Primary care physician Dr. Sam Carter sat in his office at 6:47 p.m., the hour when medicine officially becomes folklore. His computer chimed.

Another MyChart message.

He sighed, clicked, and read aloud—because some things demand witnesses, even if there are none visibly present.

“I discovered that I made a mistake in the dosage of Journavx 50 mg tablets. I took 2 tablets at 12-hour intervals instead of 1 tablet every 12 hours. This mistake has resulted in my running out of the medication today. Should I get a refill? If so, please send it to Walgreens. I'm pleased to report that I have had minimal pain since surgery. Today I have pain at 2-3 on a scale of 10. Next to no swelling or difficulty with physical therapy.”

Sam leaned back. “Well,” he said to the empty room, “that went better than expected.”

A knock. Enter Dr. Julian Whitmore, MD, PhD, FACC, FRCP, DSc—Sam’s classmate from the Perennially Top-Five-But-Never-First School of Medicine. Sam wasn’t sure which of Julian’s letters were decorative and which were load-bearing. Julian was in town to give Grand Rounds on FDA Post-Approval Therapeutics: Bridging Evidence and Excellence.

Julian glanced at the screen and the MyChart message. “Interesting. What trial was this patient enrolled in?”

Sam didn’t look up. “The ‘Got Confused and Took Double the Dose’ trial.”

Julian smiled politely. “Ah. Non-randomized.”

“Unblinded,” Sam added. “And conducted entirely in the patient’s kitchen.”

Julian pulled up a chair. “You know, in the two pivotal FDA trials, adherence was nearly perfect.”

Sam nodded. “Of course it was. In pivotal trials, patients have calendars, pill diaries, reminder calls, and a coordinator named Maggie who gently asks how they’re feeling about compliance.”

Julian frowned. “Still, deviations like this complicate interpretation.”

Sam swiveled his chair. “Julian, my patients don’t deviate. They improvise.”

He pointed at the screen. “This guy didn’t just miss a dose. He doubled it. Accidentally. And now—against all odds—he’s doing fine. Minimal pain. Good function. Therapy progressing.”

Julian pursed his lips. “Anecdotes are dangerous.”

“So are abstractions,” Sam said. “At least my anecdote texted me and apologized.”

Julian leaned forward. “But randomized controlled trials remain the gold standard.”

“Sure,” Sam said. “Gold standard. Climate-controlled. Gated community. HOA rules.”

Julian blinked.

Sam continued. “RCTs tell us if something can work under ideal conditions. What they don’t tell us is what happens when the drug escapes into the wild.”

“The wild?”

“Pharmacies. Kitchens. Pill splitters. Spouses giving advice. Google searches at 2 a.m. People with arthritis trying to open child-proof bottles designed by sadists.”

Julian smiled despite himself.

Sam read another line. “‘Should I get a refill?’”

He looked up. “In your trial, that question doesn’t exist. In my world, it’s the entire third act.”

Julian folded his arms. “That’s why post-marketing surveillance exists.”

“Barely,” Sam said. “That’s why HEOR exists.”

Julian raised an eyebrow. “Health economics and outcomes research?”

“Exactly,” Sam said. “The science of what actually happens when nobody’s watching.”

Julian hesitated. “But it’s messy.”

Sam grinned. “Yes. That’s why it’s honest.”

They sat quietly for a moment, the glow of the screen reflecting two very different careers since graduation.

Julian finally said, “In the trial, adverse events were carefully categorized.”

Sam nodded. “Here, the adverse event is running out of pills early and asking me to fix it without shame.”

Julian glanced again at the message. “He seems… reasonable.”

“He is,” Sam said. “He made a mistake. He told me. He didn’t hide it. He didn’t end up in the ER. That’s a win.”

Julian sighed. “You know, we exclude patients like this from trials.”

Sam smiled. “I know. I treat them.”

Julian stood. “Perhaps we should collaborate.”

Sam raised an eyebrow. “On what?”

Julian gestured at the screen, then paused, as if recognizing a slide from his own talk. “Studying what happens after approval. In real life.”

Sam clicked “Reply.”

“Sure,” he said. “But first I’m refilling the prescription.”

He typed:

Thanks for letting me know. These things happen. I’ll send a refill. Please go back to one tablet every twelve hours.

He thought for a moment, then added:

Glad you’re doing well. Keep up with PT.

Julian watched him send it.

“No consent form?” Julian asked.

Sam shut the laptop. “Already obtained,” he said. “It’s called trust.”

They walked out together, leaving behind the tidy certainty of trials and stepping back into the data-rich chaos of actual medicine—where mistakes happen, people adapt, and evidence doesn’t live in locked databases so much as in messages sent at inconvenient hours.

Out in the wild.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia. He is the author of several books on narrative medicine and the fictional series Real Medicine, Unreal Stories. His latest book, a novel, is Against the Tide: A Doctor’s Battle for an Undocumented Patient.