Saint Roch was never supposed to touch his patients.

According to medieval legend, that’s what a hospital director tells the pilgrim and future plague saint when he arrives in Acquapendente, a village along the Via Francigena to Rome that was buckling under a wave of bubonic plague. Even in the fourteenth century, Europeans understood that the plague was contagious, and physicians advised caregivers to save themselves rather than keep a bedside vigil for the sick. But in his hagiography, Roch reprimands the hospitalist for this warning, asking “Why should we, who imitate Christ, be so sparing of life?” Then, with a frightening certainty, “Let me go to the sick!”

The morning after Roch makes his rounds through the village, the city is cured. After packing his meager belongings and swearing the townsfolk to secrecy, Roch sets off to continue his pilgrimage, repeating this miracle in the next Italian village.

I first encountered Saint Roch’s story in medical school while studying plague saint legends following the Black Death. Roch’s cult spread just as infectiously via vox populi, yet wasn’t recognized by Rome until over a century after his hagiography came into print. It’s easy to see why the story was so popular. Even reading Roch’s exchange with the hospital director today, his readiness to serve feels heroic.

The first year of medical school was a time when expectations for the rest of my career were constantly being set by those above me. In my case, I was told how to “survive” much more than I was told how to give. Lecturers employed the term “burnout” so often that it deserves a flashcard in my AnkiDeck. There’s a reason it has become a buzzword. In 2022, 46 percent of health care workers reported feeling burned out, and 44 percent intended to change careers. The solution to burnout, I have learned, is yet another popular buzzword: boundaries.

The use of the term “boundaries” has climbed in the twenty-first century, but a similar concept has always been part of medicine. Even in the time of bubonic plague and Saint Roch, the limits on obligations to the sick were being muddled and debated. Domenico de' Domenichi, the contemporary Bishop of Brescia, characterized flight from the sick as a natural extension of God-given reason, an instinct so natural that it was even granted to birds. In 1889, William Osler prescribed “aequanimitas” to graduating doctors and nurses, a sort of stoicism and imperturbability to patient misfortune that is still the official motto of residency at Johns Hopkins Hospital.

In today’s health care model, “boundaries” might mean interrupting a patient’s story to wrap up a visit on time; limiting patient phone calls; or, in the case of shift work, leaving on time with robotic self-discipline. I think these efforts are well intentioned but not above questioning. As a buzzword, “boundaries” falls in the lexicon of therapy-speak, which has been criticized for making human relationships feel transactional rather than collaborative. And even in plague times, writers like Giovanni Boccaccio in The Decameron characterized caregivers in flight as morally depraved, leaving their loved ones to die alone with doors locked from the outside. It’s no wonder that the hero of plague times became a man like Saint Roch, a man willing to put the logic of self-preservation aside in order to care for the sick.

Saint Roch’s journey through Italy forced me to grapple with my own questions about how far I might be willing to go for the patients around me. If the plague came today, I feared I would not be like Saint Roch, eager to make the sign of the cross on his patients’ hands. Instead, would all I had been taught make me more like the cynical hospital director, erecting an antiseptic screen to separate myself from the sick?

The archetype of the “good doctor,” continuing in the tradition of Saint Roch, often depicts a man or woman defined by a certain disregard for such boundaries. One example is Dr. Jim O’Connell, the president of Boston’s Health Care for the Homeless and the subject of Tracy Kidder’s book Rough Sleepers. While reading the book with classmates, a friend mentioned that O’Connell’s clinical care pushed our conceptions of standard clinical practice. What boundaries can you have, after all, in a clinic with no walls?

In Rough Sleepers, O’Connell is a physician seen walking his patients to the pharmacy and putting his card down at the register. A physician who comes to his newly housed patient’s home in the middle of the night after getting a call that the TV won’t turn on. A physician who sometimes drives his patients to court. When I ask him about the first time he felt his boundaries start to shake, O’Connell describes the transition from his medical residency at Massachusetts General Hospital to practicing medicine among the homeless. Rapid visits and rigid systems worked at a large academic medical center. But homeless folks have been failed by these systems, so it’s natural for them to distrust the traditional medical model. In order to gain that trust back, O’Connell found he had to go outside the traditional boundaries of a physician’s job. “You have to share your own story with them while they share with you. You have to get coffee with them. Take time,” he says. “It’s no longer a fifteen-minute clinic visit in which you get everything done.”

O’Connell also notes that the notion of being embedded within a patient’s life is not radical. “When I grew up, we had a family doctor. The family doctor had delivered my mother, delivered me, delivered my sisters, lived down the street, often came over for dinner, and when we were out doing stuff in town we’d often run into him,” he says. “I remember thinking in those days that the doctor is very much a part of the community.” This medical ideal has always existed, but it’s often absent from health care for the homeless, where physician turnover is high. “The other boundary that I wasn’t really ready to broach but needed to was: Are you doing this for a short-term piece of good work, or are you doing this as your career?” More than spending an extra fifteen minutes with a patient, O’Connell needed to be ready to devote his life to the homeless.

As patients need time to learn to trust O’Connell before they open up, this time spent with them also informs the so-called boundaries he chooses to cross as a physician. When I ask about the report that he used to slip twenties to patients during appointments, he admits that he wouldn’t advise a new staff member to do the same. His giving was directed toward patients with whom he was familiar. “As I got to know people better, I felt much more comfortable if I knew them well and I knew what they wanted, just giving them some money,” he says. However, he acknowledges that giving cash is a controversial practice for physicians, and his team now hands out gift cards to McDonald’s or Dunkin’ instead.

O’Connell shrinks from allegations of heroism in his work, but his archetype in Rough Sleepers is also mythologized in modern storytelling. In the Emmy-nominated TV series The Pitt, a similar kind of physician is seen in Dr. Samira Mohan, who quickly became a fan favorite. Nicknamed “Slo-Mo” by her more cynical colleagues, Mohan is constantly criticized for taking too long with her patients (her superiors are partially concerned that it harms the hospital’s efficiency metrics). Yet Mohan’s patience with every clinical case enables her heroic saves throughout the season. She sees a patient labeled “drug-seeking” and discovers a sickle cell vaso-occlusive crisis, or reexamines a girl destined for the psych ward only to find that she actually has heavy-metal poisoning. Medicine stands at the forefront of Mohan’s life; she mentions not having a romantic partner or family nearby, and other characters warn her that medicine can’t be her everything. But that doesn’t stop Mohan from staying hours after shift for the fun of it, smiling with a perky “I love my life” long after other colleagues have crashed.

In an interview with Harper’s Bazaar, actress Supriya Ganesh states that Mohan’s character was developed in response to the “brokenness” of the medical system, which often leaves women, and particularly women of color, feeling that they aren’t taken seriously as patients. Even after being told to limit her time with every patient, Mohan chooses to spend it with the hospital’s most vulnerable. This philosophy of practice mirrors that of Saint Roch and Jim O’Connell, who also adjusted their norms of caregiving in response to social crises (plague for Roch, homelessness for O’Connell). In pushing the boundaries of normal medicine, all three of these examples are celebrated for their heroics.

Yet for all three, there comes a point in the story where no good deed goes unpunished. Roch does indeed contract plague after all his healing endeavors. Instead of being cared for, he’s driven from the city he was trying to help. In Rough Sleepers, O’Connell experiences true grief over the death of a patient and calls it “the beginning of the end.” And in The Pitt, one of Mohan’s final scenes isn’t one of victory but of despair. She’s sobbing alone in a hospital restroom, throwing her paper towel into a blood-stained trash can.

The term “health care hero” became popular around the time of the Covid-19 pandemic, but its use is not without criticism. Some physicians argue that comparing their daily work to heroics justifies their poor working conditions or outlandish quotas without calling on employers to actually support them. Yet stoic aequanimitas and rigid boundaries don’t feel like the panacea for a profession designed to walk with patients from cradle to grave. In The Woods Hole Cantata, Dr. Gerald Weissmann argues that aequanimitas was a practice “not only devoid of passion, but of joy.”

Instead of “boundaries,” an article from The Journal of Medical Ethics suggests that “reciprocity” should be the focus of current discussions on heroism and burnout. If, for example, a physician is obligated to give something up for their patients – be it health or time or resources – a community is in turn obligated to provide support in the form of compensation, protective equipment, or solidarity. Lose this reciprocity, and doctors can crash at the end of a workday, as depicted by the fictional Samira Mohan.

Reciprocity is a difficult concept for me to reconcile as a Christian. Jesus teaches us to go the extra mile for others with no thought of a return on investment (Matt. 5:41–42; Luke 6:35). But just as embedded in Christian teaching is the command, “Ask, and you will receive…” (Matt. 7:7). It’s also important to note that caregivers don’t need reciprocity directly from the patients in front of them. Anyone can support a health care worker, just as anyone can support a firefighter or a schoolteacher or a neighbor down the street. That’s the economics of community, quite simply. And if doctors aren’t embedded in community, burnout feels inevitable.

O’Connell recalls an amusing anecdote from when he received a pacemaker in the hospital. He woke up in the ICU surprised to see one of his own patients at the bedside who had found a way to get around Covid visitor policies to check on his “Dr. Jim.” It turned out that the time he had invested in relationships with his patients ended up not being for the patients alone.

Even in the case of Saint Roch, God found a way to take care of the healer. After being driven from the city, the bubo-laden pilgrim builds himself a hut in the woods to convalesce on his own. But then a stream of fresh water springs up from the ground nearby. A dog arrives with bread in his mouth and licks Roch’s black swellings. The dog’s owner finds Roch and takes the stranger into his home. Maybe Roch’s heroic fearlessness isn’t the only reason his legend spread throughout Europe so quickly. Maybe just as enthralling was the touching turn of events where a saintly caregiver, in his darkest hour of need, was also cared for.