Man's 4th Best Hospital Read online

  Also by Samuel Shem

  Novels

  The House of God

  Fine

  Mount Misery

  The Spirit of the Place

  At the Heart of the Universe

  The Buddha’s Wife: The Path of Awakening Together (with Janet Surrey)

  Plays

  Bill W. and Dr. Bob (with Janet Surrey)

  Napoleon’s Dinner

  Room for One Woman

  Nonfiction

  We Have to Talk: Healing Dialogues Between Women and Men (with Janet Surrey)

  Fiction as Resistance

  BERKLEY

  An imprint of Penguin Random House LLC

  penguinrandomhouse.com

  Copyright © 2019 by Samuel Shem

  Penguin Random House supports copyright. Copyright fuels creativity, encourages diverse voices, promotes free speech, and creates a vibrant culture. Thank you for buying an authorized edition of this book and for complying with copyright laws by not reproducing, scanning, or distributing any part of it in any form without permission. You are supporting writers and allowing Penguin Random House to continue to publish books for every reader.

  BERKLEY and the BERKLEY & B colophon are registered trademarks of Penguin Random House LLC.

  Library of Congress Cataloging-in-Publication Data

  Names: Shem, Samuel, author.

  Title: Man’s 4th best hospital / Samuel Shem.

  Other titles: Man’s fourth best hospital

  Description: First Edition. | New York : Berkley, 2019. | Sequel to: The House of God.

  Identifiers: LCCN 2019015299| ISBN 9781984805362 (hardcover) | ISBN 9781984805379 (ebook)

  Subjects: LCSH: Physicians--Fiction. | Medical education--Fiction. | GSAFD: Bildungsromans.

  Classification: LCC PS3569.H39374 M36 2019 | DDC 813/.54--dc23

  LC record available at https://lccn.loc.gov/2019015299

  First Edition: November 2019

  Jacket art and design by Colleen Reinhart

  This is a work of fiction. Names, characters, places, and incidents either are the product of the author’s imagination or are used fictitiously, and any resemblance to actual persons, living or dead, business establishments, events, or locales is entirely coincidental.

  Version_2

  To Janet and Katie

  In memory of John Updike

  With thanks to Rosemary Ahern, Tracy Bernstein, Clifton Meador, Christina Robb, Steve Schaffrau, and Mark Vonnegut

  “We came here to serve God, and also to get rich.”

  —Bernal Díaz del Castillo, Historia verdadera de la conquista de la Nueva España, 1632

  Contents

  Also by Samuel Shem

  Title Page

  Copyright

  Dedication

  Epigraph

  I. Costa Rica

  II. Man’s 4th Best Hospital

  III. The Sick Empire

  Laws of Man’s 4th Best Hospital

  About the Author

  I

  Costa Rica

  “I’m not rich because I tell the truth.”

  —Graffiti on dumpster, New York City, 2018

  1

  Except for her eyes, Berry is fully clothed. Her eyes show her relief at my close call with death, several hours ago.

  Over our decades together, but for the slightest flicker of a butterfly’s wing, we wouldn’t be here. None of us would—we all ride or fall on that flicker. But for a flicker, I’d now be a divorced alcoholic neurosurgeon on the Best Medical School faculty.

  Her relief, yes, and concern—and love. A love that, all those years ago, survived the medical internship that I, Roy Basch, novelized as The House of God.

  That crucial year, learning to be a doctor, was horrific, but we interns—Chuck, Eat My Dust Eddie, the Runt, Hyper Hooper, and I—lucked out. We had the Fat Man as our teaching resident. Brilliant, funny, earthy, insatiable. Always, amid the illusions of the hospital, being real. More than that—being with us. If you go through a death-defying experience with a guy like Fats, he’s never not with you, just past the edges of your sight.

  Now, late this June afternoon, Berry and I are on the large back patio of Tierra Tranquila—“Quiet Earth”—our little finca in Guanacaste, Costa Rica, three degrees above the equator. Battered and in some pain, I’m sitting on my lucky red metal folding chair, she beside me. Wishing that our daughter, Spring, could be here. Berry has texted her. No reply yet.

  It’s the start of the rainy season, a cooling downpour once in the afternoon, once at night, when the drumming of drops on the corrugated tin roof is a comfort. We never sleep past 5:30, awakened by the portent of dawn awakening the birds awakening the day, doves first, cooing. At 6:00 or so, toucans fly in, to feast on the bunch of plátanos quadratos I’ve cut with my cool machete and hung from a close-by mango tree. Other large birds follow: blue birds so big they seem on steroids, and paired-for-life motmots whose two tufted tail feathers are as long as the rest of their bodies, and finally the flocks of small parrots and tanagers. Now the motmots are gone. Last year, high up in the cloud forest near the Arenal Volcano, we saw motmots. Here, it’s gotten too hot. The planet is starting to boil. Soon there’ll be flamingos in the Arctic, but no Arctic. No refuge anywhere. The sick world is in our rooms. Doctors and patients alike.

  We’re 2,000 feet up the mountain—no mosquitoes. The patio overlooks fruit trees: bananas, plantanos, papayas, grapefruit, oranges, sweet lemons, tons of mangoes—everything you could want. We look past the strangler fig and coconut palm to the stream and little waterfall—we can drink the water, imagine?—and then to the rain forest, dark as Conrad’s jungle, climbing to the peak. A family of howler monkeys is coming closer. They move from fig tree to fig tree their whole lives, never touching the ground except when they die and fall. Their calls sound like the roars of lions but they’re the size of house cats. On the other side of the mountain we see the Pacific, two hours away on pocked dirt roads.

  We bought this small finca ten years ago, when America started the Midasian War and broke the back of the Middle East. Costa Rica abolished its army in 1948. Uses the money for crazy things like free health care, education, clean energy.

  Surrounded by farms, the nearest little town is down a scary 13-hairpin-turn dirt road. No phone, no Internet, no nuthin’ except land and sky and whether it will rain today or not. Given our lives in a fractured America, we don’t spend enough time here. A peaceful place, this. The national greeting? You ask: “Cómo está?”—“How are you?”; and the response is “Pura vida”—“Pure life.”

  I can spend a whole day, on and off, watching a new banana leaf appear, rolled in a tight spiral at dawn, opening to a full leaf by dusk. The sun shining through the slick new leaf is a green to die for.

  Which this morning I almost did.

  Every time we come here after a long absence, we go with Miguel, the caretaker—who looks 40 but is 73—to walk the property, climbing up the mountain to the highest point, a panorama north across the Bay of Nicoya toward the spine of volcanoes. This morning, because of the rain, mud, and overgrowth, instead of climbing up, we drove the Jeep up the road and began to walk back down. Berry and me, Miguel and Mauricio, a young ranch hand who speaks English.

  Going down a steep stretch of the cliff, I stepped on a round rock and my right ankle bent over and I started to fall, and reflexively I put down my left foot on what should have been solid but it too hit a round rock, and I again tried to put down my right but I was moving fast, kind
of running fast almost vertically down, and then flying through the air headfirst down, no time to put hands out in front of me, sailed for what seemed an eternity and landed on my face and things went black.

  I found myself facedown amidst rocks, hands behind my back. As I raised my head, I saw blurrily a stove-sized boulder a few inches in front of my face. Dimly I heard Berry and the others shouting, climbing down to me. I tried to assess—with a doctor’s mind—consciousness, wiggle of toes, eyesight. All, but for my glasses that had flown away, seemed intact. I felt something wet on the left side of my face, viscous and sticky, and wiped it away—bright red, arterial. Blood came across my left eye. I reached to stop it.

  But then hands were lifting me to sit up and Berry was staring at my face in horror. I searched with a hand—both my palms scraped bloody—in a pocket for a clean tissue and blotted my face and held it tight on my left eye. They put on my glasses—unbroken!—and I was staring at the stove-sized boulder two inches from me, realizing that if I had gone headfirst into it, I’d be dead.

  At that, I started to shake, in shock. I was able to walk with their help up to the Jeep. We sped down the 13 hairpin turns to the village of Carmona and the small clinic.

  Then something else happened, a hit of happiness, a kind of House of God joy.

  I was lying on the examining table in the modern, well-lit room for emergencies, Berry on one side and Mauricio on the other. I’d seen my face in a mirror—a large flap of skin from above my left eye was hanging down.

  After the nurse had taken my vitals, in came the doctor. And what a doctor. Standing over me she smiled just about the warmest smile I’d ever seen from a doctor—and she was gorgeous. Black hair pulled back in a ponytail, brown eyes surrounded by makeup, long lashes, eyeliner, a Modigliani face, and, as I said, that smile. She began in Spanish and I, who even after immersion classes spoke like a two-year-old, said, Non habla español and Mauricio began translating. It was clear she was a good doc—all the right questions—and, except for my maybe brief loss of consciousness, she got all the “No” answers to rule out bad shit. When she bent over to examine me, I could not help noticing that her purple blouse was—to use a line from The House—“unbuttoned down past Thursday,” breasts cradled in the lace palms of a pink bra.

  All at once, amidst this medical crisis that happened to be my own, where I found myself on what we House of God interns used to call “the opposing team, the patients,” I was on 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 We’re still alive and young! At the threat of disease and death, the sensual, the vital—and, yes, the hope. The thing that kept us going, way back then, and might, just, now.

  I luxuriated in it. She did a good job, finding nothing serious in history or physical but the torn face and question of broken ribs. She sutured the eye slowly, expertly, as if she had all the time in the world—though she was the only doc in the clinic—then snapped off her bloodstained gloves, smiled, said I should be okay but to call if things get worse, and passed me on to the nurse to dress the wounds. As she left I noticed she wasn’t wearing a wedding ring; hope springs eternal, right? And that she was wearing tight bright pink pants and red high heals—make that heels. The nurse finished up, and that was that.

  Standing up, I was shaky. Berry grabbed me, helped me out into the small waiting room filled with people. The pharmacist handed me two pill bottles—pain meds, antibiotics. I went to the window to pay. No charge. Even though I was not Costa Rican. Astonishing. In the US it would have taken hours and cost thousands for tests, X-rays, etc.—because we docs get paid more money the more procedures we do. So we do more. And more more.

  We drove back up the 13 hairpin turns home.

  * * *

  Now, in late afternoon, I’m in pain but clearheaded, Berry beside me.

  Suddenly it all hits me, the terror, the chill. Death. Other deaths flood in. Berry puts her hand on mine. In her eyes is intense care. Touched, my eyes well up. Scared as hell. Grateful she’s with me and we’re alive.

  “What, Roy?”

  “Death. All the dead in my life. Fats, others, and . . .” I stop, look down.

  She caresses my cheek. “Breathe with me. Look at me. Let’s breathe together.”

  I look into her eyes, and for a moment feel a hit of dread, glance away—but then hear the Fat Man’s voice again, saying what he always said. ‘‘Y’gotta be with. Y’gotta turn toward, in this world that as a rule turns away.”

  So I do turn toward her and, being with, tell her without words that I’m still mourning him and so many other dead too—my parents doing better as my parents, dead; and Malik, my resident in Mount Misery; and Potts that year in the House; and some patients, like Dr. Sanders. And all the others floating where the dead do float, at best resting. Or resisting.

  “But for some reason, of all of them, Fats is close. As if suddenly he’s floating nearby—all that weight, floating?—just past the level of my sight. I miss him.”

  “Good.”

  “Good?”

  “Because it’s real, his presence.”

  “Yeah, but it’s incredibly confusing.”

  “I know. And right now he’s really with you?” I nod. She pauses. “Maybe the only real resurrection of the dead is in us. We keep learning from them and from their deaths and going on with them till we die too. And then we live on in others.” She smiles. Grateful, I smile too. “Tell me, hon.”

  “Yeah, they’re all here—Fats more clearly, right now, than sometimes in person, because he was so . . . so damn big?” She smiles. “But yeah, looking back I understand him more and more.”

  “Understand, and you love; love, and you understand. With sorrow.” She smiles. “Love, understanding, and sorrow—they’re all words for the same thing.”

  Suddenly she seems to be shining. Her face really shines.

  “I’m listening.” She waits, attentive. Waits some more.

  I’m stuck, not wanting to unspool this thread of death any more.

  “All right, then,” she says, “how ’bout we meditate? Just fifteen minutes, okay?”

  She has become a Buddhist teacher. For decades I’ve been meditating with her. For years, at the end of our silence, she would ask me, “How did it go?”

  And I would describe how, in the silence, trying to follow my breath in . . . out . . . in . . . out . . . the machinery of my mind roared in, mostly in humiliating flickers of “Breaking News!”—usually bad, my version of the Three Poisons: Craving, Hatred, Delusion. After years of breathing them in, breathing them out, I’ve learned that they rarely let go of their infernal jabbering, even for a second.

  She would ask me, after this torment, “Were you able to stay with the breath?”

  “Are you kidding?” I’d say, frustrated. “All I get is busy mind. Mosquito mind, flitflitflit . . . slap! . . . flitflitflit!”

  Yet more and more, with practice, the trap would open. A letting go. A lifting up. Hits of gratitude. For the divine in the human. Maybe it would lift me up now?

  “Okay.”

  I close my eyes, focus on my breathing in . . . out . . . in . . . out. . . .

  But my mind ignites on a letter I’d gotten a couple of days ago—a letter? We’re so isolated here that in ten years but for two lost girls on foot, Jehovah’s Witnesses who’d taken a wrong turn, we’ve hardly ever seen a person let alone any “mail,” but here was a letter delivered by the farmer-cowboy with the Lone Ranger hat who every day rides his horse up from Carmona, past our house to his cattle. And in the upper-left-hand corner of the envelope is the logo of the Best Medical School and beneath it, three royal shields saying VER-I-TY and below, an animal, rampant claws outstretched (A lion? The Dean?) and in big red letters THE BEST MEDICAL SCHOOL, THE WORLD IS WAITING. For what? T
he world is waiting for the BMS? To do what? To top off THE $750 MILLION CAPITAL CAMPAIGN AND—

  Stop! Stop it! Bring it back to the breath.

  In . . . out . . . in . . . out . . .

  Despite myself, the 750 million brings back the Fat Man and us in Man’s 4th Best Hospital at that grave tipping point when medical care could go one way or another, either toward humane care or toward money and screens—which means money and money, ushering in the decline and fall of all I cared about as a doctor and damn, it still pisses me off that the money and screens won and this shit—

  “Roy!” I open my eyes. Berry. Touching my good cheek, a worried look in her eyes. “Are you all right, hon?”

  “Why?”

  “You’re really agitated—hardly breathing at all. What’s going on?”

  “Busy mind. Full of shit. Seemed like an eternity.”

  She looks at her watch. “It was less than a minute.” She offers her hand, palm up. “I’m here, right here. It’s okay now. Let’s try again. Hold my hand. I’ll be with you the whole time. I won’t let go.”

  “Promise?”

  “Promise.”

  And so feeling her hand tremble a little, I close my eyes, take a deep breath in, and then let it ride out on a sigh, and then do nothing but wait for the miracle of the next breath to spark to life in the brain stem . . . in . . . out . . . in . . . out . . . and what floats into the newsreel of this particular mind is a silly question, Why are 90 percent of all American Buddhist teachers born Jewish and called JewBues? and the wise answer from one of them, Ram Dass (born Richard Alpert), Because I’m only Jewish on my parents’ side, bringing an inner chuckle and a giving of thanks for still being alive with my girl, Berry—make that my two girls, with Spring—and then in a surprising refuge from the usual mind hell of memory or expectation, there comes a jolt of just plain joy and a sensation in a body still mostly whole, a sense on the lips of a human being smiling, and the presence of the Fat Man smiling back . . . in . . . out . . . in . . .