The Hidden Curriculum

They really don't teach you much about dying in medical school. Why should they? Isn't the goal of a physician to cure? After all, isn't death "the enemy"? 

This is the dogma that I have been pushing back against for much of my medical career. Of course, I began to learn this from my patient Mary, who has been my most profound teacher. Once she opened that door, every patient I have cared for on their journey home has added to my understanding that death is not the enemy; it is the unavoidable process we all will experience. So many other sources of wisdom, mostly outside of the medical domain, have deeply impacted and broadened my understanding of death (and life).

There have been a few physicians that have validated my growing realization that our opportunity, our duty, our privilege as physicians to be at the bedside of a dying patient needs to be honored, not hidden or denied. One of these physicians is Sir Willima Osler, the "Father of Modern Medicine” (1849-1919),  who recognized, taught and applied his insight of the healing presence and comfort of a physician who did not abandon a dying patient, and who understood (as I do now) that the dying process is primarily a spiritual one, not a medical one.

Perhaps it was this thread in my growth as a physician that caused me to be so impacted by what I learned in Boston in 1999. Invited to be one of the inaugural class of the Palliative Care Education and Practice fellowship at Harvard, I witnessed the impact of a unique approach to medical education at Harvard Medical School. They had the vision and audacity (sarcasm) to introduce half of their first-year medical students (M1) to a terminally ill patient as their initial experience in medical school. Imagine that. They turned traditional medical education on its head. Instead of denying death and not teaching about it, they told these young physicians to model Dr. Osler and use that as a foundation of their physician calling.

 Very long story made short, when I returned to NEOMED and Aultman Hospital, I used that inspiration to create a modified experience for our medical students. They were invited during their 3rd year of training (M3), while in their Family Medicine clerkship, to pair with a hospice patient at home under the guidance of a hospice program. This involved at least three visits to meet, talk with, and develop a relationship with a dying patient. In addition to attending didactic sessions, we also asked them to write a reflective essay about the experience. This curricular experiment flourished, as did the essay component. These essays consistently revealed themes about this student-patient relationship (the idealization of the interaction between "the dying are our teachers" and "WE are the medicine").

Throughout all of these subsequent years, I have been deeply moved by the number of students that wrote that this experience was career changing and life changing. I cannot remember one essay that was simply a book report or superficial; they all have been written from the heart and with intention.

I have been privileged to read many that were truly inspirational. Recently, however, I read one that was somehow above the rest. This essay, included here with the student’s permission, is skillfully and beautifully written and opened my eyes to an aspect of how "being present" with a dying person isn't so much about the dying, it is about sharing the hum of the interstate and the arguing of the blue jays.

Sun on the Patio

By Varun Nagendra 

The interstate hummed beyond a thin line of trees, and blue jays screeched in the woods just beyond the small backyard of trimmed grass. The home health aide and I sat under the umbrella’s shade, while Ed lounged quietly in his wheelchair under the blazing sun. He wore a sweater and warm sweatpants, hands resting on his lap. I remember thinking, clinically, about blood thinners and cold sensitivity. I also remember thinking to myself that the small, quaint green backyard was excellent for birdwatching, a pastime that I had recently developed. The woods lining the back perimeter were shallow but dense. They neatly kept the busy interstate and noisy world from metastasizing into the quiet, personal conversations that were to be had. Hospice was not to take place in the confines of beige walls and linoleum floors. Instead, it would be surrounded by the ordinary light of a neighborhood with ranch houses and squirrels. It would not be orchestrated by the blatant grief I had come to expect, but rather by quiet contentment, good stories, and sunny weather.

Before our first visit, I skimmed the clinical briefing sent to me by the social worker in the email: Edward “Ed” O’Connor, 87-year-old male with a history of CHF, CKD IV, atrial fibrillation on Eliquis, vascular dementia, hypertension, anemia, arthritis, and hyperlipidemia. Recently offered hemodialysis but declined. Multiple admissions this year, most recently for CHF exacerbation. PPS 40, KATZ 1. Many of the terms I was familiar with. Others hinted toward the unique realm of geriatric, palliative, and hospice care.

I promised myself I would show up open, not hiding behind my natural reflex to try to fix everything like always. That sounded noble in theory. In practice, I promptly noticed a suspicious keratotic papule near his right inner canthus and my brain jumped to UWorld lines of thinking:…keratoacanthoma, volcano like, keratin plug in the center, risk for malignancy. Then the reality of hospice tapped me on the shoulder. If it doesn’t bother him, and it won’t change the arc, it’s not the point. The point was the man in the sweater, asking to be in the sun.

 “Hi Mr. O’Connor, my name is Varun, I’m a student physician with Western Reserve Hospice. It’s a pleasure to meet you.”

He gave me a look of brief confusion followed by indifference. I interpreted it as “the more the merrier I guess.” I was unsure how to proceed. It must have been painted across my face because the home health aide dove to my rescue by introducing himself.

His name was Dave, and he told me that he had joined Ed’s journey around a year prior. In addition to helping Ed with his medications, pushing his wheelchair, and even giving him haircuts, Dave appeared to have taken on the role of friend. Their conversations weaved between banter, teasing, reminiscing, jokes, and most importantly, silence. Not the awkward kind that I expertly brought forward a few moments prior, but the comforting kind. The silence that says, “I’m here if you need me.” The silence that says, “alone but not lonely.” The silence that I aspired to replicate myself.

Interestingly, Dave had also become somewhat like Ed’s personal library. Over the past year, he had collected and remembered the details of Ed’s life as dementia slowly thinned his ability to retrieve them. I asked Ed if he had broken any bones before and he would look down and furrow his brows, trying to dig through the patchwork of memories that had been left behind. After a few moments, Dave would gently supply the memory. He also carried a teacher’s patience. He’d previously worked as a surgical assistant and, unprompted, offered me a curious trio of survival skills for navigating the operating room during my upcoming surgery rotation: know your anatomy, know your music, know your cars.

By this time, Ed appeared to have become accustomed to my presence. Soon, he was unspooling a Cleveland childhood that could have been a movie. Young Ed was reckless and adventurous. A lifelong Clevelander, he had touched the edges of the mob without ever getting lost inside it. He was Irish, but apparently the Italians didn’t mind if he were around. Restaurants would kick patrons out just so he could be seated faster. He loved scuba diving. He loved dancing even more…

“…with beautiful women, especially when you could hold them by the waist,” he clarified, smiling sheepishly like a child.

He made a point to disclose how he hated modern “dancing.”

“They just jump up and down! That’s not dancing!”

He told me about a night a woman invited him to dance and then started pogoing. He thought she’d lost her mind.

He hated Robert De Niro for some reason, and he admitted he’d run from the cops once, was caught, then released the next day because he was Irish. The way he told it, life had been brash, immediate, and often fun. He didn’t tidy up the stories to make them respectable; he told them like he had nothing to lose. And well, to that point, I guess he didn’t.

The three of us also found an easy, unexpected bridge in World War II history. Band of Brothers led to The Pacific followed by conversations about Hacksaw Ridge and Desmond Doss. Dave shared that his father had been a B-17 crew member. I recommended the new HBO miniseries Masters of the Air because it neatly fit the rhythm that they already had. Dave routinely asked Ed what movies he wanted to watch, then picked up the respective DVDs from the local library. They would then watch them together while Ed did passive motion exercises.

For a moment my mind drifted back to exam algorithms—passive versus active ROM, differentiating structures, the tidy logic of musculoskeletal charts—before I caught myself and returned to the far more human ritual unfolding in front of me.

At the end of that first visit, I also asked delicately about the home’s dynamics. Dave, equally delicate, implied that Ed’s wife preferred a very precise kind of order, timing included. He advised me to be exactly on time, not early, not late. Like clockwork, she stepped onto the patio, and when I introduced myself, she frowned.

“No one told me you are coming.”

She then mentioned a car waiting out front earlier, visibly frustrated. I explained that the social worker had arrived early and was waiting for me. She sighed and returned inside. The aide gave me a look that said, “I told you so.” I took it as a lesson about boundaries rather than a personal rebuke. His wife was home during one other visit, but she did not join us. The aide, gently, contextualized what I’d already sensed: she valued privacy to a fault, bristled at unannounced cars on the curb, and disliked the birds in her own backyard. In a different kind of narrative, I might have imagined this as a neat counterpoint with the sunny man versus the shaded house. But I knew real people don’t line up that cleanly. So instead, I took it for what it was: a home with complicated weather. My job was to be a steady witness, not a storm chaser. So, I stayed on the patio and followed Ed’s lead.

What struck me that first day was the absence of strain. There were no IV poles, no oxygen tanks hissing, no monitors—nothing except for the one occasion when his glucometer chirped.

My mind reflexively drifted toward the mechanisms of insulin resistance and the mental flowcharts I’d memorized for exams, but I reeled myself back in as soon as I saw him insist on administering his own injection. His trembling hand traveled to his right breast pocket to silence the device. Dave fetched the insulin pen; Ed handled it matter-of-factly and injected without assistance, then went back to his story. It was a tiny sequence, but it stuck with me: his agency was narrowed, not erased. He was in a wheelchair on a patio, but he could still press a plunger and return to the business at hand.

On the second visit, we began inside and then moved out to the patio. The house itself felt sparsely furnished but lived in. The living room and kitchen were full of “neat messes,” as if someone had tidied to the point of tolerance and then stopped. A pattern that I have performed all too often myself. Tables held small clusters of papers and objects that meant something to someone. A cuckoo clock kept its own counsel on the wall. None of that was clinically relevant, but it painted a clear picture of what Ed did to make a house a home.

Being the second visit, I pried a bit more by asking gentle questions to see where he wanted to go. He said he was happy with his life; the only thing he would have added was skiing in the Alps. The stories quickened again. He remembered getting lit up by a cop for speeding (he had just found out about a family medical scare). In a panic, he chose to run, but only to pull into a random driveway. Looking up at drawn guns, he admitted that he didn’t even know why he’d run. He was released the next day; later he learned the judge was his neighbor and that, in that era, being Irish carried a certain untouchability if people suspected adjacent ties. He described quitting a taxi job on the spot after a passenger was ill in the car and the manager refused to help clean it. The next day, he was begged to return since he brought in the most fares (he was one of the few white drivers). He told a string of boundary-blurring workplace stories that, to my ear, spoke to a more permissive era without human resources and Title IX. Dave chuckled and interjected his own tales of hospital stairwell lore.

I tried to ease toward deeper water, craving an understanding of his regrets, the meanings he assigned to life and death, how he’d reached the point of “no dialysis.” Again, he swatted it away with humor.

“Have you seen what I look like?” he laughed.

Ed then turned the conversation back to a midsummer melody of old neighborhoods and the logic of a younger man who took the world at speed. I had a strong temptation to redirect him again, to hunt for the dramatic solemnity I had expected of hospice. But he had already set the tempo. Who was I to change the track? If the medicine was company and a listening ear, then dose given, dose accepted. At one point we joked about skydiving; when I asked if he ever wanted to go, he laughed.

“Hell no, I’m scared of heights!”

It’s easy to write this as if I knew exactly what I was doing. I didn’t. I felt the pull to “do more” in the quiet between his sentences. Ask about fear. Ask about dying. Ask about dialysis. The old reflex: identify the gap, fill the gap, prove you’re useful, show you’re competent, educate the patient. Instead, I tried doing nothing, doing presence. It felt like driving a stick shift for the first time.

The third visit was different because his pain was different. Overnight he’d developed a first, sudden gout flare in the left big toe.

Again I felt my mind drifting into pathophysiology—urate, CKD, medication ladders—before I caught myself, realizing none of that eased the discomfort etched across his otherwise stoic face. He was uncomfortable, not because he said it or even showed it, but because the air was now filled with stories by Dave and me. Ed’s were no longer heard. The silence was back, but it was thick and uncomfortable. I felt obligated to cut the visit short. The aide wheeled him inside, and before they turned down the hall I stopped at the doorway.

“Ed, thank you for letting me work with you these past couple weeks. It has truly been an honor.”

He squeezed my hand firmly, as if to say, “don’t you soften me up with that.”

“It’s my pleasure.”

It was the plainest possible closure, and therefore the right one. No dramatization. No life lesson. Just a handshake and the hum of the interstate.

As I walked to my car, I was surprised by what I felt, and more importantly, what I didn’t. There was a small, specific sadness. I would not get to sit in that sun again and watch a man reinhabit a younger version of himself through old stories. But I didn’t feel the heavy, cinematic ache I thought hospice demanded. I then got into my car and started driving away. Cue the self-critique. What’s wrong with me? Who feels “only a little sad” leaving a dying patient? Am I a psychopath?

I turned the questions over and eventually found a different answer. He did not present as a man evaporating from the world but a man with clipped nails, coherent speech, intact dry humor, agency to administer his insulin pen, and a craving for sunlight. He’d outlived his prognosis by months. If I didn’t cry in the car, maybe it was because the moment hadn’t asked me to. Maybe what it asked was much simpler. Did you listen? Did you let him choose the subject? Did you meet him where he was?

At one point he had told me he wasn’t afraid of death, he was just waiting for it. He said it like you’d say you were waiting for the bus. He was Catholic. When I asked what he imagined was on the other side, he gestured to himself and joked, “Well, it has to be better than this.” He’d still go skiing in Europe if he could. But he didn’t dwell on it or show any longing. When his stories ran out of runway he sighed softly, “Yep. Those were good times,” and left the sentence on the table without trying to make it mean more than it did. That restraint, the refusal to sanitize, felt like the lesson I didn’t know I’d come for.

I walked into hospice thinking it was principally about grieving, about death; I walked out realizing it is equally about reconciling with life. The chart told one story: organ systems stacked against him. The patio told another: a man maximizing his presence by facing the sun, telling the truth, keeping the humor, accepting the help you need, doing the part you can. My job was not to drag him into my preferred narrative; it was to learn to live in his.

The tension I wrestled with, hope versus realism, exploration versus intrusion, showed up as small decisions. Do I ask why he declined dialysis when he is laughing about old dances? Do I name loss when he is naming presence? Do I flip the conversation toward meaning when he has clearly defined it already in the ordinary pleasure of warmth on his forearms? In the past, I might have justified a pivot by calling it “duty” or “necessary.” Here, bravery and duty looked like de-centering myself. Listening, not fixing. Witnessing, not interfering. Letting humor do its legitimate work of making the unbearable bearable.

Ed was the kind of person who never wanted to dissect speed. He didn’t care to optimize it or find purpose in it. He just wanted it. Hospice did not turn him into a philosopher because he did not need to be one to die well. What he needed, at least on those three afternoons, was a patio, a patch of sun, a good story, and the freedom to hate De Niro out loud. Beyond that, he said he was ready to go in his sleep.

What do I carry forward? First, practical discipline: arrive, observe, invite, witness. Arrive fully and leave the clinical scavenger hunt at the curb. Observe the room, or in this case, the backyard. What is the light doing? Who is near the window? What’s humming? Invite, with a question calibrated to their agenda, not mine. What would make today a good day? Stories or symptoms first? Then witness, which requires the hardest skill I know—silence.

Second, change the interview script. Less “Why didn’t you…?” and more “What felt right to you then?” Less abstract meaning-making, more concrete dignity.

Third, permission to let endings be ordinary. A firm handshake is not a failure of depth. It is an honest form of it.

I’m also more alive to the ecosystem around the patient. Dave was steady and kind; he translated atmospheres as skillfully as he tracked meds. The home itself had weather. It spoke through privacy, vigilance, irritation, and love, all in its own dialect. I learned that “support” sometimes means staying on the patio and honoring the boundary rather than trying to reroute it. Not every hard thing needs to be remade in my own framework.

The hardest moment for me was the quick flash of guilt afterward. My expectation was that a hospice experience should crack something open in a visible way, and that if it didn’t, I had failed to “feel enough.” That probably says more about my ego than about him.

The most beautiful moment? I won’t pretend it was something grand. Here, beauty was the alignment between who he was and how he was allowed to be. The sun on his sweater sleeves, a humming highway, a hand that could still grip tightly, a joke at the doorway. An ordinary exit line: “It’s my pleasure.”

When I think about the second-year version of me—the one who memorizes management trees and finds comfort in the algorithm—I want to tell him there is a different kind of algorithm for this: Notice. Name lightly. Nourish what’s already working (humor, agency, ritual). And when the urge to fix arrives, ask whether fixing would be for them or for you. People don’t always need a better plan; sometimes they need a better witness.

So yes, hospice is about endings. But my three weeks with Ed taught me that it’s also about how to stay in the middle with integrity and identity. To keep company with someone who’s angled toward the last stretch without hijacking the wheel. To stop measuring my effectiveness by the depth of my questions and start measuring it by my fidelity to theirs. To know when to stand in the shade and when to wheel someone a little further into the sun.

If I ever get another patio afternoon like this, I hope I keep the right kind of humility: to let a person’s life, its speed, its stories, and its stubborn preferences set the terms of our time together. The interstate will still hum. The blue jays will still argue. I will still notice the keratotic edges of a lesion and think of multiple-choice questions. But maybe, more reliably, I will also feel the small gravity of a warm handshake and trust that, at that moment, it is enough.

Sun on the Patio is shared with the permission of the author and is HIPAA compliant. Varun Nagendra is a third-year medical student at Northeast Ohio Medical University. He can be reached at vnagendra@neomed.edu or varun.nagendra98@gmail.com.