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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school, I read Samuel Shem’s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine.  I gained comfort from its gallows humor – and it made me feel connected to my peers during the most stressful time of my training. So when I was invited to review Shem’s “bookend” to House Of God, it was with a sense of eagerness and nostalgia that I accepted the challenge. How had the author’s thinking developed since the launch of his first blockbuster in 1978? I hoped to find a kinder, gentler Shem, perhaps looking back on his career in medicine with a sense of grace and dignity. I wanted the pomp and cruelty of his training to fade away into a kind of “it was all worth it in the end” conclusion. Alas, I was jarred into a very different reality.

The Spirit Of The Place is a gruesome portrayal of American suburban decay, mixed with some unexplained hostility towards non-Jewish Americans and those with conservative values. The hero of the book, Orville Rose, escapes his mundane American life for a two year adventure with Doctors Without Borders in Europe. He soon is ensconced in a carnal relationship with a gold-digging, alternative-medicine practicing, Buddhist, Italian yoga master who later dumps him for a Swiss banker. Orville returns from Italy to his home town of Columbia, New York, to sort out his family affairs after his mother’s death. She has arranged to transfer all of her wealth to him if he agrees to live in his childhood home for a full year and thirteen days – a fate almost worth than death.

Columbia is a horrific place, filled with poverty, violent crime, summer mosquitoes, and winter ice storms. The central medical figure is an aging general practitioner (Bill Starbuck) who regularly prescribes a kind of snake oil for various life-threatening ailments (Starbusol). Orville sees this physician as a kind of avuncular mentor, excusing his gross medical malpractice as simply “old fashioned.” Bill soon asks that Orville take over his practice while he goes on a much needed vacation, which turns out to last over a year. Orville is stuck being the only GP for a town of about seven thousand. He soon becomes overworked and overwhelmed. But that doesn’t stop him from falling in love with a single mom and polio survivor who was secretly asked by his dying mother to mail Orville letters (written in advance) after her demise. These letters are filled with venom and manipulative accusations (paging Dr. Freud).

The plot makes the reader predisposed to feel empathy for the protagonist, but Shem so exposes Orville’s character flaws that he is nearly entirely unlikable. Every tender moment in the book is derailed by some sort of unpleasant comment or thought. Take for example, the death of Dr. Starbuck. Orville is at his bedside in the ICU, explaining how important it is to treat patients with dignity, even when they are unconscious. He gently whispers that it’s ok for Dr. Starbuck “to let go” and provides one last facial shave as the man drifts off into his final breaths. And in the middle of this, what does Orville also think to himself?

“…Bill’s groin, the purple crowned penis that had had its share of adventures in repayment for his tending the whores on Diamond street. ‘Two dollars a housecall, Bill, and you never came away empty-handed.’ He took out his comb and combed Bill’s thin hair, gray lines on a shiny dome.”

And then there’s the awkward sex scene where Orville describes kissing his lover’s limb shriveled from the polio virus. I’ll save that one for your imagination.

The point, we are left to assume, of this depressing exploration of human defects (from the physical to the emotional, and at every level of organization – from the family unit to the city government and even national and international politics) is to promote tolerance and understanding of the human condition. Unfortunately the book is more likely to suck the last breath of optimism and hope out of you. The darkness has consumed the light, and with little to admire in any character portrayed in The Spirit Of The Place, it is difficult to read. In fact, it took me over two months to complete it.

That being said, Shem is an excellent writer. And for those who enjoy wrist-slitting fiction, this may be just the book for you. I was personally quite astonished by Abraham Verghese’s exuberant cover jacket blurb:

“An incredible and heartfelt story… The Spirit Of The Place entertains, satisfies, and affirms; it is beautifully conceived and brilliantly executed.”

Clearly not everyone agrees with my analysis. I’d be curious to know which one of us is crazy – me, Verghese, or Shem?

I suppose Shem would say we all are, and that’s the point…

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One Response to “The Spirit Of The Place: Samuel Shem’s New Book May Depress You”

  1. Root Passages says:

    Very good article about spirit of the place Samuel Shem’s new book may depress.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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