fourteen

RED CARDS

Smoking anywhere on hospital grounds is banned with the vigor of a religious prohibition, but patients and visitors continue to smoke in front of the hospital’s most visible entrance. Their disregard of the prohibition reminds me of how the recommendations of physicians fail. Or how they backfire: Physicians used to recommend cigarettes to patients. If you look, you can easily find old advertisements claiming that dentists smoke Viceroys, but physicians smoke Camels. Camels were, physician pitchmen avowed, less irritating for the throat.1

In Denver, many of our hospital smokers are lighting up joints or vaping marijuana. Although smoking marijuana publicly is illegal in Colorado, the law is inconsistently enforced, and so you can often smell its oily aroma as you enter the hospital. Our local magazines carry images of physicians recommending different strains—an indica such as Blue Widow for multiple sclerosis, a sativa such as Candy Jack for cancer—which makes the possibility of physicians recommending cigarettes suddenly seem less outré. Indeed, if you ask the marijuana smokers on the Micah bench, many will tell you that a physician recommended marijuana.

Unlike the cigarette smokers, who typically look shame-faced about smoking, the marijuana smokers are often evangelistic about their own habit. They say it is the only medicine that works. They will show you their state-issued medical marijuana registry card, popularly called a “red card” because of its red border. The phrase always makes me think of soccer matches, where referees pull a red card out of their pocket to signal that a player’s foul is so egregious he or she has been exiled to the bench. In Colorado, pulling a red card out of your pocket provides access to medical marijuana, granting you an affirmative defense against prosecution. These red cards keep you in the game rather than take you out of it. When I ask someone with a red card how he or she came by it, I am usually told that the patient initiated the conversation and asked the physician for marijuana. The physician served the patient’s needs, but as a customer service agent.

Because their habit is medicalized, most of the marijuana smokers will happily talk with me if I find a seat on the Micah bench. Most of them would be more likely to share a joint with a physician than to pinch it out prematurely when a doctor walked by.

One of my favorite smokers was a young man who sat vigil on the Micah bench, waiting for news of his friend in the surgical ICU. Cyrus was as thin as a wind-ravaged tree in late autumn, fingering a collection of Wallace Stevens poems in his left hand while he used his right to hold a lit marijuana cigarette and absentmindedly stroke his hair.

He did not want to be called Cyrus. He had rechristened himself Fusion Mondrian. He told me that the name was originally a literary conceit, but it was such a good name that he decided to make it real. His speech-acts had that power. The name was a month old, as long as his tenure in Colorado. He had relocated from Houston the month before “to spread a creative gospel that will make the world a more interesting place.” He looked like he would be more interesting company than the regulars in the hospital’s cafeteria, so I sat awhile, listening to his poetic phrases.

“How have you been making out since you came to Colorado?”

“It’s been electric.”

“Ah, okay. How have you been supporting yourself?”

“I am an artist and aphorist.”

“Much of a market for that?”

“I live on the bird’s fire-fangled feathers dangling down.”

“Nice line. I like Stevens too. So you sell the feathers?”

“No. I move about. When I was in Texas, Colorado was the bronze distance, like a mid-tropic zone, or better yet, a chromatic color scale that could only be explained in music, so I shuffled the moments and moved north.”

“Was medical marijuana part of the attraction?”

“Sure. The weed here is Whitmanesque, like mother of pearl, leading to sudden insights of an artistic nature, then a really diverse group of tears, and finishing with an ocean at the end of the mind.”

“Not palms?”

“No, an ocean. I prefer the aesthetic climate.”

We have no ocean in Colorado, but Cyrus was on to something with his comment about the aesthetic climate. Colorado is an aspirational state, an idea as much as a place. My great-great-grandfather sailed from Germany to seek his fortune in a Colorado silver mine. Today, young men like Cyrus wash up on the hospital’s shores every week—erstwhile English majors, coffee-shop philosophers, and secondhand romantics who chased the wild mercury in their minds to Colorado, seeking a plant rather than a precious metal (though the potential for profit is still there: marijuana was a $700 million industry in its first full year of operation).2

There was Marcus, who left a Roxborough, Massachusetts, group home to attend the 420 Rally in downtown Denver. He was thrilled at smoking marijuana with thousands of other enthusiasts in a park facing the state capitol, and he liked the weather, so he decided to stay. He lived on Denver’s streets in the summer and moved into the shelters in the winter. He declined the hospital’s offer of a bus ticket back to the Bay State, where his sister had a spare room waiting for him. He told me, “I have a red card, and it works every time I want to travel in my mind. A bus ticket works only once.”

Zeke had a girlfriend in Denver who had mailed duct-taped and bubble-wrapped packages of BHO, honey-colored hash oil filtered through lighter fluid into crystallized resins, to his Wisconsin home. He loved the BHO, and he loved her, so he moved to Colorado. When he arrived, they celebrated by sampling a fresh batch, but it was too potent for Zeke. Within eight hours of his arrival in Denver, his girlfriend brought him down from Capitol Hill to the hospital, seeking medical assistance for his paranoia. She broke up with him in the Emergency Department.

While visiting from Illinois, Salvador drank grape sativa sodas with friends. The edibles—multicolored gummy bears sprayed with aerosolized hash oil, chocolate bars filled with cannabis, cane sugar sodas infused with sativa—surprise people because they look and taste like the sugared treats favored by ten-year-olds, but they pack a medicated punch. Those sodas can have 75 mg of THC, the chief psychoactive component of cannabis, so gulping a single one can be the equivalent of smoking several joints.

Three sodas in, Salvador decided to chase a blood moon down Federal Boulevard on a friend’s motorcycle. When he clipped the fender of a Mustang while racing a red light, Salvador went over his handlebars, caterwauling into the warm light of a summer night. When he landed, his body splintered into a textbook of eponymous fractures—a Le Fort III fracture of his left maxilla, an Allman II fracture of his left clavicle, and a Gustilo III fracture of his left tibia and fibula. The paramedics delivered him to Accident and Emergency, the emergency physicians staunched his wounds, the surgeons soldered his bones together, and the internists treated his pneumothorax. By the time we saw him in the Psych Department, he was eager to leave the hospital and try a different strain of cannabis. When we asked him about changing his habits, all he would commit to was staying off his cousin’s bike while high. He had lost his driver’s license after the accident, but he still had his red card. He was still in the game.

I am young enough to sympathize with these young men. I remember wanting to light out for parts unknown and seek a life beyond familiar frontiers, and I remember settling for moving halfway across the continent to resolve relationships that were doomed before I arrived and salting my speech with lines copped from poets. I appreciate the spirit of their endeavors.

What I struggle to appreciate are the motives of the physicians who sign for their red cards.

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A couple of years ago, my colleagues and I surveyed every patient admitted to our inpatient unit for a year. We found that by their own report, our patients are seven times more likely to have a red card than the average Coloradan.3 The implication is debatable. Many of my patients tell me that marijuana helps them. I counter that if marijuana were as helpful as they claim, they probably would not be in the hospital, that there is very little evidence for using marijuana as a medicine, but there are stacks of scientific papers showing that marijuana exacerbates mental illnesses, especially for people under the age of twenty-five.⁴ But arguing is pointless. Moralizing helps no one, and I learned from writing a Cochrane review that patients often find scientific data unconvincing.

When it became clear how often we were caring for young people with red cards, we attempted to coordinate our care with that of the physicians recommending the pot. We asked patients for the names of the physicians who had recommended their marijuana, but many could not recall the physician’s name, a quotidian failure in contemporary medicine. Some knew the physician’s name but said that the recommending physician had asked that it be kept secret, an uncommon failure in contemporary medicine. A few patients did give us the recommending physician’s name. When we called to report that a patient in the physician’s practice was hospitalized and requested a call back to coordinate care, none of the physicians ever responded. Surprised, I tried to track down some of the physicians recommending medical marijuana. It proved difficult.

Like many states, Colorado keeps an online database where any physician can look up a patient and see the controlled substances—benzodiazepines, narcotics, stimulants, and the like—that a patient is receiving and who prescribed them. Although these medications are clinically useful, they are widely abused; the database helps physicians keep track of who is receiving what meds and from whom in our fractured healthcare system. In the hospital, we use the database to contact outpatient physicians to tell them that their patients are misusing or abusing the medications they prescribed. In Colorado, however, a physician recommends, rather than prescribes, medical marijuana, so the physicians who recommend marijuana are not included in the database.

I looked up the separate database kept by the state of the patients registered to use medical marijuana and the physicians who recommended marijuana to them, but the patients and physicians in this register are anonymous. While maintaining anonymity, this register discloses enough data to give a sense of big trends, including the number of red cards a physician has signed. In the past fourteen years, fifteen physicians have signed up more than half the patients, and thirty-five physicians signed up 90 percent of the patients on the state registry.5

The registry does not name these physicians, but you can find hints in local newspapers and magazines. Some physicians advertise their willingness to sign red cards, and some speak to the press, which has reported that these physicians have signed up people for red cards while examining them in motels, within marijuana dispensaries, or in Airstream trailers parked next to dispensaries that move daily for the convenience of patients and the discretion of the physicians. Salvador had mentioned getting his red card from a physician in an Airstream trailer flying a Red Cross flag, so I looked up the company and gave them a call. They would neither identify the physician nor allow me to leave a message seeking to coordinate care for Salvador.

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Finally, I met a red card physician who would talk to me. Dr. Paul Bregman is a great talker and asked me to meet him at a restaurant near the hospital. He arrived wearing scuffed Air Jordans, baggy tweed pants, a black T-shirt, and the kind of green blazer given out to the winners of golf tournaments. He was bespectacled and paunchy but looked wonderfully alert, and as I reached out to shake his right hand he placed a bag of Ho-Hos infused with cannabis into my left.

“What’s this?”

“Samples. I want you to see the amazing.”

“You know, I was hoping for the lunch special.”

He took the Ho-Hos back and as the hostess walked us to our table started talking. He was generous with his story. He was a radiologist who used to be in academic medicine, training residents to identify subtle lesions and flaws in the body. Long hours. Nights on call fragmenting his sleep. He became manic—the full fire—and spent years in treatment. He needed electroconvulsive therapy to compose himself, but he still could not reclaim his previous equanimity. He stopped practicing medicine and went on disability. He had climbed Osler’s ladder, and then fallen off. After he had spent months purposelessly puttering, a friend introduced him to marijuana, which helped him endure being disabled and losing his social status as a physician. When medical marijuana was allowed in Colorado, he dusted off his medical license and started recommending it to other sufferers for a fee.

I asked him how the system worked. He said that patients seeking marijuana came to him. Most patients who found him had used pot before, but some were novices, curious to see whether marijuana would work better than conventional treatments. Some patients had multiple sclerosis or cancer, but most had nagging injuries and old ailments that had never been resolved with other treatments. I asked whether he performed physical examinations (something few radiologists do), and he laughed. He said that he was an expert, but not in the physical examination, and he did not see the need for an examination anyway. By listening to a patient’s story (another skill in which radiologists receive scant training), he claimed that he could discern what kind of marijuana the person needed.

He told me that he assumed other physicians had examined his patients, and he encouraged patients to bring in their medical records; he saw his own role as a kind of consultant. He spoke with patients for ten or fifteen minutes and recommended a marijuana strain, a mechanism of delivery, a dose, and a frequency. He rarely saw patients for return visits, encouraging them to follow up with their regular physicians. He wished more medical marijuana physicians would do a better job of coordinating the patient’s care, but he admitted that he did not initiate coordination-of-care conversations with physicians like me.

As the meal went on, I enjoyed his enthusiasm and sympathized with his situation, but I worried about his imprudence. He had described himself as an expert in a practice for which his radiology training had not prepared him: a practice where he saw patients one time, performed no examination, and then recommended a single treatment—marijuana. He told me that although he also recommended lifestyle changes, he prescribed no other medications. He admitted that he knew more about marijuana than he did about his patients’ physical exam, but his patients paid in cash and left the visits happy. I asked about complications—what did he suggest for patients, such as Zeke, who became paranoid? He confidently stated that high doses of sugar could alleviate any psychosis, a claim I wished Archie Cochrane had been at the table to hear. I asked whether he thought that marijuana was simply a form of patent medicine, in which every possible ailment—the list he rattled off included dementia, diabetes, fibromyalgia, hepatitis C, psoriasis, and rheumatoid arthritis—would respond to the same prescription. He laughed and said I did not understand. He felt better on marijuana. His patients felt better on marijuana. His patients wanted marijuana. He provided what they wanted.

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I spend my days navigating the gaps between what patients want and what I recommend. On any given week, I might meet a woman who has almost killed herself using a particular medicine but becomes angry when I refuse to prescribe the same medicine to her at discharge, or a man who abuses alcohol who wants me to sign him up for disability instead of rehab. I receive these kinds of requests as misdirected statements of need. The patients are certainly in need, but they are usually demoralized and are taking the simplest way out of their situation, even if that way is contrary to their health.

Society grants physicians and other medical practitioners the ability to bend the rules of the social order. We can bend the rules toward justice or toward self-interest, and we have a great deal of latitude in deciding what the difference is. In Colorado, a radiologist can, without performing a mental or physical examination, give a patient permission to grow, possess, and use dozens of marijuana plants. More prosaically, physicians like me can prescribe medications for almost any indication, write letters excusing patients from work or school or in support of a disability claim, testify that a particular act was a willful crime or an unintended action motivated by mental illness, and declare a person fit or unfit to manage his or her own finances. Physicians authorize patients’ access to medications, procedures, and social roles that are otherwise unavailable.

In his classic study The Social System, the sociologist Talcott Parsons argued that societies grant authority to physicians and patients through what he calls the “sick role.” Every culture constructs illness differently, but Parsons observed that, in its broad contours, every culture has an account of how a person enters the social role of being a patient. In the sick role, a patient is exempted from normal social responsibilities. A patient is excused from class or work or familial obligations because he or she is sick. A patient is considered sick because of something beyond the control of his or her own will. A person who is sick cannot become well simply by deciding to be or by learning a new skill. But a patient who is sick is expected to want to get well. Patients are allowed the sick role only if they are committed to doing what they can to leave it. Finally, a patient is expected to seek “technically competent help” and to cooperate with that help. A patient is expected to depend upon others, including physicians and other practitioners.6

Within the sick role, physicians have obligations, just as patients do. For Parsons, the chief obligation of a physician is to be an altruistic professional whose behavior is governed by the ethics of the medical profession, not by self-interest. Parsons had a particular moral version of the physician in mind, a universalized image shaped by the Protestant faith of his childhood. His description of a physician as an altruistic professional who embodies universal and neutral collective ideals was published in 1951, and it can seem outmoded today. Physicians and patients no longer share the social consensus—about what it means to be ill, to seek medical assistance, or to administer medical assistance—that Parsons was able to assume in the middle of the twentieth century.

It seems that one consequence of the loss of social consensus has been the rise of the quality-improvement movement, whose adherents distrust the professional ethics Parsons could assume operated. Because we no longer agree on what it means to be a professional, we instead pursue standardized outcomes through industrial processes perfected by quality-improvement advocates.

What seems peculiar to me is that even after we lost our shared sense of the physician’s role, we not only preserved our view of the patient’s social role, we extended it. Over the past fifty years, we have expanded the sick role so that conditions once considered a part of everyday existence are now considered illnesses. An aging man is urged to rub testosterone cream on his shoulders, while a woman with visible hair on her lips applies eflornithine cream twice daily, both treatments requiring a physician’s prescription. The sick role remains the doorway to many changes in social circumstances, and physicians open that door.

Opening that door can, in many instances, be very lucrative for physicians.

The popular press documents stories of “pill mills,” practices where physicians prescribe controlled substances such as benzodiazepines, narcotics, and stimulants for inappropriate indications at unsound amounts for obscene profits. These physicians become, like slaves in Aristotle’s formulation, the animated tools of their patients’ desires. Unlike Aristotle’s slaves, however, they can become quite wealthy, trading their privileged access to restricted treatments for money.

Pill mills are pilloried with such vigor that I suspect we offer them up as sacrifices for the rest of medicine’s sins. After all, even physicians who operate legal practices do so in an environment where the rules governing their practice have undergone startling changes since Parsons’s time.

In Remaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers, the historian Nancy Tomes revealed how changes since Parson’s era have turned patients into consumers and most physicians into customer service agents. One change Tomes identified was the lifting of the prohibition against advertising medical services. It was long considered unprofessional to advertise medical services, and before 1982, the American Medical Association formally forbade physicians to advertise. Fifteen years later, the Food and Drug Administration allowed pharmaceutical companies to begin advertising directly to the public. Today, physicians, hospitals, insurers, and pharmaceutical companies advertise their wares in every possible setting. Tomes identified their ability to do so, based on the rise of market research and the advertising industry, as an additional change. Market researchers and advertisers turned healthy but anxious people into patients and patients into consumers; they created a need for a medical product or intervention, and then filled the need with a new pill or cream or procedure. Advertisers championed the “rights” of consumers to receive their brand-name treatments at brand-name prices. Now we live in a world where physicians, hospitals, insurers, and pharmaceutical companies all conceal their failures from public view but trumpet their successes with the techniques of contemporary advertising.7

Those techniques have altered our daily lives in many ways. Consider just one metric, the use of prescription drugs: two-thirds of Americans now take a medication available to them only with a physician’s prescription. Americans spend twice as much on pharmaceutical medications as they spend on new automobiles. And one outcome of this is that twice as many American are killed by prescription medications as are killed in automobile accidents every year.⁸

The effects on the practice of medicine are perverse. Pharmaceutical companies direct the majority of their advertising efforts to the people who can open the door to their profitable treatments; for every six American physicians, there is one pharmaceutical salesperson. Physicians who are frequent prescribers are groomed and detailed by pharmaceutical corporations to increase prescriptions of profitable pharmaceuticals. In my own specialty of psychiatry, some psychiatrists describe themselves as “psychopharmacologists,” as if they ministered to medications rather than to patients.

I know a psychiatrist who describes himself this way. He also routinely shows up on the lists of physicians who receive tens of thousands of dollars a year from pharmaceutical companies in exchange for promoting their medications. A few years ago, I admitted a string of his patients to the unit, all of whom had decompensated after he switched them to a new medication whose manufacturer was paying for him to give talks around town. I called him and shared my concern; he offered to bring lunch to the hospital and meet with me. I agreed, assuming that two physicians could work out their differences over a collegial meal.

When I entered the conference room where we were to meet, I realized that he had come with a lunch paid for by the manufacturer of the new medication. As I walked in the door, he offered me a box lunch and a handshake, then began clicking his way through a slide deck prepared by the manufacturer of, coincidentally, the same medication for which I had previously written a Cochrane review. A few years previously I had sifted through all the published and unpublished data on the same drug. While writing the Cochrane review required two years of unpaid labor, this physician was being paid to deliver me an hour-long speech about its benefits written by the manufacturer. I had to admit that his presentation was more exciting than our review, if decidedly less systematic.

I left the unopened box lunch on the conference room table a few minutes later. As near as I could tell, he was as self-interested as the pot-permitting radiologist, but not as cheerful.

Back on the ward, I ran into a fellow physician who had skipped the lunch, having scoped out the intent more quickly than I. He thought me naive and the drug-repping physician cheap. He joked that if you are going to use your medical license for the benefit of a large corporation, you should become your own for-profit corporation. He proposed an openly criminal exchange, an offshore website that would provide electronically signed prescriptions for Xanax, Fentanyl, or Ambien to anyone willing to pay with a valid credit card. He did some quick calculations and figured out that if he could keep it up for six months, he could retire young from medicine. Until such a tax shelter is in place, though, he decided to continue practicing workaday medicine, seeing one patient at a time.

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We call them by that contested term patients. Each patient is a person, irreducibly complex and particular, but when I meet hospitalized people, I welcome them as patients, as people in Parsons’s sick role. They have responsibilities as patients, and I have responsibilities to them as a physician. These responsibilities are often obscured, but they remain accessible.

Years ago, Stanley Hauerwas taught me that for all of medicine’s problems, we can still find reminders of its shadowed purpose in its language. So when we call physicians, and other practitioners, professionals, Hauerwas says we are drawing upon a memory of the original idea of the profession as “a calling for a special service to the common good.” Similarly, he claimed that one moral significance of calling ill people “patients” is that it reminds us of the virtue of patience, of persevering through the inevitable diminishments, sufferings, and losses of human existence. He advised all future patients—all of us, really—to practice patience before we inevitably become sick.9

But this sounds difficult. If one could choose, who would choose patient suffering over immediate relief? Who is willing to wait when he or she is simply inconvenienced, let alone when his or her health is imperiled?

The contemporary Dutch philosopher Annemarie Mol recently wrote that ill people are best understood as patients precisely because no one would choose illness, frailty, diminishment, and death. Like Hauerwas, Mol observed that although we talk in contemporary medicine about making health choices and choosing treatment options, this language misses the reality of our lives. Our lives are concerned with making do with the bodies we have rather than choosing better bodies. Mol made this observation in her quietly profound The Logic of Care: Health and the Problem of Patient Choice, which developed out of careful observation of patients and medical practitioners in a diabetes clinic in the Netherlands. In the clinic she found, within the languages and practices of patients and practitioners, two competing logics.

The first logic, the logic of choice, was adopted as a corrective to the paternalism of medicine. We gave up one cliché, the doctor knows best, in favor of another, the customer is always right. Mol observed that when we imagine ill people using this logic, we alternately imagine them as consumers choosing medical services on a healthcare market or citizens entering into contracts with healthcare providers. Although these models have distinct registers, Mol observed that both emphasize an ill person’s ability to make a choice for his or her health. Emphasizing choice appeals to our contemporary interest in using market-based reforms to achieve efficiency and effectiveness, but Mol observed that fostering patient choice has eroded preexisting practices established to ensure good care. Choice cannot account for the realities of living with a diseased body. We cannot purchase health as we can other products, nor can we enter into a contract that will guarantee predictable outcomes from our unpredictable bodies. The only predictable outcome of life is that we will die, a reality from which the logic of choice intentionally distracts customers. In the logic of choice, professionals enable this distraction by limiting their role to the presentation of facts and the use of instruments to enact the choices made by an ill person.

The second logic, the logic of care, harks back to an older language, in which ill people were understood as patients. In this logic, an ill person is not constituted either by his or her choices or by an ability or inability to make those choices but by the practices in which he or she engages while adapting to living with illness. In this conception, making treatment decisions is one among many practices, not the practice that gives a person his or her identity. The question is how to live with and within our bodies. The logic of choice promises mastery over the body, so what matters to an ill person is who masters the body and what outcomes are achieved. The logic of care is less concerned with outcomes because what matters is whether or not someone cares for you. From professionals, the logic of care requires patience, mutual respect, and the ability to take nothing for granted. Patients must admit their own frailty, vulnerability, and suffering. Patients are actively involved in tenaciously adapting to a life with illness, which demands energy and determination.10

If Tomes showed me how advertisers and markets taught patients to understand themselves as consumers and physicians to understand themselves as customer service agents, Mol showed me how these changes altered medical practice. When we understood ill people as customers, we altered the social relationship of illness. We neglected the ways that our lives are contingent, dependent upon circumstances beyond our control. When we became focused on choosing our own medical treatments, we forgot that we live in bodies that grow, love, weaken, and die. Mol is bracingly clear-eyed about our mortality and that our bodies are pleasurable but fragile.

The moral act in the logic of choice is making a choice. The moral act in the logic of care is practical activities. Choice is a discrete activity with a beginning and an end. Care is an open-ended process. Choice is a transaction. Care is a relationship. Choice promises outcomes. Care promises only presence. Choice tames or transcends the body. Care occurs only with the body. Choice asks who is in charge of the body. Care asks how we live with the body. Choice assumes that scientific knowledge is becoming ever more certain. Care attunes scientific knowledge to particular patients. Choice is about managing the body. Care is about doctoring the body.

Mol used doctoring in a particular way, to describe the adaptations we make to our particular situations, with all their contingencies. She did not limit doctoring to the work of physicians, or even of other medical practitioners, but extended it to everyone who cares for the body. She wanted all of us, patient, professional, and otherwise, to engage in the experience and experiment of doctoring, of practically tinkering with the body. Mol asked us to renew the language of professional and patient, which is threatened by the marketing-sanctioned language of choice, to remind us of our shared frailties and vulnerabilities.

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A few years ago, a government regulator decided that our unit would be more customer-friendly if the treatment plans, which we create with each patient when he or she is admitted to the hospital, included the stated goals of the patients. The regulator’s forms forced me to record whatever goals a patient identified. For a week, I wrote down goals like “to finish the suicide I started,” “to get the moon to stop bothering me,” and “to change the United States Constitution so that the FBI has direct authority over the CIA.” Each patient insisted that these phrases best described his or her treatment goals.

Writing out these goals helped, in a fashion. I was able to convince the regulator that repeating patients’ goals verbatim would not work on the unit. It also made it clear to me that I am not in the business of customer service. I will not complete a patient’s botched suicide. I have no power over the moon, to say nothing of the Constitution. I could not help patients meet these goals.

And yet I could sit with each patient and listen to him or to her, so that we could try, together, to find a common rhythm where we could find the logic of care. Even the regulators have evidence for the benefit of a common rhythm. In a report, the Joint Commission, the leading regulator of medicine, attributed more than two-thirds of all serious adverse events in hospitals to failures of communication.11 So perhaps we could all agree that physicians and patients should try to rediscover those common rhythms. With Cyrus, finding a common rhythm meant talking in words borrowed from a Wallace Stevens poem. I would not be his customer service agent, but, perhaps I could be a witness to his experience as we sat together on the Micah bench.