Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman  

Welcome to the icy planet of Gethin in a kingdom of karhide along a treacherous mountain path, Lord Berosty picks his way through ice and wind and snow. He carries in his bags half the years, yelled from his orchards and as many riches as he could gather, he hopes the tribute will be sufficient for the foretellers, a group of seers said to be able to glimpse the future. Lord Berosty knows the answer he seeks is not cheap. He wants to know the unknowable. His question on what day will I die? When Lord Berosty finally reaches the Foreteller stronghold, they accept his offering, and so he asks his question, they enter their trance, disappearing into the darkness of their visions. Berosty waits anxiously. When they finally emerge, their answer is simple, you will die on the 19th day, burasty Panics the 19th, but which month, which year, when he demands, they tell him more, begging, threatening, yelling, but The foretelling is done. Berosty makes the long journey home in a haze.

This is The Nocturnists Uncertainty in Medicine. I'm Emily Silverman, and today we're exploring the uncertainty of death. Death is one of life's only certainties, and yet also one of its greatest mysteries. It can be hard to talk about without resorting to vagaries or cliches, and so to kick off this episode, we turned to the late, great sci fi author Ursula Le Guin. Le guin's novels are full of intricate world building, deep philosophy and parables passed down through generations. One of these parables from her novel, The Left Hand of Darkness, tells of Lord Berosty REM or reap, a powerful man determined to undo the uncertainty of death. Back on Planet Gethin Berosty locks himself in a tower counting down to the 19th of every month, refusing to eat and waiting for death. You will die on the 19th day. This answer becomes Berosty's curse. Six months pass, and then 10 he's driven mad by waiting. Meanwhile his beloved Herber of gagner watches on in agony. Burasty is unraveling, and there's nothing Herber can do to save him. So Herber himself decides to make the long journey to the foretellers. When he arrives, he is ragged, grief, stricken with no fortune to offer. He falls to his knees, please. He begs, I will give you my life. The answer I seek is not for me but for my love. The foretellers are moved by his passion, and so agree to answer his question. The asker always pays what he has to pay, warns the head Foreteller, but Herbert cannot imagine a greater price than the one He and Berosty are already paying. And so he goes quiet, thinking long and hard. Finally, he asks, How long will Berosty REM or EPE live? The foretellers gather and slip into their trance. A time later, they emerge their answer. Longer than Herber of gegenar, it is not the answer Herber had hoped for, but it is an answer, and so he begins his long journey home in. When he arrives, he finds berasti as bleak as ever in his tower, slumped over a great table of red stone head in his hands, my love. Herber says, I have been to the foretellers. I have received an answer. Berosty looks up a light of hope flickering in his broken eyes. I asked them how long you will live, and their answer was that Berosty will live longer than herbersti absorbs this news. How long you fool. You had one question, and you did not ask on what day and month and year I will die consumed with rage, Berosty  takes up the great table of redstone as if it were light as a tin can, and brings it down on his love Herbers head killing him instantly. He cannot stand anything after that, and he leaves the tower, but only to wander in lonely madness, searching for Herber. A month later on the 19th he takes his own life, but by this point, he has, in a way, already been dead for a long time in

The moral of this parable feels relatively straightforward. Don't seek to know the unknowable, especially where death is concerned. But in a way, isn't this the expectation we pin on modern medicine every day. Today's stories dive into the mystery of death. What do you do when answers only lead to more questions? How do you respond when attempts to control death fail, creating new suffering in its wake? In the stories ahead, you'll hear clinicians and patients grappling with the reality of death, but also finding moments To live inside the unknown rather than resisting it. 

Hannah Kirsch, MD  

I'm in the CPR stands for couch potato room, because that's what my grandparents called their TV slash computer room. I'm wearing my running shorts and button down combo that I think we're all familiar with since 2020 and nothing in particular is really happening. When the phone goes off, I know instantly it's my mother, because she's the only one whose ringtone is the Imperial March from Star Wars, and I'm annoyed because nine times out of 10 when she's calling me in the middle of my work day, it's to fetch something that she can definitely fetch for herself. And I know she hasn't been feeling well, so I'm trying not to be annoyed, because maybe she does really need me to take care of something for her. When I pick up, I don't have any idea that she's going to say in a totally normal voice that she's intending to take her own life with medical assistance, because you think that's something that somebody would walk up to floors to tell you, I don't know how to respond, except in a completely normal tone of voice, because the alternative is to process a whole flood of feelings in about five seconds. All I can say is, okay, do you want me to call the doctor, or are you going to do it? And she says she'll take care of it. So even though she didn't tell me in a particularly serious way, I know she means I know she means business. I used to think I was very comfortable with death, and what I realized was, in the space of about 15 seconds, is uncomfortable with death when it's very near or ambiguously far.

Emily Silverman  

Now, Hannah's mom's death was somewhere in between. She told Hannah over the phone, I'll do it sometime in the next couple of weeks. I'll let you know when I choose a day.

Hannah Kirsch, MD  

When you know something bad is coming in hours, you can pull out all the stops. Everybody comes to the bedside, all the medicine, right? Everybody is there. And when you know something is happening in months or years, you. You can go about your life like everything is okay, and you can live out your petty squabbles and live out mother daughter relationships, which are never normal in the way you've always lived out your relationships, when all of a sudden, this is something you're thinking about on a medium term. It's what doctors are worst at having to give measured energy to something measured time, rather than cramming or playing the very long game. And it's a skill I did not expect to have to bring to bear in my personal life, especially when it comes to something I thought I was unusually happy to confront, which was dying. My husband and my partner call it microdosing death, because I tell them that I think about them dying all the time, not every day. It's like, once a week, and like, you know, just kind of like, sit with it. How's it going to make me feel right? Because when the moment comes, like I've kind of been there already, and I thought that would make me ready, and then all of a sudden, I wasn't quite sure what to do. I sat there. You know, nothing's different. I'm still wearing the business in the top party and the bottom outfit, and it feels like I should go back to work, and it also feels wrong to just do that. The other thing I'm thinking is that it is the wrong thing to do to impose your own feelings on somebody else's choices. This is hammered into us professionally, and so what I want to do is run down there and interrupt her day and say, Why the hell did you call me? But what I don't want to do is make her question her decision, or question my judgment of her decision, or or think that what she is doing is the wrong thing in one of the last decisions she's ever going to make.

Emily Silverman  

Who decides. It's a question that came up again and again in the stories we received about death and uncertainty. Sometimes death is a decision that we're able to make for ourselves, but more often, it's fully beyond our control. The next story comes from Scott an emergency care doctor, who says that dealing with life and death decisions, especially when his patients aren't able to make those decisions for themselves, is one of the hardest parts of his job. One story from early on in his career still haunts him.

Scott Fruhan, MD, MBA  

The image that stands out the most to me is essentially the end of the story, when I was finally walking out of this hospital room after a long night, and the image of this patient's grandson, and I think the only way I can describe it is a look of hatred. Earlier in the evening, I walked into the resuscitation room of the ER, and there was an elderly patient who didn't speak English, and she had just been brought in by an ambulance, and she was critically ill. She had very low blood pressure, barely conscious, Delirious from the low blood pressure. And the cause of it, as best I could tell, was a condition called ventricular tachycardia, which is a acute heart abnormality that is usually best treated with an electric shock. Sometimes you can use medicines, but an electric shock is the primary treatment, and she was accompanied by her grandson.

Emily Silverman  

He was a big guy with a leather jacket and neck tattoos, and Scott said he looked scared.

Scott Fruhan, MD, MBA  

I remember the alarm on the monitor kept going off every 30 seconds, as it often does when someone's blood pressure is critically low, and I would just automatically reach up and push the yellow button that temporarily mutes it. The patient we tried to communicate with in her native language using the iPad video interpreter that we have, and it was malfunctioning, and the Wi Fi was cutting out, and the interpreters at one point said, I can't really understand what she's saying, but it's something about soup, so clearly not helpful. So the question was, okay, so normally this would be actually fairly straightforward. I would hook up the equipment, we would deliver an electric shock, and hopefully this would solve the immediate problem, although I'm sure there would be. Other underlying problems that we would have to deal with, but I couldn't do that because the EMS personnel were showing me what's called an Advanced Directive, which is a very important and theoretically compassionate document filled out by a patient with their primary care physician that directs future providers like myself on what the patient's wishes would be, ranging from full, aggressive, potentially uncomfortable treatment options to comfort focused treatment. But what this patient had selected was the middle option, which is selective treatment, which has as its goal, treating the medical condition, but without resorting to so called burdensome measures, which, of course, is a subjective and uncertain term.

Emily Silverman  

The uncertainty Scott faced wasn't just around the type of intervention the patient might have wanted, but also about the legal ramifications of how he chose to interpret the Advanced Directive if he were to give her a shock, and it turned out that that was counter to her wishes, could he be held liable, but if he didn't give her the shock?

Scott Fruhan, MD, MBA  

I spent the next few minutes trying to understand, with the help of the patient's grandson, what the patient would have wanted in this circumstance, which is more or less an impossible exercise. This was a form letter document with check boxes written in a language that the patient didn't read, and I had no idea what the nature of the conversation had been between her and her primary care physician. The grandson had never heard of this kind of document. He was surprised that his grandmother would have signed something that would be anything less than fully aggressive measures to prolong her life, and I didn't really have answers to most of his questions, like, Would an electric shock definitely work? Would it not work and require further electric shocks of more intensity. Would the alternative treatment of a medication IV drip be effective? I didn't have answers to these questions.

Emily Silverman  

But still, Scott pressed him to choose shock or no shock, given everything you know about her, what do you think your grandmother would want?

Scott Fruhan, MD, MBA  

I think ultimately, I was afraid of making this decision and sort of trying to put the burden of that decision on him, when, in reality, it's really not a decision that anyone other than the patient could make and she couldn't make it in that moment. In a way, it's the only decision any of us will ever have to make in our lives that has truly irreversible consequences.

Scott Fruhan, MD, MBA  

The grandson ultimately decided that the best way to honor the advanced directive was not to give electric shocks and to start the less effective treatment of the IV drip of medicine. So I did that. The patient stayed in the ER, about another half an hour with a very low blood pressure, drifting in and out of consciousness, and eventually was admitted upstairs to the hospital. A few hours later, as my shift was ending, I got a call from the hospitalist upstairs, and he said, Hey, can you come up here and talk to this family? Because I've got multiple generations of family here who arrived and had a conversation and asked me to shock the patient, and I did, and it fixed her heart, and now she's fine, and they really want to talk to you. So I went upstairs, and there was a sort of angry Patriarch who was not understanding why I had not given her the shock in the first place. And I tried to explain, we were trying to make our best decision on her wishes. And I looked over in the corner, and the grandson was there, kind of with his head in his hand. Boy, the expression on his face, you can't fake hatred like that.

Emily Silverman  

In retrospect, Scott says he would have done it differently. He would have given the patient a shock sooner, but at the time, he was stuck in the uncertainty of it all.

After hearing Scott's story, we wanted to talk to someone who has a lot of experience making life and death decisions for people who aren't able to make those decisions themselves. So we called up Shweta, a neuro intensivist and encephalographer. Shweta works with people who have brain and spine injuries, and most of her patients are in a coma.

Shweta Goswami, MD  

A common question we're asked to answer is, why are they in a coma? This

Emily Silverman  

question can be pretty complicated, but it's nothing in comparison to the one that inevitably comes next. Will they wake up?

Shweta Goswami, MD  

So I had this gentleman in his late 50s, early 60s, who was on a hike with his wife, walked a mile and a half and then suddenly passed out when I saw him about a day later, he was still in a coma.

Emily Silverman  

Shweta got called in to help the cardiology team figure out how likely it was that the patient would wake up. If the chances were good, the cardiologist would investigate the cause of the heart attack and potentially do some interventions. But if he were unlikely to wake up, from a systemic point of view, it would be a waste of time and energy to do the investigation. So Shweta started weighing the known factors.

Shweta Goswami, MD  

It took eight minutes before someone could start by standard CPR. He had no anesthetics on him, but then there were things that were going for him. He had his brain stem reflexes right away. He didn't have any seizures, and yeah, there was damage on his MRI brain, but it wasn't so catastrophic.

Emily Silverman  

Shweta said that every day she examined him, basic brain stem functions seemed to be returning By the third day, when she squeezed his arm, he moved a finger just a hair, she advocated pretty hard to give him a full cardiac workup to do anything else she argued ran the risk of becoming a self fulfilling prophecy. She was also careful about how she talked about the chances with the patient's wife.

Shweta Goswami, MD  

All it takes is one person with a pessimistic view to spend a few minutes talking to the family member in passing and say, I don't think they're going to make it to really change their mind. So I usually try to start these conversations to tell them that this is complicated and I really don't know if he's gonna wake up. And if anyone ever tries to pinpoint a percentage, I will continue to say, like, literally, 5050, I don't know.

Emily Silverman  

Instead, she'll talk about what she does know, which, in this patient's case was that he had his brain stem reflexes, and she'd known people with worse structural damage who had woken up. The man's wife opted to put him on a time limited trial. Basically, they would keep his body alive for three to six months to see if he would wake up.

Shweta Goswami, MD  

I've been called naive. I've been called, you know, way too hopeful. But what I'm trying to do is be an advocate for the person, especially when just two days ago, she was going on a hike with her husband that she didn't know had medical problems, it feels too much to then say by day five, he's not waking up. Let's just say we tried, and that was good enough.

Emily Silverman  

With this patient, though, like most patients she works with, Shweta, never found out what happened.

Shweta Goswami, MD  

As an intensivist, I don't get the longitudinal relationship, and most of my patients are in a coma, so they have no recollection of me if they ever wake up. I just continuously live in a world of uncertainty where I hope that they woke up. I hope I was accurate in pushing for this person to get a trick and a peg. But you know, at some point, I do have to stop and say, I don't know if I was right or wrong, but I'm here to take care of the patient, first and foremost, and the family, and at least find some solace that I did my best with what I knew.

Emily Silverman  

A world of uncertainty. Shweta says that in her work, there's only one thing that is certain, and that's how they define brain death.

Shweta Goswami, MD  

Brain death is certain. There are legal ramifications, medical ramifications, and we're taught to be extra careful when we define brain death, but when we do define brain death. It is final. That is it. It is a death certificate.

Emily Silverman  

Now this can create an interesting dynamic. Pronouncing a patient brain dead triggers a whole series of protocols, life supporting technologies are removed. Hospitals have policies for how long you can keep the body, but the certainty of this definition can sometimes feel at odds with the actual process of death, which is much less black and white.

Shweta Goswami, MD  

There have been circumstances where you know everything else is gone, their pupils don't react, their corneals Don't react. You're going down the list of rudimentary brain stem function, and somewhere deep in there, well protected, is one or two neurons in the medulla that are triggering some breath, and therefore they're not brain dead. And everyone has personal opinions about what that means.

Emily Silverman  

For example, take this one case Shweta worked on. 

Shweta Goswami, MD  

I had a family whose loved one underwent a elective neurosurgical procedure for a meningioma repair, and it was a really, really large meningioma had complications. She ended up having intracranial bleeding, and it was a catastrophic brain injury. Essentially the last piece of the puzzle in order for us to confirm her brain death was apnea testing, and the family was very resistant. To the point where they were ready to get lawyers involved, because they're Orthodox Jew and they do not believe in brain death. They believe in circulatory death.

Emily Silverman  

Shweta was faced with a decision complete the apnea testing and declare the patient officially brain dead, or just let them eventually pass away when their heart gives out. The family did end up getting a lawyer involved.

Shweta Goswami, MD  

You know, there's certainty for me, but not for the family. 

Emily Silverman  

This can be the hardest part of the job. Shweta says navigating the enormous range of relationships to death that her patients and their families have. For example, She recently had a patient, a young woman, who came to them in a coma caused by cancer that had spread to her cerebrospinal fluid.

Shweta Goswami, MD  

She got rushed into her ICU to place an external ventricular drain, and she wakes up really. Her other decision maker is her teenage son, and that's about it. And it was one of those days where I was I was done. I was emotionally spent.

Emily Silverman  

Shweta couldn't bring herself to talk to the patient. She'd hit her quota of hard conversations for the day, and so she asked if someone else on the team could fill in for her. 

Shweta Goswami, MD  

I knew that this is a terminal situation, but nobody wanted to talk to her about the fact that she's gonna die of cancer. And so then every other day after that, it was like, We need to talk about hospice. We needed to bring in hospice. And every day she would shoo hospice away. She would say, I don't want hospice. I want to live. I want everything done. And her platelet count was like two. Nobody was going to surgerize her. We just kept giving her blood products every day, every day she avoided it. And finally, on the fifth day, I went in and I said, Look, I know I am the last person you want to talk to me about, but let me just be honest with you, you're gonna die. The only control you have is how you die. And here are your options, either we take the drain out and you may survive a day or two, but you get to see the sun outside, or you bleed to death. And she immediately told me, I want to bleed to death in the hospital. And I walked out of the room, and I was like, why are we forcing hospice when she doesn't want it? And I think the second I like, let go of that, I felt a sigh of relief, like, you know, I'm doing my best for her, and if what she wants is this catastrophic injury that I want to avoid, because I don't want to be on the other end doing chest compressions on somebody who's bleeding, but that's what she wants, and I'm here to take care of her, and if she knows what that is, then she knows what that is. 

Emily Silverman  

Shweta says that as someone who frequently walks into the room and immediately feels the expectation, whether from herself or others, to fix a situation, it helps to remind herself of what she can and can't control. 

Shweta Goswami, MD  

Sometimes, when I find myself really worked up or stressed about a case, I ask myself, why is this bothering me. It's bothering me because I don't have control over this aspect, and I wish I did. Okay, well, I'll say it to myself like I don't have control over this. Let's focus on what I have control over. I can be honest and upfront with the family members about what it is that we can do next, and that's frequently a conversation I'll have when it comes to that fear of dying. We're in this, like, gray zone, and they don't know what to do, because they're like, well, we never talked about this very specific scenario, and whether or not they would have wanted this or this. And I would say, Well, you can't have these conversations. That's not how the world works. But you know, the control we have right now is how we die, because we know we're going to die. You okay, it's interesting. There's some irony in it. I'm not that old. I take care of all the old people, and I'm frequently the one. I'm telling them that death is certain and that there's no avoiding it.

Emily Silverman  

Even with all her experience facing death, though, Shweta says it still sometimes feels unfathomably, unfathomably large.

Shweta Goswami, MD  

I have this feeling too, every once in a while when I'm like, thinking about space, like outer space and the stars, and you know, it's you feel so little when you finally see somebody like, truly pass away. And now it's this, like lifeless body. There's, there's this feeling of, like, whatever was on my to do list, it just immediately goes away, and I just feel instantaneously small, because here was somebody who had a life and and that that's it. That's it. And now this is the body.

Emily Silverman  

Our final story comes from David Elkin, a psychiatrist and teacher.

David Elkin, MD  

I was a very beginning of fourth year medical student back in Philadelphia, and I had not been a very good third year medical student at all. So as a fourth year student, I was very anxious about my knowledge base and my place, but I ended up on a cardiology service. This was my first acting internship when you're taking on more responsibility. I was assigned to work with a patient who was in his late 60s. He had a valve that was leaking and needed to be replaced, which is a fairly straightforward procedure, usually has a high success rate. The patient was in very good health otherwise, and was judged to be an excellent surgical candidate. And as the medical student, I had a lot of time spent with him. I ended up feeling kind of close to him.

Emily Silverman  

On the eve of the surgery, David says the patient was getting apprehensive.

David Elkin, MD  

He had this sort of slightly panicked look, and he said to me, you know, I just think I should maybe say goodbye to my wife. What do you think like? Just in case, I remember feeling this gush of protectiveness, and it was about his feeling, but it was also when I look back about the possibility of him dying.

Emily Silverman  

Diva tried to reassure him.

David Elkin, MD  

You're an excellent surgical candidate. You're in great shape. The doctors are very good here. They know what they're doing. He didn't look reassured. He just said, again, I know I think, I think I should maybe say goodbye to my wife in case something happens I don't make it.

Emily Silverman  

David tried to reassure him again, and even shared the example of his own grandma, who'd been in terrible shape going into the very same procedure and had been fine, but again, the patient didn't seem reassured.

David Elkin, MD  

There was a dance. He would look anxious and scared and a little desperate, and I would start to feel my anxiety rise, and I would quickly reassure him. We went back and forth like that on multiple occasions. I just kept reassuring him. There was definitely some sense that I was trying to placate my own anxiety at that point, but I didn't realize it, you know, I just kept thinking, well, you're gonna, you're gonna scare your wife, and I was worried that he was going to maybe, in some sense, psych himself out. But then it happened again the next morning pre op, like 530 or six, and I kept hoping that he would have gotten a good night's rest, and felt differently, and he did. Yeah, so I ended up scrubbing in on surgery because I was concerned about him, and I I wasn't sure about my role, but I just wanted to be there and send whatever reassurance I could, I guess, some unscientific way. So I was watching as they cracked his chest and opened him up and put him on bypass and when to start replacing the valve, and then things started to go south. I can still remember the beeping and the alarms and just realizing that he was coding in front of me. I can still, you know, I still have that feeling in me, as I'm describing, it would just like, could sort of feel the blood rushing out of me, almost like just this sick feeling of like, oh no. And after all these attempts to try and bring him back, they ended up calling the code saying time of death. You I came out of the or immediately realizing, like, what have I done? Like, I mean, actively prevented him from saying goodbye to his wife like I had all this power, and what did I just do with it? I thought about what I could do to make things right, and I thought about telling his wife, but then I realized that would probably be even more painful for her, but it was again, the sense of isolation. I didn't reach out to anyone. I just sat there and and just like the sense of disbelief just creeping over me.

Emily Silverman  

Here, it's worth emphasizing that this story happened over 40 years ago. David still thinks about it.

David Elkin, MD  

It's it still feels crushingly sad, not even that something else could have happened, that the course of this could have been different, but that he would have had his chance to say goodbye to his wife, that they could have had one. Last hug, and kind of tried to imagine what he might have said to her, because he obviously loved her quite a bit. Yeah, what could have been, I think that haunts me still.

When I was a little kid, I was in the back of the car on the expressway outside of Philadelphia, heading into the city my father was driving, and I suddenly realized that the cars were not like the little car trip set that I had at home, where they would run around on a track and they could only fit in that little groove, and there was a little spring or motor that kind of pushed them around. The cars would never crash into each other because they had their separate tracks. But then I looked around and I had this dizzying sense at like, six years old, I think it's like, God, the only thing that's keeping these cars from crashing is each driver doing the right thing. Coming to the hospital. Was like that. It was like, oh my god, like medicine is supposed to be this perfected science, and it's not. It's like they're people doing these things, and it's only as good as the people that are doing this stuff.

I think if I'd handled it now, I would have said, Well, tell me more about who you're worried about. I would have invited him more to talk about that. And I again, I'll never know this could be me projecting onto what I remember about him, but I think, I think he probably would have said, I'm afraid of dying. It might have taken us to a place where we would have gotten into spiritual questions about what happens when you die, questions that I was very uncomfortable with. I think it was just frightening to me. And again, it felt more like I was taking care of my own feelings without realizing it, taking care of my own feelings while thinking I was taking care of his but I think now I would have leaned into it. I would have asked you more, what is it you're feeling? What's making you want to talk to your wife? What do you think is going to happen? What do you think the chances are? What's telling you that all of that could have been explored.

Emily Silverman  

Light is The Left Hand of Darkness and darkness the right hand of light. Two are one, life and death lying together like levers, like hands joined together like the end and the way. This is Ursula Le Guin, also from her novel The Left Hand of Darkness, which is where we started this episode in the hour, we've explored the paradox at the heart of medicine, that death is both inevitable and unknowable. It's something we all must face, and yet no two people meet it the same way for clinicians, navigating that space means not only caring for the patient, but witnessing their relationship to death and reckoning with our own next week, we turn to spirituality and uncertainty, how people find meaning, connection and even peace in the midst of the Unknown, because when there's nothing more to do, what remains is often what matters most. See you then. Thanks for listening to the Nocturnists Uncertainty in Medicine. Our core uncertainty team includes me, Emily Silverman, the Nocturnes head of story development Molly Rose Williams, producer and editor, Sam Osborn and our student producers are Claire Nimura and Celine Everett. Special thanks to Maggie Jackson and Paul Han. Our executive producer is Ali Block. Our program director is Ashley Pettit. Our original theme music was composed by Ashton Spencer, and additional music came from Blue Dot sessions. Artwork for Uncertainty in Medicine was created by Eleni  Debo, who is represented by folio illustration and animation agency, the nocturnist. Uncertainty in Medicine was made possible by generous support from the ABIM Foundation, the Gordon and Betty Moore Foundation and the Josiah Macy Jr Foundation. The nocturnist title sponsor is the California Medical Association, a physician led organization that works to keep the doctor patient relationship at the heart of medicine. To learn more, visit cmadocs.org, the Nocturnists is also made possible by support from listeners like you. In fact, we recently moved over to substack, which makes it easier than ever to support our work directly by joining us for a monthly or annual membership, you'll become an essential part of our creative community. If you enjoy the show, consider signing up today at the nocturnists.substack.com. If you enjoyed this episode, please share with a friend or colleague. Post on social media and help others find us by giving us a rating and review in your favorite podcast app. I'm your host. Emily Silverman, see you next week.