at all?"

  "Because it's so hard to say no. If you're programmed from age six to be a doctor, invest years in it, develop your repressive skills so that you can't even recall how miserable you were during internship, you can't stop. Can a star take himself out of a ballgame? No way:"

  She was right. What could we say. We sat, still, absorbed, hushed, as the afternoon shadows inched on. Berry answered some questions about psychiatry, and as we awoke to what she was saying, she turned our picnic into a sort of group session. The theme was loss.

  "What all loss do you mean?" asked Chuck.

  "What each of you has lost this year. I know it first hand only from Roy but I've heard about the MORs and RORs and . . . and Eddies break and . . " She paused, and then, her voice trembling, said, " And Potts. You lost Potts. If you felt that loss, you'd still be crying. You're crippled by your guilt, the guilt of killing off the cherished parts of yourselves:'

  In the darkening grove, silence hung somber as a shroud. I felt choked up. What had I killed off? Days like this one, my creativity, my ability to love. Gloom. Stasis. Doom. Finally, with the sun curdling down its the reddening hills, Gilheeny asked softly, "These men are wounded. Can anything still be done?"

  "Guilt's a hot potato?whoever holds onto it burned. You're all doing a slow burn. Give it up. Get mad. Give it back to the ones who infantalized you. Is there a House shrink to talk to?"

  There was: Dr. Frank, the psychiatrist at the B-M Deli lunch on our first day in the House. He'd mentioned suicide, and the Fish had canned him. He'd stayed canned the whole year. Why? Returning to the canoes, we floated toward the sounds of oceans, each wondering what had been lost, how this Dr. Frank might help find it, and finally, as the lightning bugs began their dance, wondering how to take this rage and stick it to the ones who'd ripped off parts of each of us, these House Robber Barons, the House Bosses of Loss.

  I was on call that night, and arrived from the canoe trip with blistered hands, my drunkenness beginning to hang, preoccupied with what Berry had said, and mad about being back inside the House. It was hot and humid, and my sweatiness brought back memories of the terrifying summer I'd spent as a new tern a year before. Everything had happened. An admission was awaiting me in the E.W. It was to turn out to be extraordinary in that it was to be redeeming. I was greeted in the E.W. by the Pearl, who wanted to warn me about this particular patient, but I wasn't in the mood and I picked up the clipboard and read: "Nathan Zock, 63; bloody diarrhea? benign polyp." No wonder the Pearl had wanted a word with me. Zock, of the MICU Zocks and of the Wing of Zock, which had shut out summer from my on?call room.

  Irritated, I entered the room, the Pearl rolling in at my heels. I had never seen so much flesh. Six bovine Zocks, overinflated flesh balloons, hovered around the stretcher, chomping, sucking, nibbling, snacking, smacking in a tribute to Freud's oral stage of development. Gems glittering, the Pearl introduced me to Nate Zock's fat kids, in an effort to herd them away from the stretcher on which Nate Zock allegedly lay. As they edged back, they dislodged a nasty?eyed chalkvoiced macaw of a woman with artificially black hair, who, hearing my name, said, "Well, young Dr. Kildare, it's about time?"

  "Trixie," came an authoritative voice from the stretcher, "shut up!"

  She did. There lay Nate, a rubbery?faced sixty, a bit booze?riddled, but with wealth in his manner and decisiveness in his mien. Even hassled by the herd, he was calm. The Pearl introduced me and left. Immediately I was besieged by the non?Nate Zocks. Everyone wanted feeding, about the diagnosis, prognosis, and the portending emergency: that Nate might not procure the best room in the House. To work on the latter problem, Trixie kept hinting in my ear the name Zock and "do you know who Nate is, have you heard of the Wing of Zock, eh?" After being sucked on for about three minutes, I'd had it and said loudly, "OK, everyone but Nate, get out of this room now!" Shock. No one moved. To talk like th
at to Zocks?

  "You wait a minute, young Dr. Kil?"

  "Trixie, shut up and get out!" said Nate, and when Nate Zock talked, even other Zocks listened. The room cleared fast. As I began my exam, Nate went on.

  Thay're too fat. We tried, but nothing worked. You know, Dr. Pearlstein told me about you, Basch, he warned me, he said you're a, tough guy, that I shouldn't try to cross you. Said you're very good, but straightforward. I like that. Docs should be tough. When you're rich as I am, people don't treat you tough enough."

  I nodded, and continuing my exam, asked what his business was.

  "Nuts and bolts. Started with five hundred bucks ill the depression, and now . . . millions. Nuts and bolt not the best, but the most."

  I told Nate that as long as we didn't do anything much to his bleeding gut, it would probably heal. A I finished, Trixie poked her head in, upset, saying that Nate would get only the second?best room in the House. Nate told her to scram, and said, "So what? I always get the best room; nobody visits you in the best room. So I'll rough it for a night. So what? That's what happened to those kids: all the time the best, and what happens? Fat. Too goddamn fat."

  789 had had a rough day. Caught in a maze of tests ordered by Olive. O.'s Private, Little Otto, whose name still?still!?rang no belt in Stockholm, Sev was discouraged about making any headway with the humps. His first admission of the day had seen Sev and th radiology resident decide that the patient had a lesion on chest X ray, and when he presented the case to me, I dismayed him by quoting a House LAW: IF THE RADIOLOGY RESIDENT AND THE BMS BOTH SEE A LESION ON THE CHEST X RAY. THERE CAN BE NO LESION THERE. Despite Sev's insistence, the lesion turned out to be the technician's bracelet, and Sev was crushed. I tried to cheer him, but he'd have none of it, so I gave up. I'd try no more for anyone that night. "Sev," I said, hoisting myself down from the top bunk to the bottom, "I'm going to sleep. I want you to get your scrub suit and change into it now, so that you won't come barging in here later, turn on the light, and wake me up:' Through half?open eyes I saw the short, bearded scholar strip down, bare his pimply and already flabby body to the neon, quickly and scurrilously slip on his morgues gray scrub suit, and then pause. I asked what was the matter. After the thoughtful pause so characteristic of him, he said, "Dr. Basch, I've got several hours' more work to do tonight, and you don't. How come you're always going to sleep and I'm always staying awake?"