The Cricket Breeders

By Oskar Rausch

Russ Pelletier is seventy-three years old, and he is the coolest man I have ever met who owns a Saab. He has defended doctors and sued doctors, sometimes in the same calendar year, and he regards this the way a fisherman regards switching from the river to the lake. He skis. He has a tattoo he will not explain. He takes a sauna the way the Finns do, which is to say silently, and this is how I came to know him: the two of us, strangers, sitting on cedar at a Lutheran retreat center in the Upper Peninsula, saying nothing to each other for forty-five minutes, which in Finland constitutes a friendship.

On the third day he spoke.

“Do you know about the crickets?”

I did not know about the crickets.

Russ had seen it on the Discovery Channel, late, on the kind of night when a man of his age gets up to use the bathroom and makes the mistake of walking past a television. The segment was about children in Vietnam. These were children who did not have iPhones or iPads or consoles. If they wanted to play a video game they went to a shop and paid by the half hour, like a parking meter, and when the half hour ended so did the game, whether or not you were in the middle of something. So mostly they did not do that. Mostly they fought crickets.

Here is the method, as Russ explained it to me, and as I have since confirmed with my friend Omar, who is a doctor and has seen it done, and who went very quiet when I told him why I was asking.

You catch a cricket. You pull a single strand of hair from your own head. You tie the hair around the cricket’s neck—gently, gently, because if you tie it too tight the head comes off, and then you have nothing, you have wasted a hair. Then you shake it. You shake the cricket around on the end of the hair until it is upset enough to show its fangs and open its wings, and when it is in that condition, trembling and furious and ready to kill something, you release it into the arena, where another child has done the same thing to another cricket, and the two crickets, who have no quarrel with each other and until ten minutes ago were both eating the same leaf, fight until one of them stops.

“I sat up in bed,” Russ said. “I said, out loud, to no one: that’s it. That’s the whole thing. That’s my career.”

He laid it out for me the way he lays things out for juries, with a long pause after every point so you can feel yourself agreeing.

The cricket is the doctor. The doctor does not know he is in a fight. He is eating a leaf. He is seeing twenty-six patients, of whom eleven are there for something that will resolve on its own and two are there for something that will not, and he is trying very hard to figure out which two. He has no quarrel with anyone. He went into this to help. That is the first and most important fact about a cricket: it would rather be in the grass.

The hair is the lawsuit. It is remarkably thin. It is made from the plaintiff’s own head—a real grievance, a real loss, a real strand of somebody’s actual life—and this is what gives it its strength, because you cannot argue with a hair. You can only be tied up in one. The children know that the tie must be gentle. Too tight and the head comes off, and a cricket with no head cannot fight, cannot settle, cannot be insured. A doctor who is destroyed outright is of no use to anyone. The art is in the restraint. You want him alive, and tied, and panicking.

The shaking is discovery. Russ was particularly pleased with this one. “Eighteen months,” he said. “Depositions. Interrogatories. You request every chart. You request his texts. You request the texts of the nurse who was on break.” You shake the cricket until he shows his fangs—which is to say, until he says something defensive in a deposition that can be read back to him later in a different tone of voice—and until he opens his wings, which is the moment he hires his own expert, who is also a cricket, but an older one, who has learned to fight for money.

The arena is the courtroom. The two crickets are the two experts. Neither of them has ever met the patient.

And the judge?

Russ smiled. In the dark of the sauna he looked like something carved. “The judge isn’t the judge,” he said. “The judge is the kid holding the money.”

Because in Vietnam—and here is the part the Discovery Channel got right and the law schools do not—the crickets were never the point. Nobody loved the crickets. The crickets were a medium. The point was the circle of other children around the arena, and the bets, and the way a half hour of someone else’s fight could be made to pay better than a half hour of your own video game. The children with the best crickets did not become wealthy. The children who ran the betting did.

“Contingency,” Russ said, and leaned back against the cedar, and closed his eyes, a man at peace.

I asked him what happens to the losing cricket.

He thought about it.

“Well, in Vietnam, nothing. It doesn’t die. People think they fight to the death but they don’t. The loser just—stops. It stops chirping. It turns around and walks to the edge of the arena and it won’t fight anymore, no matter how you shake it. You can tie a hair around it all day. Nothing. It’s done. It’s just a cricket now.”

He opened one eye.

“We call that early retirement. Or Florida. Or administrative medicine. I’ve seen a lot of them walk to the edge.”

And the winner?

“Oh, the winner goes right back in the box,” Russ said. “That’s the beauty of it. The winner proved he can fight. He’s worth more now. Insurable. Somebody’s going to want to tie a hair around that one.”

Omar, when I told him all this, did not laugh, which is unusual for him, because he laughs at almost everything, as a kind of medical necessity. He asked me instead whether the children in Vietnam ever felt bad about the crickets. I said I did not think so. I said they were children, and the crickets were crickets, and nobody had ever asked the crickets.

“That’s the part,” he said. “That’s the whole part. Nobody asks the cricket.”

Then he asked me how tight the hair has to be before the head comes off, and whether anyone had ever measured it, and I said I assumed that was the kind of thing you learned by doing, and he said yes, in his experience, it was.

Russ, for the record, is retired now. He does not keep crickets. He keeps bees, which he says is the opposite thing: thousands of them, all on the same side, and if you treat them well they make something sweet, and if you treat them badly they all come at you at once. He says he thought about going into that line of work instead, back in 1979.

“But there’s no money in bees,” he said. “Everybody knows what a bee is going to do.”


Oskar Rausch is Omar’s former cabin mate and sauna buddy. He has never been sued, tied up, or shaken, but he has been to Florida.

Negligence by Policy

A Tale of Shared Accountability

This is a work of satire and fiction.

The best and most beautiful plants are fertilized with shit.

I. The Window

The waiting room of Quaternary Risk Management had fourteen chairs, a water cooler with no cups, and a television playing the system’s commercial, in which a woman jogged across a bridge at dawn while a voice said together eleven times. A banner read: Quaternary Health. The fourth level of care. Please complete the first three. Under it, smaller: One concern per visit.

Marisol Vega had one concern. It was thirteen years old and sitting next to her.

His name was Dante. He was playing Super Mario on his grandfather’s original Game Boy, the gray brick with the green screen. It was older than Quaternary’s electronic medical record and, unlike the record, had never gone down for maintenance. The volume was all the way up. He had been told about the volume. He had considered the information and declined.

Her complaint was on the form in block letters so there could be no confusion.

In 2013 I called Quaternary for a contraception appointment. The first available new-patient visit was four months out. I took it. By the time it came, it was a prenatal visit. I would like to know who decided four months.

The form had a dropdown for Nature of Concern. None of the options was “conceived.” The closest was Parking, which was at least where it had started.

II. The Wait

Four months was not a decision. That was the first thing she would learn. It was a template.

New-patient slots were made on one side of the four-foot gap in the belt and consumed on the other, and in between they fell. The ones that survived the crossing were released on the first of the month, at midnight, to whoever was holding. Marisol had held for forty minutes, the full length of the hold music, which had been shown in trials to resolve a third of all complaints without intervention. She had not been resolved. She had been given October.

Dr. Anjali Patel saw her. Dr. Patel was told at 7:58 that it was a contraception consult and at 8:04 that it was not. She found the heartbeat. She said, “Well. Okay. Let’s do this.” She wrote the prenatal vitamins and stayed eleven minutes past the slot, which the practice administrator flagged in her quarterly throughput review. It was the only part of the process that worked, and it was the only part anyone would ever be punished for.

III. The Liaison

At 9:15 a door opened and a man in a lanyard said “Vega?” the way you say the name of a dog you are not sure is yours. His badge said Patient Experience Liaison. He led them to a room with a round table, a box of tissues, and the word INTEGRITY framed over a photograph of a canoe.

“First, I want to thank you for sharing your experience.”

“I haven’t shared it yet.”

“And I want to honor that.” He found the date on the form and did the math. You could watch him do it. “So this is outside our standard thirty-day window.”

“By how much?”

“Roughly four thousand seven hundred days.” He said it kindly. “But I’d be happy to open a new case. Our next intake is February.”

Through the wall, Dante reached the underground level. The music changed. The liaison flinched.

IV. The Ecosystem

Here is what Marisol learned over the next three hours. You cannot sue Quaternary Health, because Quaternary Health is not, in the legal sense, a thing.

It is a care ecosystem. It is a family of brands. It is a nonprofit that owns a management company that contracts with a physician group that is an LLC that leases its doctors to a hospital that belongs to a foundation whose board meets in a city none of them live in. You cannot sue an ecosystem. You can only sue a tree.

The tree was Dr. Patel.

Her name was on the chart. It was the only name on anything. She had not set the template; the template was set by a Patient Access Optimization Committee that was disbanded in 2016, in a building sold in 2019 to a company that makes dental implants. She had not built the gap. She had not recorded the hold music. She had done the visit, and done it well, and so when Marisol asked the only question she had come to ask, the liaison slid a piece of paper across the table with one name on it, and the name drove a 2011 Corolla.

This was the arrangement. The system employed the doctor, or did not, depending on which was cheaper that year. The insurer credentialed her, billed under her, and denied in her name. The system built the schedule, set the wait, decided that fourteen minutes was a visit and that a new patient could hold for a season. And when the wait produced a consequence, a missed cancer, a missed stroke, a thirteen-year-old in the lobby, the system turned, slowly and with great institutional warmth, and held the doctor up in front of itself.

She was the only one in the building with a license to lose. That was what made her useful.

Her malpractice carrier was the Policy, from the case on the executive floor: one company, mandatory, its address a post office box in the Caribbean, owned personally by Richard. It had never paid a claim. The box was four inches wide. A letter from a law firm she had never heard of went out to Dr. Patel that morning, encouraging her to contact her carrier, which was owned by the man whose system had built the schedule, which was the thing she was being sued for.

V. The Drill

At 11:20 the drilling began.

Nobody on the fourth floor had anticipated a Game Boy. The Threat Assessment Matrix covered firearms, bodily fluids, and journalists. It had nothing on an eight-bit soundtrack at full volume for three hours in a space designed to absorb grief. By ten the Chief Risk Officer had a tic. By ten-thirty the VP of Patient Experience could no longer hear the word together. By eleven a memo had gone out, and the memo had made a team.

It was called the Rapid Response Response Team, because the Rapid Response Team already existed and did something medical. The acronym was RRRT. Everyone pronounced it as a small burp.

Four physician assistants, three nurse practitioners, and a rotating squadron of Caribbean medical students, who had been issued drones. The drones hovered at a regulatory altitude of four hundred feet, from which nothing could be seen, but the students were very good at being deployed, which was the skill Quaternary had been developing in them all along. Between shifts they flew the drones south to check on the post office box. It was still there. It was still four inches wide.

The PAs and NPs were issued Nerf blasters. The blasters had been through Supply Chain, so each foam dart carried a barcode, a lot number, and a unit cost of $340.

Their mission was to protect Richard.

Richard was the Chief Utilization Officer. He had never met a patient, and it had gone very well for him. Dante was the closest he had ever come, and the formations existed to keep it that way. Whenever a Mario shirt was seen or a Mario theme was heard, the RRRT assembled around Richard in one of six approved formations and escorted him to the safe room, which was a conference room with a better canoe.

There was the Pyramid, NP on top. The Turtle, seven providers crouched with blasters out and Richard in the middle holding a latte. The Chevron, the Lotus, the Phalanx, and one a PA named Brittany invented in the first ten minutes that involved everyone spinning in place and was called, officially, the Brittany.

They were extremely good at it. These were people who intubated, who ran codes, who saw thirty patients a day under someone else’s name. Give them a drill and they would drill. Richard, who wore a velvet blazer on Mondays and favored the word groovy when he thought it would land, walked through a Turtle at 11:40 and shouted “Who IS this boy?” Nobody answered. Nobody on the team had been told. They had been told there was a threat and to form up. They had not been told why.

That was also the arrangement.

Richard was the one person in the building who could not be sued. He was the only one with a guard.

VI. The Glass

Marisol watched through the conference room wall while the liaison explained, for the third time, that the physician group was a separate entity and that concerns about Dr. Patel’s care should go to the state board.

“I don’t have concerns about Dr. Patel’s care. Dr. Patel’s care was the only part that was fine.”

“I’m hearing that.”

“I have concerns about the four months.”

“And I want to validate that the four months was outside Dr. Patel’s control.”

“Yes. That’s my point. Whose control was it in?”

He opened his mouth. In the hallway, seven providers dropped into a Lotus. A drone drifted past the window at four hundred feet, seeing nothing. On the far side of the glass, Dante found the warp zone.

At 1:00 the liaison stood, which meant the meeting was over. Marisol asked for a copy of her complaint.

“Of the complaint?”

“The one I wrote. On the form. An hour ago.”

He explained that once a concern was received, it became part of Quaternary’s quality improvement work product, which was privileged, and could not be released, including to the person who had written it, because releasing it would discourage people from writing it.

She could request her own words through Release of Information. She had not checked the box. Processing took thirty days. What she would receive was not the complaint but a two-page summary describing the complaint, prepared by a person who had not read it.

“I have it memorized,” she said.

“We’d ask that you not,” he said, and gave her a tote bag that said together.

VII. The Cafeteria

She found Dr. Patel by accident at 1:15. Dr. Patel was eating a yogurt standing up, reading the letter. They sat down together. It was not dramatic. There was nowhere else to sit.

“I remember you. You were the contraception visit.”

“I was the contraception visit.”

“How is he?”

“He’s loud.”

They could hear him from there. “They put me on the letter,” Dr. Patel said. Not quite a question.

“I didn’t put you on the letter.”

“Nobody ever does. It just arrives with your name on it. Like the schedule.” She capped the yogurt. “You know what their defense is going to be? That I should have seen you sooner. Me. One body. The physician failed to ensure timely access.“

“Can’t you leave?”

Dr. Patel lifted her ankle an inch. The chain was light. It was thirty miles long. “A fifth of my salary is in a locked box until December. My insurance is in a box in the Caribbean. I’m in this box.” She stood and put the letter in her coat. “I came here to practice medicine. I’m the padding.”

“I came here to sue somebody,” Marisol said. “I don’t think I want to sue you.”

“Nobody ever does. That’s what makes it work.”

VIII. The Survey

At 2:00 Marisol collected Dante from the lobby. The RRRT had gone to lunch, except the drones, which circled the parking structure, logging it. Richard, from inside a Turtle, gave her a thumbs up.

In the car Dante paused the game. The red light was on. Low battery. Six hours on four AAs, longer than anything in the building had gone without a reboot.

“What were you even complaining about?”

She thought about how to say it. “I made an appointment to not have you, and they made me wait so long I had you instead.”

He considered this. He was thirteen, and he was, by any measure, the strongest argument against Quaternary Health that anyone had ever carried into that waiting room, and he knew it.

“So who’s in trouble?”

“Dr. Patel.”

“The nice one?”

“The nice one.”

He turned the Game Boy back on. The music started. It was, she realized, pulling out under the drones, the only thing in the building that had answered to its own name.

Her phone buzzed before she reached the road. Quaternary wanted to know how likely she was, from zero to ten, to recommend Quaternary Health to friends and family.

She gave them a four. One for each month.

FIN