Life Lessons

Gravely ill patients teach medical students about listening and compassion.

Steve Cappiello, his life changed by “a hunk of plastic,” and student Patrick Codd.Portrait by Mark Ostow

In a room where somber faces are the norm, Steve Cappiello is beaming. The tall, muscular 36-year-old points to his feet with a kid’s delight and declares, “Today was the first day I tied my shoes in a year. It sounds small, but it was big for me. I never thought a hunk of plastic would change my life as much as it has.”

Cappiello is referring to the prosthetic left arm he has been awaiting for months, since losing his limb to cancer. For this once-hardworking day laborer from Brockton, Massachusetts, the “hunk of plastic” offers a chance to regain independence, support his family, and feel useful again. No longer will he need to ask for help buttoning his pants or tying his laces.

“That’s awesome,” Patrick Codd says as Cappiello bends the cabled arm and maneuvers its hooked hand. Codd, a medical student, has also been looking forward to this moment, having witnessed Cappiello’s emotional low during the weeks before his insurance company approved coverage for the prosthesis. The harrowing story began in the summer of 2003, when a glass pane fell on Cappiello’s hand and broke some bones as he removed lead paint from an historic home. The tennis-ball-sized mass that soon ballooned on his wrist caused round-the clock pain that he claims was ignored by his community doctor for several months, yet drove Cappiello to puncture the growth with a nail and run it under scalding water to relieve the ache.

When it was finally diagnosed as sarcoma, the cancer had already chewed through his bones; his oncologist believes it was probably present before the injury. After several rounds of chemotherapy and radiation, and hours of surgery to reconstruct his hand, another mass appeared on his arm—which Cappiello agreed to have amputated above the elbow.

Now, as they sit in an examination room at Dana-Farber Cancer Institute in Boston, where Cappiello eventually came for treatment, Codd probes Cappiello’s anger at the months lost before his diagnosis, as well as his fears about the future. “Every day I pray to God that my kids don’t get cancer,” he says.

This is a scene that could easily be played out between a physician and his patient. But Cappiello is not Codd’s patient; he is his teacher. The two were matched as part of a Harvard Medical School (HMS) class called “Living with Life-Threatening Illness,” which pairs first-year students with individuals facing grave conditions to give the future doctors an intimate view of the patient-family experience. For the past 11 years, students in this elective have learned lessons not easily found in a textbook—about how to connect with patients and become, in the words of course co-director and associate professor of psychiatry Susan Block, “a healing presence in the face of suffering.”

Codd, a clean-cut, 23-year-old redhead from Colorado, was one of 19 students who enrolled in the course last spring. The three-pronged class features meetings with patients (in homes, medical settings, or wherever else they choose), weekly small-group discussions with faculty members and fellow students, and lectures covering such topics as spirituality, hospice services, and cross-cultural care. The accompanying reading list includes poems, essays, and popular and academic articles by leaders in the field, such as professor of psychiatry Edwin Hughes “Ned” Cassem, Recanati professor of medicine Jerome Groopman, and Rachel Naomi Remen, the California physician and best-selling author of My Grandfather’s Blessings.

On one level, “Living with Life-Threatening Illness” is about the simplest of concepts: how to say hello, say goodbye, and listen. But by tackling issues so often avoided, the course also helps at least a handful of trainees become more comfortable with death and dying as they begin evolving from laypeople into doctors. This comes at a time when patients and families increasingly seek better end-of-life and palliative (comfort) care for themselves and their loved ones.

In an article in the New England Journal of Medicine last September, Block and associate professor of medicine J. Andrew Billings, her husband and the course’s co-founder, explained how the class prepares students for providing end-of-life care. “Foremost, their tendency to avoid the sadness, hopelessness, and helplessness they had associated with dying persons,” they wrote, “is replaced by a sense of the approachability of the dying, an interest in the medical, psychosocial, and spiritual aspects of ‘the case,’ and a belief in the possibility of doing good work through such encounters.”

From February to May 2005, amid the national furor over brain-damaged patient Terri Schiavo’s right to live or die and the lingering death of Pope John Paul II, Codd and his fellow students traveled down an emotionally challenging path as they explored their own feelings about mortality and pondered such questions as, “What would be most important and terrifying to you if told you had six months to live?”

By putting themselves in their patients’ shoes, the students grasped the value of hope and the need for seriously ill people to set realistic goals—like attending a child’s wedding or graduation. They discovered the power of teamwork to solve problems and to support one another in the future as physicians facing enormous professional pressures. Perhaps most important, the group learned that even when a patient has no more known chances for cure, the expression “There’s nothing more we can do” is never acceptable.

“Sitting down with a person and talking about real things is one of the most rewarding experiences in medicine,” says associate professor of psychiatry Marshall Forstein of the Cambridge Health Alliance, who has taught in the course for many years. “Students learn that the time you take to sit at the bedside of a patient who’s about to undergo surgery and say, ‘I came to see how you’re doing,’ is what’s important. Your technical skills are important, too, but patients thirst for connection.

“Medicine has become so technology-oriented—do, cure, fix—that we’ve lost sight of the fact that the most important part of the job is caring for people,” Forstein adds. “We want students to learn more about themselves as people, rather than about the tools they have to offer patients.”

Patrick Codd signed up for the course to balance his classroom learning about physiology and ion transfers with down-to-earth conversations with patients. He wanted to learn these skills to emulate his grandfather, a retired “black bag” doctor who Codd says could walk into a room, listen quietly, and then say “the perfect thing” to make his patient feel better. The aspiring neuroscientist, who is enrolled in a joint medical program at Harvard and MIT (see sidebar, “Courses of Study”), spent hours talking with Cappiello in person and by phone. The differences in their socioeconomic backgrounds were overshadowed by their common purpose: to make Codd a better doctor. “The stories Steve related to me of his suffering were heart-wrenching,” Codd reflects, “and will forever shape the way I see people in pain.”

Matthew Newnan’s room on the eighth floor of Children’s Hospital Boston exudes as much personality as the six-year-old patient who occupies it. The small space is jammed this April afternoon with toys, cheery drawings, and likenesses of Pooh and Tigger painted on the window. Matthew sits on the bed with his mom as nurses stop by in turn to adjust the bags and tubes cascading from his IV pole. Normally a vibrant boy who commands the hospital hallways with his charm, Matthew today is uncomfortable, teary, and eager to nap.

First-year student Mark Hanudel sits by Matthew’s bed and tenderly rubs the boy’s shoulder as he reclines. Matthew takes off his glasses and hearing aids with his mother’s help, cradles two stuffed animals, and says, “Night, night.”

Taking advantage of the quiet spell, Hanudel asks Erin Newnan about her yearning to reunite Matthew with his two sisters and father at home in New Hampshire. She shows Hanudel the binder detailing her son’s medications, allergies, dressing-change schedules, and other aspects of care for microvillus inclusion disease, a rare gastrointestinal disorder that has left Matthew with severe diarrhea and hearing loss, and hospitalized him for long stretches. It even led the family to relocate temporarily to Pittsburgh for his liver/intestine transplant and recovery. “Now, instead of predicting the future,” Newnan tells Hanudel, “we go month to month, day to day.”

Even though the gravity of Matthew’s condition weighs on her emotionally, physically, and financially, Newnan’s commitment to her son—including sleeping on an inflatable bed in Matthew’s hospital room for months—are seared into Hanudel’s memory. “What observing the Newnans has shown me is the extent to which people will fight for something they love,” says Hanudel, a North Carolinian with a warm and easy manner who wants to go into pediatrics. “Witnessing Erin’s steadfast determination to celebrate Matthew’s life each day in the face of his debilitating illness was a remarkable experience. I’ve seen how nothing is insurmountable, and how people are capable of extraordinary things.”

Through the course, Hanudel and his classmates discovered the extent to which illness causes loss: of physical ability and looks, of self-esteem and control. Patients often had trouble planning because of the ups and downs of treatment; “I was supposed to meet my patient this week, but she was too tired to get together” was a common refrain. As the weeks passed, some of the patient volunteers in declining health came to accept their fate, while others remained hopeful or went from death’s edge to improved health. A few died.

The trainees discovered that every patient differs in his or her degree of openness, hunger for information, level of spirituality, and ways of coping; while one prays, another crawls under the covers to cry. Hope, they learned, is not always for a cure, and strength can mean acceptance—not just fighting one’s illness until the very end. The students saw the key role that doctors often play in patients’ lives, and they repeatedly called it a “privilege” to be with people at such a meaningful time.

Patients who assist in the course are recruited by the “Living with Life-Threatening Illness” faculty, and matching is done to maximize diversity (of diseases, ages, and willingness to open up) within the small groups, enriching the weekly discussions as students share what they’ve learned from their patients. Last spring, each group had six or seven doctors-to-be and two experienced physicians to guide them.

While some student-patient pairs hit it off immediately, others struggled to click. Andrew Billings, who co-leads the HMS Center for Palliative Care with Susan Block, believes those rocky relationships will help these future doctors prepare for careers in medicine, when they will see hundreds of patients, only some of whom will want to connect. “They realize that even if they don’t bond closely, there is much to learn from and offer to such patients,” notes Billings, who also directs the Massachusetts General Hospital Palliative Care Service.

Mistakes are turned into learning opportunities during the “Living” course. The students are encouraged to apologize to their patients if they say or do something seemingly inappropriate, and then to relate the awkward moment during class. Many of them also learn “don’ts” from their patients. Course alumna Kemi Babagbemi, M.D. ’98, is a diagnostic radiologist specializing in breast imaging and ultrasound at Boston’s Brigham and Women’s Hospital. She still carries lessons from her patient: Show your human side, try never to deliver bad news over the phone, and have the patient repeat what you’ve said to ensure that he or she understands it. “Be as clear as possible with the facts, but never take away hope till you have nothing else,” Babagbemi says. “If there’s a 95 percent chance that it’s cancer, there’s still a 5 percent chance that it’s not.”

For physician-in-training Mark Hanudel, “Living with Life-Threatening Illness” showed how each patient’s life extends beyond the hospital walls, and how important patient-caregiver communication can be. To underscore her family’s desire to have Matthew discharged as soon as possible, Erin Newnan posted a letter from one daughter on his hospital door and medical charts. “Dear Doctors,” it read. “My birthday is April 16th. I’m going to be 10. For my birthday it would be the best present if you could get Matthew home. I am going to ask God, too. Sincerely, Jessica Newnan.” Jessica nearly got her wish: Matthew headed back to New Hampshire in late April.

Areej El-Jawahri recalls vividly the moment she realized her medical calling. The year was 1991, and she and her family were still living in Baghdad. Her aunt was about to give birth, so eight-year-old El-Jawahri accompanied her dad and youngest uncle to the hospital. There, the screams of pain, tears, and blood from adults and children injured in the then-unfolding Persian Gulf war left an indelible mark.

“There wasn’t enough space in the hospital, so everyone was in the hallways,” El-Jawahri recounts. “I remember there was a young-looking man holding a bowl of ice with the remains of his left arm. He was screaming, and nobody was taking care of him. I sat next to my uncle and whispered in his ear that I really wanted to be a doctor. He said, ‘Why?’ and I said, ‘Because I want to help all those people out there.’ He sat me in his lap and said, ‘Then you’ll be the best doctor in the world.’”

El-Jawahri and her family left Iraq several years later and in 1997 immigrated to the United States, settling in Michigan. While attending the University of Michigan, her passion for medicine was strengthened by two encounters with death: watching a close friend perish after a hit-and-run car accident, and the loss of that same uncle to lung cancer.

“He died at age 39 and was one of my best friends,” El-Jawahri explained to her small group on the first day of class. “My family saw that I was really good at taking care of him, and I’m trying to see if this is a field I’d like to stay in. It seems amazing that people can have so much strength and willingness to survive in these kinds of situations. It puts life into perspective and makes me feel, ‘So, we have an exam tomorrow. Big deal.’”

Paired with a 60-something woman with metastatic breast cancer, El-Jawahri chatted with her by phone and in the hospital and hospice center, observing the seesawing of her patient’s health and emotions. They became close, shed tears together, and talked about everything from what the woman was reading to how she wanted to be remembered.

That kind of bond was what course founders envisioned when they conceived what would become “Living with Life-Threatening Illness” in the fall of 1993. Then-students Anne Hallward ’88, M.D. ’97, and Joshua Hauser ’89, M.D. ’95, had independently concluded that more instruction around end-of-life situations was needed at Harvard, preferably before students began immersing themselves in direct patient care. Hauser, for his part, wanted to learn more about helping dying patients cope because of encounters with two gravely ill patients during year three of medical school. He took the next year off to focus on medical ethics and communications, and discovered that Hallward was also exploring end-of-life-care teaching. Her interest stemmed from her work before medical school as a hospital chaplain in Washington, D.C., accompanying doctors as they broke bad news to families of trauma victims. Many physicians were anxious and unprepared, of-ten fleeing the room after uttering the words, saying them abruptly, or being uncomfortable around the families, she recalls. “I came to Harvard thinking, ‘Wow, doctors really need more help with this, and I wonder what and how they are learning about it.’”

The pair met regularly in late 1993 and early 1994 and designed their “dream curriculum,” then sought out supportive faculty members, including Billings and Block, now chief of psychosocial oncology and palliative care at Dana-Farber and Brigham and Women’s Hospital. Hallward and Hauser worked with this small group to refine the curriculum, which debuted in the spring of 1995, and then taught for several years in the course. Although originally dubbed “Care near the End of Life,” it was soon renamed to reflect the fact that it was as much about living as about dying.

Although it is one of only a dozen or so such classes in the country, “Living” is part of a growing trend that has its roots in the teachings of the late Elisabeth Kübler-Ross (author of On Death and Dying) and many others. Medical schools have made dramatic progress during the past five years in exposing students to end-of-life issues, notes Diane Meier, director of the Hertzberg Palliative Care Institute at the Mount Sinai School of Medicine in New York City. She and fellow authorities say that is largely due to the proliferation of hospital-based palliative-care programs, where students can train, and to factors including reports by the National Institute of Medicine and others calling for change, funding from such organizations as the Robert Wood Johnson Foundation, debates over assisted suicide, new medical-training requirements, and—not least—demand by patients and families.

Despite this shift, Harvard investigators and others have found significant gaps in medical-school curricula and powerful forces countering the trend. The “physician culture” has long focused on diagnosing ailments and extending life, while considering death a personal and professional failure. That “hidden curriculum” of values and attitudes is widely conveyed to doctors-in-training, Billings and Block say, especially during their hurried third and fourth years on the wards. Once in practice themselves, these physicians may avoid discussing death for fear of dashing a patient’s hope.

At the same time, many Americans hesitate to raise the “D-word” with their loved ones or with their healthcare providers. “Research shows that most people have strong feelings about how they want to die,” observes Block. “But sometimes patients don’t share their feelings with doctors because they’re afraid the doctors will give up on them, or that they’ll be perceived as having a bad attitude.”

In a 2004 survey of medical-school deans around the United States, Amy Sullivan, Ed.D. ’97, of Dana-Farber, and her colleagues found that most of the 51 administrators responding described end-of-life-care education as “very important.” But few schools offered extensive training, and two-thirds of the respondents felt not enough time was devoted to this area. Within the field itself, viewpoints differ about whether the material is best woven into the curriculum or concentrated in a separate course, and whether the first year is the best time to impart these skills. Many concur, however, that these concepts should be reinforced throughout the four years of medical school and beyond.

“I agree that if the material is not reinforced, [a course like this] is just a feel-good exercise,” comments Hauser, who specializes in palliative-care education and is now based at Northwestern University. “On the other hand, if it is reinforced, it’s pretty special. And to be reinforced, you need to have a spark in the beginning.” Beyond providing a spark, “Living with Life-Threatening Illness” helps students find balance in their conversations with patients. “Just because someone is dying or has a serious illness doesn’t mean that’s all they want to talk about,” he says. “I remember different moments in the course where we went over people’s visits with patients and said, ‘How much time did you spend talking about his/her illness?’ And someone said, ‘We barely did. We went out for coffee and talked about the Red Sox.’ And that was probably even more valuable than talking about the illness.”

At Harvard Medical School, “Living with Life-Threatening Illness” has remained relatively unchanged over the years, enrolling from 20 to 50 students (out of 165 in each first-year class). An early study indicated that the course helped participants feel more comfortable with dying patients, and both student evaluations and anecdotal evidence suggest that it has had a powerful influence on its graduates. “The course gave me a template for how to talk about intimate things with patients,” says fourth-year M.D.-Ph.D. student Mauro Zappaterra, who, like many enrollees over the years, was inspired to consider oncology as a specialty. “It is the only course I’ve had that really taught me about caring. I learned that if I keep being open to hearing patients’ stories, I won’t burn out.”

Faculty members also find the experience rewarding. An impressive number—drawn from various disciplines and Boston-area institutions—contribute their time each year, allowing for close student-faculty contact. Some professors have taught in the course for many years, and pediatric oncologist Jennifer Mack, M.D. ’98, also took it as a student.

When the class was launched in 1995, organizers worried that they’d have trouble recruiting patients, but the opposite has been the case. “Patients want to do this,” explains Susan Block. “When you’re sick and dependent and vulnerable, you feel diminished as a person. Being a teacher is a way to feel you have something to offer, to contribute to the world and express your gratitude to the healthcare system that has helped you. It’s an opportunity to leave a legacy to the next generation of doctors.”

Erin and Scott Newnan and their family signed on twice and, like other patient-family volunteers, found several benefits. “It’s a great experience to have someone like Mark [Hanudel], with the time to sit down and hear some of this story,” Erin said at the end of one hospital visit. “Because when you’re a doctor and you’re in and out of a room, you don’t get the full picture. I hope this type of class catches on at other institutions. The medical community will be better for it.”

A similar desire to impart her knowledge drove 55-year-old Margo Figueredo to volunteer while undergoing care for end-stage pancreatic cancer. She and her family welcomed student Micah Berry into their home in Mansfield, Massachusetts, and introduced him to numerous relatives and neighbors. Figueredo described her cancer journey and even told Berry one day that she sensed the end was near; two weeks later, she died. At her funeral, family members shook Berry’s hand and thanked him for being part of Margo’s final weeks.

“When Dr. Block mentioned the course to Margo, she just jumped at the chance. She got her joy from being with others and helping,” said widower George Figueredo. Teaching Micah “gave her the sense that she could still have a purpose. We just opened up our hearts and souls to him.”

It’s a raw April morning, and Teresa Kim and Sopheavy (“so-pea-vee”) Seng grab a booth at the Red Rose, a Cambodian-Thai-Chinese restaurant in Lowell, a mostly working-class city north of Boston. It’s one of many meetings these two young women will have during the semester. Seng is a 19-year-old Cambodian immigrant who was treated for nasopharyngeal cancer (in her nose, throat, and brain) while in high school, then later found herself coughing up blood from a terrifying gastrointestinal illness related to schistosomiasis. “She’s only 19, but she’s lived 20 lives of experiences,” says first-year medical student Kim, who is close in age but has never faced a medical crisis, let alone two.

Over pad thai and fried rice, they talk about Seng’s family, her college classes and grocery-store job, the side effects of medication, God and fate, and the teen’s own desire to become a doctor. Seng’s cheerful disposition masks the profound sadness and isolation this slight young woman feels as she struggles to maintain hope amid her uncertain future. “Before my cancer treatment I felt, ‘I’m young. I have a lot of time,’” Seng tells Kim. “After all that has gone on, I say, ‘You know what? You never know what’s going to happen.’ So whatever I want to do, I do it. If I want to go to the mall or see a movie, I go.” Kim nods supportively and says, “I wish I could live like that. You get a lot out of every day that way, instead of putting things off till next week or next summer or next year.”

The conversation seems comfortable, as if between two friends. At the same time, as Kim poses questions between bites, this thoughtful Korean-American student from Connecticut is practicing some of the interview tips gleaned in the course. Use a patient’s own words. Be comfortable with silence. Take cues from your patients.

“When you’re sitting with a patient, you can be so concerned with your questions that you’re obsessing about what you’re going to say instead of listening,” noted instructor Marshall Forstein during one small-group session. “Train yourself to pick up on the thread of a patient’s story.” To Forstein, the doctor-patient relationship is a contract of sorts between two people trying to solve a medical puzzle. “In some ways, you’re a plumber,” he explained. “You’re trying to find the source of the leak.”

Part of the quandary involves looking beyond the symptoms to the cultural, religious, social, and psychosocial context in which the patient (and his or her family) experiences them. “Students learn to elicit and value the patient’s perspective and come to understand that each person’s approach to dealing with illness is unique—a fundamental tenet of a patient-centered approach to doctoring,” Block and Billings stated in their article. “And they have an opportunity to understand how their backgrounds both inform and obscure their appreciation of others and to reflect on, and modify, their own values and beliefs about life, death, and dying.”

To appreciate the impact of Seng’s cancer diagnosis, for instance, Kim had to grasp the family’s shock after doctors found cancerous tumors in Seng’s throat. Because Seng and her parents spoke mostly Khmer, they relied on her eldest brother to translate. “When they heard the word ‘cancer,’ they did not think, ‘disease of excess cell proliferation,’” Kim wrote in her final paper for the class. “In contrast to this biomedical-ized meaning, the word ‘cancer’ to them carried a much more frightening, fatal, and stigmatized meaning—it seemed to mean one of the most terrible things in the world that could ever happen to you.”

More exposure to various perspectives came from the students themselves. The 19 members of last spring’s class included the privileged children of doctors and the son of a recovering heroin addict. Students represented a spectrum of religions and cultures, and when not in class, some organized hunger walks or book drives or danced in the first-year talent show. Like El-Jawahri, many had already encountered death or serious illness through the experiences of a relative or friend, or while on the job before medical school.

The hope is that “Living,” combined with their other classroom and textbook learning, will add humanity to their professional personae, so they’ll see patients as people first and death as a natural part of life. And they’ll have a richer vocabulary to tap when, for example, a patient has visibly gone downhill. “Never lie to your patient,” Forstein advises, “but be gently honest: ‘Boy, it’s hard for both of us to see you like that, but I’m not afraid to come see you.’”

In Teresa Kim’s case, the class underscored how difficult it is to understand another person’s physical, emotional, and spiritual pain, as well as how strongly someone can hold on to life in the face of overwhelming disease. “I still have much to learn about compassion and how to connect with patients without completely losing myself in their suffering,” she says. “But Sopheavy has shown me how to really listen and bear witness, not only to her suffering, but to the strength of her spirit.”

For the final session of “Living with Life-Threatening Illness,” each student is invited to bring in something meaningful—a poem, song, or thought—as well as a flower representing his or her patient relationship. Sitting around a conference-room table at Dana-Farber, the students and faculty members prepare to take turns reflecting on what they’ve learned during the semester. The patients are absent, but they are a strong presence. 

Matthew Zerden, a first-year from Georgia whose 36-year-old patient had recurring cervical cancer, is the first student to speak during this touchy-feely, though fitting, conclusion. “Thank you for teaching me what it’s like to live with a complex illness, especially being diagnosed at a young age,” says Zerden, who watched his patient go from anguish to relief after she opted for hospice care. “For teaching me what it means to wake up and not be able to get out of bed, to struggle with pain and addiction [to pain medication]. To help me re-appreciate my own life, to realize that most of what I complain about is mundane, and to remember that life really is wonderful.”

Zerden places his flower in a large glass vase at the table’s center, which gradually fills with tulips, sunflowers, and roses to form a vibrant bouquet. One student recites an Auden poem, while another shares one in her native Chinese. A third student passes around pictures of “Warhammer 40,000” miniature soldiers in honor of her teenage patient, with whom she eventually bonded through his hobby. “I’m fortunate and privileged he’s let me into his world,” she says. The faculty members also take turns expressing their emotions, one by playing the banjo. The students thank their patients for their time, wish them peace, and promise to remember them. It’s clear they have absorbed valuable life lessons about resilience, hope, and the fragility of life.

Although some continue seeing their patients for weeks, months, and even years, most heed the course guidelines and end their visits by May—despite the awkwardness of the break. Faculty say the process of saying goodbye and thank you is a critical one that allows the students to say, “You’ve been an important teacher and I’ll carry you with me in my practice.” They also hope it will spur patients to have similar conversations with their own family and friends.

“You give patients an enormous gift by consciously saying to them, ‘This is the last time I’m going to see you, and I want to tell you what you’ve meant to me,’” course co-founder Anne Hallward, now a Maine-based psychiatrist, remarked in an interview. “So often, people who are dying don’t get that experience because people don’t know how to bring it up.”

For their final meeting, Kim had given Seng a copy of The Alchemist, a fable about a shepherd who follows his dream, as well as a journal to help the young refugee document her fears and hopes. Seng, in turn, offered the medical student a dollar bill she had painstakingly folded into a pair of cranes, resembling two people talking. In an e-mail message in June, Seng said she enjoyed sharing what she knows about being seriously ill, and also learned from Kim’s questions. “It is hard for me to say ‘goodbye’ to a friend,” she wrote, “especially one I can talk to and who understands me.”

In early June, Patrick Codd bid farewell to Steve Cappiello. He left him in much better spirits than when they’d met four months earlier; with the help of his healthcare team, family, part-time job, and prosthetic arm, Cappiello had pulled out of his funk. But Codd realized his full thank-you would have to wait, and he described their parting this way: “As I stood there in the lobby at Dana-Farber thinking back on these experiences, watching Steve walk away swinging his new arm with regained confidence, I finally realized why my last thanks to him felt incomplete. I could only give Steve half a thank-you. The other half will have to wait for 10 years from now, when I am the doctor seeing a patient complaining of pain…and don’t listen to my peers who insist the complaint is drug-seeking behavior, or something the patient should simply be able to ‘tough out.’

“My medical practice will forever be shaped by the hard-bought lessons that Steve so graciously shared with me,” Codd continued. “It is because of this heartfelt gratitude that I had to laugh a little when at our last meeting he asked, ‘So, do you think any of this helped you at all?’ I replied with all honesty, ‘Steve, you were the best teacher I have had.’”


Debra Bradley Ruder, an editor at Dana-Farber Cancer Institute and a freelance journalist, has written extensively about higher education and healthcare issues. She is working on a book about conversations at the end of life.

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