WHEN THE AILING CITIZENS OF TINY, CRUMBLING COLUMBIA, N.Y., visit general practitioner Bill Starbuck, they’re more likely to leave with a bottle of his home-brewed cure-all Starbusol than with a referral to a specialist. Yet his nostrum is less a wink at backwoods medicine than a symbol of genuine concern for his patients—to help them feel better whether he can diagnose the problem or not. In his new novel, The Spirit of the PlaceSamuel Shem describes how Starbuck’s compassion draws in a lonely, aimless teenager named Orville Rose, who follows him into the profession and, after fleeing Columbia to practice in the wider world, reluctantly returns to his roots.

“We expect the world of doctors,” John Updike wrote in an introduction to The House of God, Shem’s lauded 1978 novel exposing the harsh realities of medical internship. In his new book, excerpted here, Shem (pen name of psychiatrist Stephen Bergman) explores what it means to live up to that expectation.

In that first glance, both doctors did the dance of diagnosis on each other, scanning the body for new decay or disease.

Orville was startled to find signs of Bill being a lot further down the road than two years before. A short, oval-shaped man whose crisp white shirt and clasped tie billowed over his plump tummy, his rumpled dark slacks slumped over his only fashion statement, pointy Italian shoes. On his bald head and round face, which sat on his collared neck like an egg in a cup, were dark senile keratoses and other plants in the skin-garden of aging. A recently burned-off basal cell carcinoma glowed on his sharp nose. The lenses of his glasses had thickened several diopters—cataracts?—magnifying his eyes so that they seemed to be peering up out of deep water, big and roaming. Bill’s girlish lips were now tinged with blue, a trace of cyanosis, a sign of the lessened ejection fraction of Bill’s heart. The only exercise this body had known was poker. The two hearing aids were new. Orville felt in Bill’s handshake the old firmness and yet a new fragility, the bones afloat in the puffy skin.

Ushering Orville in, Bill’s hand was on his shoulder. Bill was a toucher, a great toucher. You might forget what he told you was wrong with you or what he was going to do about it, but you remembered that touch. Hours later the place he’d touched still felt special. Warm in winter, cool in summer.

“Good t’see you, son,” Bill said, settling in behind the big cluttered desk and a YES SMOKING sign. His words came out in a calm, deliberate way, with significant torsion of his lips, as if each word was being molded as delicately as an egg and required care to survive. His greeting blew the scent of fresh scallions at Orville. Bill’s addiction, besides nicotine, was fresh scallions. When in season, his rural patients kept him supplied. Bill “the Scallion” Starbuck. Bill shook a Camel free and lit up, blowing out two dragons of smoke.

Now, sitting in the patient’s chair, Orville looked around the oak-paneled room, once the living room of the small house. Over the fireplace was the 14-point buck, tilted a little, and on the wall was the photo of the man in the cowboy hat and scowl, his handlebar moustache drooping down, his arms crossed over his chest, and a revolver clasped in one hand, pointing up past his ear. Josiah Macy, Columbian Doctor, 1834–1861.

Behind Bill, reaching to the high, stamped-tin ceiling, was the glassed-in medicine cabinet that seemed to hold everything, from musty old textbooks to bottles of medicine to boxes with red crosses now gone pink from the sunlight to chrome instruments that may have been put down five minutes ago, or five years.

“Sorry about your mother, Orvy,” Bill was saying, shaping his words slowly. “Massive MI. Went quick. I know you didn’t have the…the perfect relationship with her, and that can make it all the harder now. I’m sorry. Real sorry, son.”

Orville felt sadness rise in his throat, gritty, tingling his lip, his nostrils, presaging real tears. As he fought them down, he sensed how his whole life had been caringly held by this kind, maybe wise old man. He remembered himself as a sick child, body burning with fever, thrashing around unable to breathe, and hallucinating in the middle of the interminable night in his parents’ bed wondering if the terror of breathlessness would ever end, and dimly sensing the arrival of Dr. Bill in a cloud of scallions and tobacco and feeling the cooling stethoscope like a friendly flat hand on a riled burning chest, and then turned face-down, butt-up, holding someone’s—his father’s?—hand for the shot, the strange bite of the needle not hurting as much as you feared but just when you thought it was over the searing rush that seemed to last and last, like your butt was a hot skillet, and you tried to fight away the hand doing it to you and then it was over and the pain was being massaged to a dull ache and you eased down into the featherdown of sleep. And as a teenager, embarked on a course of rank failure, when he refused to talk with his family about anything close to his heart, being sent to Bill for advice.

Bill never gave advice. He sat and smoked and told stories. The summer after a desolate sophomore year when Orville was bored half out of his mind and depressed out of the other half, Bill began to take him around with him, let him help out in the office, go on house calls out in the country. Deliveries, deaths and everything in between.

Orville was enthralled by the intense contact with people at crucial times of their lives. Coming from a family in which nothing much ever seemed to take place between the sighing and the silence, it was incredible for the boy to see that things actually happened in life, actually got done.