He stands at the intersection of two major streets, by a gas station.

Disheveled, holding up a cardboard sign.

“REPENT.”

People drive past him as he walks back and forth, restless as a caged panther.

I come to a stop as the light turns red.

He makes eye contact with me. 1/

Sir William Osler said that medicine is a science of uncertainty, and an art of probability.

I think about this more and more as the years go by.

Wrapped within Osler’s truth is another, more painful one.

To know Medicine is to know loss. 2/

I know many people will disagree with me.

How can medicine be loss? How much good has medicine done? How many lives have been saved?

I don’t doubt this for a moment. Medicine has done vast amounts of good.

To heal and be able to heal, is a privilege, and a gift.

But... 3/

Early in my career, I’m taking care of a patient (details have been changed).

He is an elderly gentleman with a kind disposition and sense of humor. He possesses that great gift of being able to intuitively put things in perspective.

At today’s visit he has many questions. 4/

During the course of a workup by his primary care physician, the patient was found to have an aortic aneurysm, dangerously large.

Surgery has been recommended.

He is asking for my opinion.

His kidneys are in good shape. I briefly go over the pros and cons. I recommend it. 5/

I don’t ask him what his thoughts are. I don’t ask him for his concerns.

He is the last patient on a busy Friday afternoon.

I tell him that if his PCP and a vascular surgeon are recommending it, I’m okay with it too.

He nods, and I can tell he wants to ask me something. 6/

I don’t create the space he needs. I quickly ask if there’s anything else, while I close my laptop.

It is the first time I have ever rushed him. I think he senses it, because he swallows his question and gets up to leave.

I feel a twinge of regret. But I’m exhausted. 7/

Before he leaves, he shakes my hand. “Always a pleasure, doc. God bless you.”

Those are the last words he will ever say to me.

The surgery is complex, and he develops a host of terrible complications.

The day he dies, I feel strangely numb.

God bless me. God keep me. 8/

The cruel irony of medicine is no heights of success can ever compensate for the depths of loss.

The euphoria that comes with saving a life can last for days, weeks, perhaps months.

The heartbreak never leaves you.

Medicine is life.

Life is often a lesson in letting go. 9/

I’ve been having dreams.

Manifestations of regret, perhaps, or loss.

In my dreams I see him again. I see myself, rushing through our last appointment.

I wish I had been his doctor, instead of his clinic conductor.

Maybe things might have been different, had I listened. 10/

Success is a wonderful cheerleader. It will breathe life into you. It will lift you.

Loss is an unforgiving teacher. It will humble you. It will strip you down. It will open your eyes.

I have made mistakes in my career.

Those I know of, I remember.

Every one. 11/

In my dreams I know what the outcome will be, and it’s maddening to watch myself rush into it.

I suppose now I know what climate scientists feel like every day.

Or infectious disease specialists watching crowded pools.

There is no dread like the needlessly inevitable. 12/

You learn to compartmentalize early in medicine. You learn to be systematic, to perform complex decision-making at a high level. You learn to be proficient with vast amounts of data.

Nobody teaches you how to seek forgiveness, or how to forgive yourself.

How to grieve. 13/

At the intersection, the man holding the sign makes eye contact with me.

He screams, “REPENT! Or ain’t nobody gonna forgive YOU!”

His eyes blaze with a wild fervor.

I wonder if he knows.

As the light turns green, I drive away, towards an absolution that may never come...