In May, 2002, Parker Palmer facilitated a retreat for residency program directors who had received the Accreditation Council for Graduate Medical Education's (ACGME's) Parker Palmer Courage to Teach Award. During the retreat, a case was presented, a case in which a liver transplant donor had died while in intensive care. He died despite the fact that the surgery had gone smoothly and despite the fact that his wife, who was with him throughout the entire postsurgical period, insisted repeatedly and to no avail that her husband was going downhill fast. Three months later, the state health commissioner issued an incident report saying, “The hospital allowed this patient to undergo a major high-risk procedure and then left his postoperative care in the hands of an overburdened, mostly junior staff, without appropriate supervision.” On the day the donor died, a first-year surgical resident with twelve days of experience in the transplant unit had been left alone to care for thirty-four patients. She could not – and did not – monitor every patient with the care and precision required.