"Fine" is his new book, a funny, sensitive, even adventurous account of the metamorphosis of a resident in psychiatry, but Samuel Shem will always be known to the nation's medical students, interns and residents as the author of "The House of God."
A sort of "Animal House" with substance, a less preachy "M*A*S*H," this cult classic has been read as studiously as "Gray's Anatomy" by virtually every student in any English-speaking medical school since it was published in 1978. It has sold well over a million copies, and even now, seven years later, it sells 300 copies a day.
"It's gotten so that you haven't gone to med school if you haven't read 'House of God,' " says a bioethics professor.
Sam Shem -- a pseudonym -- is a physician and psychiatrist himself. He graduated from Harvard Medical School, thinly disguised in "The House of God" as BMS, or Best Medical School. BMS is affiliated with the House of God, a hospital "founded in 1913 by the American People of Israel when their medically qualified Sons and Daughters could not get good internships in good hospitals because of discrimination."
Shem himself interned at Beth Israel Hospital in Boston and describes it as "the worst year of my life."
That he went to medical school at all is due at least in part to his freshman English composition instructor at Harvard.
He really liked the idea of writing, and he turned in his first composition with something of a sense of destiny. "I worked on it like hell," he recalls. "After all, it was my first grade I was going to get at Harvard. When I got it back from the woman there wasn't a mark on the paper, and down at the bottom in little letters in red ink was 'see me.' "
He went to her office. "I said, 'What is it?' and she said, 'This is too terrible to grade. This is beneath F,' " Shem recalls. "I was heartbroken.
"She never could tell me what was wrong, but she kept on giving me Ds and D-minuses. I figured, here she is a grad student in English and she must know what she was doing. So all through Harvard, I never tried to write again. I was crushed.
"Later on I found out that there were only two people in the class who got As. One of them was the son of a famous writer. The other was the captain of the freshman golf team. He was sleeping with her. I was on the golf team, too, and he told me."
He pauses. And sighs. "I'd love to find that woman today . . . "
But that was around the time Sam Shem got into cockroaches.
Cockroaches and golf got him a Rhodes scholarship, and when he returned from Balliol College at Oxford three years later he went to medical school.
The Thirteenth Law of the House of God: The delivery of medical care is to do as much nothing as possible.
The first thing Samuel Shem remembers about medical school is losing the brachial plexus in his anatomy class. As a result, he attended as few classes as possible.
Then he became an intern at Beth Israel, where he came to the conclusion that in many emergency-room cases in big-city teaching hospitals, the most humane treatment is to permit a patient to die. Not, as he was taught, to take every possible heroic step to keep the patient alive, quality of life notwithstanding.
As he became immersed in the unexpected horror of decaying and diseased humanity, his lifeline was his humor. "The House of God" was written, he says, "as catharsis . . . I just didn't want anyone else to have to go through that cruelty."
. . . in a domino progression, the injection of radioactive dye for her brain scan shut down her kidneys, and the dye study of her kidneys overloaded her heart, and the medication for her heart made her vomit, which altered her electrolyte balance in a life-threatening way, which increased her dementia and shut down her bowel . . . the cleanout for which dehydrated her and really shut down her tormented kidneys, which led to infection, the need for dialysis, and big-time complications. . . . She and I became exhausted, and she became very sick . . .
Lisa Rubin, a 25-year-old senior medical student at George Washington University Medical Center, says she "read the book between my first and second year. When I came to med school I had a real idealistic, glorified idea of what it was about, and 'House of God' was my introduction to the fact that my view and the reality were somewhat different.
"You get angry at that stage when you hear patients called 'gomers' an acronym for "get out of my emergency room," the female of which is "gomere" , but when you're called at 3 a.m. and find a patient vomiting and incontinent and you're trying to put in an i.v. line and they're flailing around and as soon as you get the line in they'll knock it out and you start getting angry because you have nowhere else to put it -- I'm not saying that's right, but that's the only way to preserve your own sanity.
" 'House of God' has the sort of humor that keeps you going. If you can't laugh at it, you'll cry. And if you cry, you won't make it."
At House of God, the chief resident, known as the Fat Man, teaches the young intern the rules and the ways to "buff" and "turf." Buffing a chart is to make it look as though something has been done for a patient when, in fact, the Thirteenth Law has been followed to the letter.
As for turfing:
. . . My first very own patient was a LOL in NAD little old lady in no apparent distress in need of a checkup and a prescription for a new artificial breast and padded bra with fillable pockets. Who knew how to write a prescription? Not me. She wrote it, I signed it . . . Next was a Portuguese woman who wanted me to do something about her corns. Who knew about corns? I toyed with the idea of writing her a prescription for an artificial foot and a padded shoe with fillable socks, but then I remembered the Fat Man and TURFED her to podiatry . . .
Doing any "nothing" is anathema to the medico-political hierarchy that runs not only House of God but also BMS and the Mount St. Elsewheres, the community hospitals in which patients are often dumped.
The term "St. Elsewhere," created by Shem, so quickly became part of the medical vernacular that spokesmen for MTM Enterprises, which produces the TV program "St. Elsewhere," swear that the phrase was just plucked out of the air, that it had been a part of the medical argot forever.
And it is not just the title of "St. Elsewhere" that is reminiscent of "House of God." Says Shem, "Wherever I go, I get the same response -- 'Oh, do you write "St. Elsewhere?" ' Lots of people have suggested legal action." Pause. "Mostly they're lawyers." He shrugs and grins.
He has blue eyes, a bald head and a boyish grin. He is 40 years old, and it isn't so much that he doesn't look his age, but there is always a sense that some mischief is lurking behind what is, on the surface, a distinctly intellectual face. Often it is just the merest twitch of a lip, a twinkle -- yes, really, a twinkle -- in his eye that makes one feel one is about to be had. Or about to laugh.
He is an athlete -- his requisite Rhodes scholarship sport was not bridge, as was that of his "House of God" protagonist. In high school he was captain of the soccer team, the tennis team, the golf team. He still plays, and, confides a friend, one of his golf buddies is author John Updike.
"I thought Harvard took me because of my athletics," he says. "I thought I was dumb."
The Third Law: At a cardiac arrest, the first procedure is to take your own pulse.
The Sixth Law: There is no body cavity that cannot be reached with a number-14 needle and a good strong arm.
The Ninth Law: The only good admission is a dead admission.
At Oxford, Samuel Shem's Rhodes project was on the neurophysiology of the cockroach. There was nothing whimsical about it, except perhaps its choice in the first place.
Ben W. Heineman Jr., a Washington lawyer who was a year ahead of Shem both as a Harvard undergraduate and an Oxford Rhodes scholar, remembers seeking him out at Oxford. "I would visit him in the neurophysiology lab, where you walked in and there were 20 feet of oscilloscopes darting and jumping at you, and there in the middle would be 'Dr.' Shem, sticking electrodes into a cockroach . . . "
"You can see learning in a single cell loop," Shem says, and Dr. Fine, the troubled psychiatrist hero of his new book, says much the same thing.
Fine has trained grasshoppers to do all sorts of intellectual exercises one wouldn't expect of an insect. As zany as it sounds -- and Shem knows zany when he sees it, and milks it for all it's worth -- practically all of Fine's science is based on fact, some on those Oxford roaches, some on newer discoveries about how the brain works.
On the other hand, Fine, who has a block about his first name, which only becomes understandable on the last page, invents some calcium rocks he sucks on throughout the book to enhance intelligence. After reading "Fine," Updike wrote Shem to congratulate him on writing "the first chemical novel."
When Shem wasn't trying to shock some sense into cockroaches at Oxford, he was writing plays and knocking about with Heineman.
Heineman, who was there to work on a book about race relations in England in the '60s (published as "The Politics of the Powerless"), recalls that he was having some problems with his book, and that Shem, who had gone home to get married and found that his fiance' had decided that maybe marriage wasn't the way to go, was having some problems with his life. The two of them became fast friends.
The fiance' ended up a clinical psychologist and, although she still lives with Shem, they still haven't married. "We're only up to heavy petting," Shem will tell friends. Or, in true psychoanalytic fashion, he answers a query with another: "What's the hurry?"
Both of his books are dedicated to the pair -- Heineman and "J," or Janet Surrey, Shem's constant companion for two decades.
Shem, who practices in the Boston area, admits to a certain conflict about his use of a nom de plume. At first, he says, it was to protect his psychiatric patients. Then, as his plays started winning awards and being performed in New York -- albeit off Broadway, where his latest, "Ground Zero," is in preproduction -- he realized that Samuel Shem was his writing persona.
A few people, mostly close friends and his editor, know both selves. Most of his theater and literary cohorts know only Shem. Although his photograph is on the dust jacket of "Fine" and he poses for newspaper pictures, most of his patients know only Dr. (let's call him) Shrink.
It has led to an almost legendary mystique. The real identity of Samuel Shem in some quarters is a microcosm of the national curiosity about the identity of Deep Throat. Watergate, in fact, is a recurring theme in "The House of God," reflecting on a cosmic scale the disillusion of the book's intern-protagonist with medicine and life alike.
Dr. Gail Povar, who teaches bioethics at the George Washington University Medical Center, says that what the book does "is provide all of the black humor all of us use with a black language. It pulled together all the jargon and created a language for a particular group. It created a universal experience people can use as a shorthand between themselves, as a buffer between themselves and the situation."
One bioethics professor said she does not use the book in her classes because "the older doctors would be apoplectic."
Kathryn Hunter, who teaches literature to medical students at the University of Rochester School of Medicine, doesn't use it in her classes, either, "because it should be kept as an underground classic."
Hunter has written and published articles on the satire in "The House of God," which she likens to that of Jonathan Swift, but she has, to her disappointment, never met Shem himself. "I read a version of my paper at a meeting in Massachussetts, and someone said they thought he was in the audience, but I'm sure if he had been, I'd have known, and no one said anything . . . "
"The problem of not seeing the book as satire," says Povar, "is its potential for instilling horror and terror. You might think, 'God, if this is the way people feel about my 78-year-old grandmother, how can I ever let her go to a hospital?' . . . It treads so close to the edge of reality, it can be misconstrued as reality."
There is a room in House of God that the Fat Man calls "The Rose Room," because most of the gomeres there are named Rose.
"My grandmother," says Heineman happily, "is named Rose . . . "