thirteen

DOCTORS WITHOUT SILVER

I decided to become a physician when I collected Franciszek from an Emergency Department in Chicago. At the time, I was young and angry. Franciszek was old and intoxicated.

I had seen high school drinking and college drinking—intoxicated friends acting exuberantly and stupidly. They pulled down curtains or kissed strangers or threw punches. At their worst, they looked cruel.

At his worst, Franciszek looked desolate. His poorly dyed hair had receded, leaving no shade for the bruises on his forehead. The bruises matched the hematomas on his arm, where the phlebotomists had drawn blood and the nurses had started fluids. Taped to his left cubital fossa, inside his elbow, was that day’s intravenous needle, dripping saltwater and thiamine into his vein. He had fallen down drunk and woken up, again, in an Emergency Department detox bed.

When I arrived, many people were waiting to be seen. But when I told the clerk that I was here to collect Franciszek, a homeless Polish immigrant, a nurse immediately came over.

“Did you know this loser has been in my ED fifteen times in the past thirty days?”

“No, I didn’t. Has he been a problem?”

“No, he’s always calm, just really drunk and tearful. Pathetic.”

She handed me Franciszek’s medical record and pointed to the blood-alcohol levels from his admissions—314, 457, 512—levels that would have killed the college drunks I knew. While I tried to figure out the medical record’s abbreviations and scribbles, she abruptly pulled back the curtains around Franciszek’s borrowed bed. Franciszek lay curled up without opening his eyes, whimpering like an abused animal. She flapped on all the lights with a sweep of her left hand. With the knuckles of her right, she rubbed his chest and yelled, “Your ride is here. Ride is here. Time to go. To go. Go!”

I was the ride, a twenty-two-year-old AmeriCorps volunteer at Interfaith House, a respite center for the homeless on Chicago’s West Side. The center had a deal with several hospitals: If a hospital agreed to provide follow-up care, the center would allow the hospital to discharge its homeless patients to the facility. We would house and feed them and sign them up for whatever housing, services, and jobs we could find. My job was whatever unskilled work needed doing each day. I cleaned closets, administered drug tests, and admitted new people. When the staff driver was unavailable, I drove the passenger van, taking people to the medical appointments promised them by the discharging hospitals. I got to know Chicago by figuring out where every community health clinic, dialysis center, and hospital was located.

That day, I was sent to pick up Franciszek. He had identified the center as his next of kin. No one at Interfaith House was literally related to Franciszek, but we knew him as well as anyone did. A year before, he had crashed his truck and woken up hungover in another hospital with a compound tibia fracture. He lost his commercial truck driver’s license and with it his job, income, and apartment. With nowhere to go, he accepted the hospital’s referral to Interfaith House. Unlike most people, who stayed less than a month before they tired of the hassles attendant on sharing a building with sixty homeless strangers, he had stayed for ten months. He got sober, healed his leg, and became a role model. He helped out with the grounds, secured a job, and met with donors to show off what the center could do. He was our success story, our family’s prodigal son restored to health. The center’s social workers found him a studio apartment in a nearby Polish neighborhood and furnished it with secondhand furniture. On the day he left, we held a party and served cake and punch. We celebrated ten clean months during which his reticent smile had returned and his rounded spine had straightened. It was a graduation party sponsored by his social services family.

I thought about what it would be like to have no family except for social services personnel as I collected Franciszek from the hospital. When the nurse pulled back the curtains and enveloped Franciszek in sterile light, he began thanking me. Something decent in me grasped his left hand while the nurse hectored him to sign discharge papers with his tremulous right hand. She removed his intravenous line without a word and, tasks accomplished, wheeled him out of the room. As she pushed his hospital bed, she dropped the rails as though she were opening the pen of a bum steer, and shoved him into a wheelchair. As I wheeled Franciszek toward the door, a physician said, “See you next time.” I wanted to spit and mutter something indecent.

Franciszek cried as we drove down Pulaski. His lips, frosted white from dehydration, quivered. He smelled of the cheap schnapps he favored. He was ashamed, and his eyes never met mine as he attempted justifications, but his stories returned, inevitably, to the single certain fact of his life.

He drank.

Before that afternoon, I had been undecided about my future. Record-store clerk? Sportswriter? English teacher? I was confused, in the privileged way that young liberal arts graduates are often confused, by my plethora of choices. On that day, though, I was confused by Franciszek’s condition and the way he was received at the hospital. I was naive, believing that nurses and physicians were supposed to serve Franciszek instead of humiliate him.

Franciszek and I returned to the center. I asked him to wait in the admissions room while I gathered the intake forms. He nodded and sat with his eyes cast down at the beige linoleum of the admission room, the room where we went through the belongings of the newly admitted, throwing out bottles of sugared rotgut, boxes of improvised crack pipes, and the bags of store-brand corn starch which could trick a hungry stomach into feeling full. The floor was pitched at an angle, causing his possessions to roll away from him, as they had for the past few years. Over those years, Franciszek had become accustomed to the invasions, the interminable waiting, and the impersonal forms of service agencies. To hasten the process, I started on the intake forms using records from his previous admission, the first of many times I would start the documentation of a patient encounter before seeing a patient. With the forms prefilled, I only had to ask Franciszek a few questions.

“Anything bothering you physically?”

“No.”

“Any sense of why this happened again?”

“Alone, I am alone. I drink.”

“Anyone you want me to call?”

“No.”

I did not know what to say. I completed the forms. I rifled through the clear plastic bag labeled “Patient Belongings” with which the hospital had discharged Franciszek. I showed him to a bed.

I left the building, started a borrowed car, turned the stereo up, and listened to a mixtape from a friend back home. As the songs propelled me across Chicago, every good I could imagine felt undone. The ten months of Franciszek’s sobriety had ended, the fruits of the staff’s labor had proved short-lived, and the physicians and nurses at the local Emergency Department had revived him without welcoming him.

With my brooding thoughts, I made my way south to the Dominican priory where I was living with a group of friars and priests—some in training, some active, some retired—who sponsored the AmeriCorps program in which I was enrolled. The idea was that AmeriCorps volunteers spent their days at a local social service agency and their nights and weekends living with the Dominicans as a way of experiencing a life of service. The priory was a massive four-story brick building built during boom times for the Catholic Church, when priories bustled with young Dominicans. By the time I arrived, the long bust had begun, and there were enough free rooms to provide a private room for each volunteer.

I returned home that evening in time for vespers. A few months earlier, I had been in college, where I could return to the dorm when I chose and do what I pleased when I got there. If I had been still in college, I would have spent the evening alone with my festering resentments, but at the priory I was expected to attend vespers. The community’s modest chapel was on the first floor; no one could sneak into the house without passing it. I took off my winter coat and dutifully collected a hymnal. I entered the chapel and found a seat in wooden pews that faced each other. The brothers and priests looked almost as disinclined to be there as I was. Still, we all opened our hymnals and sang, off-key, from the seventy-second psalm: “He will rescue the poor at their call,/those no one speaks for./Those no one cares for/he hears and will save,/save their lives from violence,/lives precious in his eyes.”1 I thought of Franciszek. When he would be rescued? When would his life be saved? The hymn left me hungry for an unfulfilled promise, but at least we named that promise, and named it together.

The Dominicans, however, seemed more like grumpy bachelors than holy celibates. They followed evening vespers with plates of pot roast and potatoes, then rode the elevator up a flight to the lounge, where we sat in worn recliners, sipping cut-rate scotch and watching laugh-track sitcoms. These men had joined their lives together, but I never seriously considered paying the admission price of celibacy for their version of communal life. The prospect of fighting over the remote with thirty other men for the rest of my life was another disincentive.

The communal life I found more compelling was the life enjoyed by their sister community, the Sinsinawa Dominicans. Whereas the brothers and priests seemed similar to the other resigned middle-aged Midwestern men I knew, the nuns seemed strangely alive in the absence of men. Indeed, when I visited their motherhouse in rural Wisconsin, it seemed as though they never died. Walking along the sunlit halls, I met an octogenarian who was still teaching elementary school, a nonagenarian serving as spiritual director to the novices, and a centenarian who read to the blind. The priory smelled of menthol, but the motherhouse smelled of the sweet breads the sisters sold to support themselves. When they sang together, they sang boldly and in harmony. Afterward, they talked eagerly of their work as they sat at table. I met nuns who taught nearby and in Nicaragua, nuns who ran hospitals, and nuns who worked in hospitals as nurses or physicians.

Those women intrigued me. I had never met a nun who was also a nurse or physician, a contemporary Hildegard of Bingen. When I mentioned this to the one of the sisters, she laughed and told me nuns had been working as nurses and physicians for millennia, founding hundreds of hospitals in the United States alone. She said that when she was a teenage novice, her community sent her to medical school. She had come from a farming family and never imagined she could become a physician, but she went to medical school because her community called her to the practice. That sounded like precisely the kind of communal direction I was looking for, so I started telling her about Franciszek and the other people I met at Interfaith House. When I got to the part about singing the seventy-second psalm and longing for its promise, she asked if perhaps I should serve by becoming a physician, handed me a holy card, then moved on to her next conversation.

I never really thought of physicians as servants. As a child, the white-coated physicians I knew were kind-hearted and civic-minded, but bourgeois, professionals. They drove better cars and lived in larger houses than their neighbors. They offered a professional’s service for a professional’s fee. When I worked at Interfaith House, I talked daily to people discharged from Chicago’s hospitals. Few spoke of being served by a physician. When I looked over the medical records sent with them from the hospitals, I saw only indecipherable codes written by numerous physicians. When I accompanied a patient on medical visits, the physicians seemed to be, like those who had treated Franciszek, curt technicians who dismissed the patient after ensuring that he or she was no longer in imminent danger. I had never met a physician whom I could describe as a servant, but this nun assumed that physicians served.

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Puzzled by the nun’s suggestion, I started looking for evidence of physician-servants.

She had given me a holy card, the Catholic version of a baseball card, for two saints I did not know, Cosmas and Damian. On the front, the saints were portrayed as fresh-faced boys in matching halos, red velvet robes, and green calf-length gowns. They looked as though their pious mother had dressed them up for the third-century version of the family Christmas card. The back of the card bore the caption “Physicians and Martyrs” and a prayer, written in the passive plea of the genre, that these saints would transform the bearers into “willing and loving servants.”

Curious, I started looking around used bookstores for more information on these saints. Few sections of a used bookstore are as neglected as the medicine or the religion section; the books that straddle the two are invariably dusty and marked down. In that overlap, I found books whose covers included stethoscopes transmuted into religious symbols, books with heroic portraits of once-charismatic authors, and a series of pamphlets, one of which mentioned that Cosmas and Damian were acclaimed as “holy unmercenaries,” or “as doctors without silver,” because they would never accept payment for the medical care they provided.2 Sounded like hagiography to me; I could not imagine physicians working without pay.

I moved on to the bioethics section, where I found a book called Suffering Presence, by Stanley Hauerwas. The back cover promised that it addressed key questions in bioethics. I brought it home and skipped sitcoms and scotch in favor of reading it that evening. I had never really read theology before and was engaged by its rhetorical force. Hauerwas did not engage in tedious methodological arguments, like the postmodern critical theory I labored through as an undergraduate, but sounded deep questions about illness and health. I did not register the entire argument, but I understood his claim to be the same as the nun’s. It was once commonplace, he wrote, for a physician to conceive of himself or herself as a servant commissioned by a community, and he argued that this conception was still necessary. I underlined such passages as “Medicine needs the church not to supply a foundation for its moral commitments, but rather as a resource of the habits and practices necessary to sustain the care of those in pain over the long haul.”3 Hauerwas wrote that if medicine did not have the church or a community similar to one, physicians would not be able to endure being present to suffering of their patients. Without a community, physicians would be overwhelmed by that suffering and become alienated from the ill people they were supposed to serve. If a community called physicians to serve the ill, however, then they could fulfill their vocation, “to serve as a bridge between the world of the sick and the world of the healthy.”⁴

Hauerwas believed physicians could be a bridge between the ill and the well, but I had seen little of that in my work with the homeless, so I wrote him a letter telling him so. He wrote back, asking me to work for him that summer. A few months later, I left Franciszek and the brothers in the priory and moved to Durham, North Carolina, to work for Stanley. When I arrived, he gave me a stack of books to read, several boxes of papers to organize, and a question.

“What do you want to be?”

“A bioethicist.”

“People think bioethicists are assholes. They tell everybody what to do but don’t do it themselves. You need to serve somebody. You should go to medical school.”

I figured that was the closest I would ever come to a commissioning.

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While waiting to start medical school, I looked for signs of physicians who worked as servants, without silver.

Stanley Hauerwas introduced me to the Catholic Worker, a loose-knit group of anarchists, pacifists, and former altar boys who operate houses of hospitality for the poor. The houses engage in various works of art, agriculture, education, medicine, prayer, and resistance in the spirit of their founder, Dorothy Day. For a year, I volunteered occasionally at House of Grace, a Catholic Worker house run by two women, one a nurse practitioner. On weeknights, she would see ill patients in a rundown row house. On the first floor, we volunteers would run a warm shower for patients who were dirty and bring a plate of food to patients who were hungry. When the nurse practitioner was ready, we would escort the waiting patients upstairs, past an indifferently displayed collection of radical posters and holy cards. One evening, I noticed the Cosmas and Damian card among their number. The tradition of the holy unmercenaries, the doctors without silver, was alive, at least in that row house.

I told myself that being unmercenary was fine for them, but too much for me. I was still a student; they were practitioners. I was accumulating student loans; they had paid theirs. Excuses, of course, but I kept looking for a more approachable way to be a physician-servant.

I lived in a commune for a year, but I grew tired of the bickering and the vegan dinners. At least the Dominicans served scotch.

I also read the books of David Hilfiker, a physician who worked for several years in a rural private practice before joining a Protestant analogue of the Catholic Worker in an impoverished neighborhood in Washington, D.C. Reading Hilfiker was bracing: he disclosed the emotional challenges of practicing medicine, of bearing full responsibility. Instead of writing about his triumphs, he wrote about his mistakes. And instead of using his mistakes as the rhetorical grounds for the need for a better laboratory test, a larger evidence base, or a quality-improvement initiative, Hilfiker understood them as a reminder of his own limits and the limits of medicine. He advised physicians to abandon their pretense of perfection. He eventually concluded that the only way to throw off the yoke of perfection was to live among the poor patients he served. He gave up his isolating bourgeois life as a private practitioner for a communal life, in which he and his family lived with the indigent ill, in order to practice medicine as a servant, and as one who could admit his mistakes and be forgiven for them.5

Hilfiker’s honesty and service seemed both ideal and impossible to me—I was more reluctant than “willing and loving”—so I tried to approach it with an analogue. When I started medical school, I signed up as a volunteer at the school’s free medical and dental clinic. It was open one night a week, and while the number of patients ranged from two to twenty people, the clinic was always well staffed with eager volunteers from the university’s medical, nursing, pharmacy, physical therapy, public health, and social work schools. A student from each discipline saw every patient. A patient presenting with a straightforward complaint—a mandatory school physical, a simple urinary-tract infection—endured a three-hour exam, swarmed about by well-intentioned students. An efficiency expert could have taught us a great deal about how to run that clinic.

Although I enjoyed my time in the clinic, in hindsight, I recognize that it was far more helpful for me than for the patients. Volunteering in the clinic was a weekly reminder of why I enrolled in medical school, something I needed during days of indifferent lectures, even if it was only an abstraction of the House of Grace or Hilfiker’s clinic. We did not live with our patients. We drove to the neighborhood, provided a student’s version of a professional’s service, and then drove home. For all our good intentions, the student clinic was another iteration of the training wards of Osler’s hospitals, where the bodies of the poor and the indigent were the pathology textbooks for student practitioners. Patients received care without charge, but they did so in exchange for functioning as a textbook.

I continued searching for my version of the physician-servant, and my search led me back to Stanley Hauerwas. He convinced me to take a leave of absence from medical school to study the history of physicians as servants with him.

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In my medical school, the history of medicine began with an invocation of Hippocrates and his oath, then jumped ahead to Ignaz Semelweiss and his efforts at antisepsis. The less said about the intervening centuries, the better. But Stanley wanted me to look at those intervening years.

He taught me about the initial break between Platonic and Hippocratic medicine. In Platonic medicine, a physician sought to diagnose disease as an ontological entity, a concrete fact that should be named rightly. A competent Platonic physician identified the disease the patient had. In Hippocratic medicine, a physician sought to understand an ill person by learning the beneficial and deleterious forces in his or her life, and then helped a patient as he or she sought repair. A competent Hippocratic physician understood the patient.6

Stanley Hauerwas showed me that even though Hippocratic physicians sought understanding, they did not seek the solidarity with the ill that servants such as Hilfiker or the Catholic Workers or the nun from the Sinsinawa Dominicans sought. To illustrate the difference, he gave me Guenter Risse’s Mending Bodies, Saving Souls: A History of Hospitals. Risse wrote that, for Hellenistic physicians, the god Asclepius was the paradigm. In Asclepius’s temples, an ill believer entered into an exchange relationship with the deity, giving gifts for health. In the clinics and hospitals of Hellenistic physicians, an ill believer likewise entered into an exchange relationship with the physician, paying a fee for the physician’s services. Asclepius saw only the ill who sought him out, worshipped him, and made sacrifices in his name. So Hellenistic physicians saw only the ill who entered into the exchange relationship between patient and physician. In ancient Greece, Risse wrote, there “was no public duty toward the sick” because “illness remained a private concern.”⁷ If you were ill, you could receive succor from your kin or, if you had the means, enter into an exchange relationship with a physician. There was no public philanthropy for impoverished or estranged ill people.

Social welfare for the indigent became a communal responsibility, Risse wrote, only with the rise of the Jewish tradition of hospitality to the dispossessed and the Christian tradition of charity to the indigent. Jewish and Christian physicians practiced the Hellenistic medicine of their era—they did not develop a unique account of medicine, of why people fall ill, the treatments they should receive, or how they were restored to health—but were distinguished from other physicians by why they practiced medicine and for whom they practiced it.

In the Diaspora, Hellenistic Jewish physicians had a particular interest in the poor and the stranger because they belonged to a community formed by prophetic hopes for something more than fee-for-service relationships with deities. I saw this in the book of Micah, where the prophet called his hearers to approach God with virtuous behavior instead of sacrificial offerings:

With what shall I come before the LORD, and bow before God most high?

Shall I come before him with burnt offerings, with calves a year old?

Will the LORD be pleased with thousands of rams, with myriad streams of oil?

Shall I give my firstborn for my crime, the fruit of my body for the sin of my soul?

You have been told, O mortal, what is good, and what the LORD requires of you:

Only to do justice and to love goodness, and to walk humbly with your God.8

The people who heard and transmitted this text were called not just to be competent in exchange for a fee, but to be virtuous servants who performed works of mercy.

The Gospel of Matthew describes Jesus delivering a similar list of the works of mercy to his followers at the peak of his public ministry—“I was hungry and you gave me food, I was thirsty and you gave me drink, a stranger and you welcomed me, naked and you clothed me, ill and you cared for me, in prison and you visited me.”⁹ Although this list of the works of mercy would be familiar to Jewish communities as gemilut hasadim, the meaning of the works was altered when Jesus identified himself with the hungry, the thirsty, the stranger, the naked, the ill, and the imprisoned—the least-valued people in society. Jesus called his disciples to attend to those who are ill, poor, weak, or powerless as the way to attend to him.

In the first centuries after the death of Jesus, his followers debated to whom the text was addressed. Should the followers of Jesus serve only other followers of Jesus? Early Christians including Jerome, Augustine, John Chrysostom, and Gregory of Nyssa insisted that the followers of Jesus must serve all humanity—especially the least—and their interpretation became normative.

Jesus told his followers to see the ill as a servant would, whether they were serving food to the hungry or tending the sick. The servant’s gaze was quite different from the clinical gaze that I was being trained to use in medical school, where seeing patients in terms of parts and money seemed like an updated version of sacrificial exchange offerings. I watched every day as patients entered the hospital as though it were a temple, with high hopes for what its practitioners could accomplish, and exited days or weeks later with bills they could never pay. When I asked attending physicians how much the tests and studies we were ordering would cost our patients, none could answer. One attending thought my questions signified an interest in billing, so he pulled me aside and showed me documentation tips to optimize my future salary. You needed at least three items in the review of systems. You needed specific diagnoses. You needed to document your time, because you were paid for it.

I appreciated being taught the mechanics of the exchange offering, but I wanted to know what a place shaped by the works of mercy looked like, a place were you saw patients like a servant.

Stanley Hauerwas taught me that public hospitals were built to perform the works of mercy. The first public hospital was built by Basil of Caesarea, the fourth century’s version of William Osler.10 Basil grew up in privilege and was well educated, studying Hippocratic medicine in Athens before beginning a career as a lawyer and teacher of rhetoric. In 358 C.E., he experienced a spiritual awakening, gave away his inheritance, and sought a rigorous life in ascetic desert communities. Visiting monks in Egypt, Palestine, and Syria, he marveled at their holiness, but he was disappointed to find that they did not practice works of mercy, so he left the desert and reentered public life. In the city of Caesarea, Basil soon became an assistant to the bishop, administering the bishop’s charities, building food pantries and soup kitchens. He sold his own possessions to purchase food for neighbors during famines and persuaded his wealthy neighbors to do the same. Basil asked his parishioners, “What keeps you from giving now? Isn’t the poor person there? Aren’t your own warehouses full? Isn’t the reward promised?” He continued, “The command is clear: the hungry person is dying now, the naked person is freezing now, the person in debt is beaten now—and you want to wait until tomorrow? . . . The bread in your cupboard belongs to the hungry person; the coat hanging unused in your closet belongs to the person who needs it; the shoes rotting in your closet belong to the person with no shoes; the money, which you put in the bank, belongs to the poor. You do wrong to everyone you could help, but fail to help.”11

Basil’s exhortations were powerful, but it was hard to imagine following them today. Perhaps it meant walking with Franciszek as he began again, along with his fellow ill travelers, at Interfaith House. Perhaps I could have seen him get sober for the final time. Perhaps it meant picking him up from another Emergency Department six months later. Perhaps, but I never found out. I moved away from Chicago before Franciszek finished writing his story.

I do know that, almost twenty years later, I have a great deal more sympathy for the nurses and physicians I met with Franciszek. My training has given me experiences like theirs, moments when I have become the kind of person I swore on that afternoon never to become. If I remember the story of Franciszek’s being shamed, it is because it was the first time I witnessed such an event, but it is also because I prefer to remember the failings of his nurses and physicians rather than my own.

The people I have shunned and shamed are nameless in my memory, but I can remember the many times when I retreated to the call room or the nurse’s station or my office to complete the documentation necessary for our exchange offering rather than sit with a patient like Franciszek in all of his or her infirmity. Sitting alone, working on the stacks of paperwork that now constitute a physician’s day, I realize that Basil’s homily is directed at me. I do wrong to everyone I could help but fail to help.

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In 370, the bishop of Caesarea died, and Basil was named his successor. Soon after being installed, Basil realized a plan he had formed while touring monastic communities as a young man. He built a ptochotropeion, or house for the poor, the ill, and the dispossessed, on the outskirts of Caesarea. Basil located the ptochotropeion at the edge of his city so that it would be accessible to the needy, especially travelers and strangers. In The Birth of the Hospital in the Byzantine Empire, the historian Timothy Miller describes the ptochotropeion as a collection of buildings housing a large number of ill people, men and women alike. When patients entered, the clerics, deacons, and deaconesses who supervised the ptochotropeion gave them rest, regular meals, and nursing care. After these disciplines were exhausted, the supervising clergy would call in the lay physicians. Physicians administered the medicines of the day in an effort to remove ill humors and, if deemed necessary, cauterized the flesh to create blisters and burns to expel ill humors.12

On occasion, Basil himself provided medical care at the ptochotropeion, but as bishop he was also responsible for the social welfare of the entire city, and his work as bishop prefigured contemporary public health efforts. Risse noted that in Hellenistic society, medical care was “a personal, individualized hospitalitas,” chiefly offered in the homes of physicians on the basis of an individual patient’s ability to pay for medical care. According to Risse, in the face of the famine and disease that often gripped an entire community and set the ill along the roads of Byzantium in search of food and respite, Hellenistic medical care was “clearly inadequate.”¹³ During public health crises, Hellenistic society lacked a communitarian ideology strong enough to succor the ill. Basil stepped into the breach and developed a system of social welfare and public health that ameliorated the effects of famine.

Today, many scholars consider Basil’s ptochotropeion the first hospital in Western society. He is also, after a fashion, the first healthcare reformer, because his tenure inspired the building of hospitals for the indigent ill in cities throughout the West.

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After I finished my work with Stanley Hauerwas and then my psychiatry residency, I wanted to see what had become of Basil’s vision. I took a job at a contemporary hospital for the indigent ill. Denver Health is a direct descendant of both Basil’s ptochotropeion, as a refuge for the indigent ill, and Osler’s teaching wards, as a place for the wise, as Flexner’s Report put it, to be brought to book. I never left, because it is a place that provides physicians and other practitioners daily opportunities to serve the ill while teaching students and residents to do likewise.

Still, Denver Health suffers from what Victoria Sweet noticed at Laguna Honda. Laguna Honda’s purpose, to care for the ill stranger irrespective of his or her ability to pay, was defined millennia ago. But when people receive care as patients or work in these hospitals as practitioners, Sweet wrote, they follow scripts initiated by their predecessors with little awareness of how the scripts developed. Sweet drew my attention to the way the past has become an obscured “faint shadow,” but remains “active in our thoughts and desires,” when we practice medicine in these settings.14

At Denver Health, the faint shadow of Basil’s desire to create a house of healing for the indigent ill is still active in the thoughts and desires of its practitioners, even though few of them know of our debt to Basil’s hospital and the way it was animated by Jewish and Christian accounts of charity. I wonder how aware of the past one must be in order to sustain practices we have inherited. How long can practices endure as faint shadows? How long can we describe the hospital as a factory before we forget that it began as a poorhouse?

I sometimes ask myself these questions from the small garden in front of the hospital, where a bench was installed that I have come to regard as an emblem of this shadowed purpose. The bench is an artful half circle, cut from stone, on which the words “DO JUSTICE. LOVE GOODNESS. WALK HUMBLY.” are carved. No source is named, no text cited, no mention is made of the communities that carried those words for centuries and responded to their prophetic demands. The “Micah bench” is a clue to what hospitals once were (and could still be), but I worry that if its origins remain in the shadows, physicians will forget that they are the servants of their patients. We will be more like customer service agents instead.