The Small Cemetery Within: The Patients We Carry With Us Long After They're Gone

[gentle music] Small Cemetery Within by Arif Hakan Under, MD.

Every physician carries within himself a small cemetery, where from time to time he goes to pray.

Rene Lariche.

For years, I kept this sentence in the margins of my notebooks and on the first slides of lectures, admiring it as a beautifully crafted line rather than recognizing it as a description of my own life in medicine.

I would quote it at conferences, nod when colleagues smiled in recognition, and then return to clinic to focus on tumor boards, laboratory values, and treatment protocols.

Only after several years in medical oncology did I realize that a similar cemetery had been forming quietly inside me, and that it had begun to shape how I entered each patient's room and how I left the hospital each evening.

One evening, I met a thirty-two-year-old teacher with metastatic cervical cancer.

She arrived with her husband and a stack of folders almost as tall as she was.

Her first question was not about prognosis or treatment options.

Instead, she asked, "Will I have enough time to finish the school year?" I explained lines of therapy, schedules, and potential side effects.

I spoke about response rates and median survival.

But none of these terms contained her classroom or the faces of her students.

At the end of the visit, she read the chemotherapy consent form carefully, then looked up and said, "So we will try, and if it doesn't work, at least we know we tried with our eyes open." That sentence stayed with me long after I'd forgotten the exact doses and timing of the regimen I prescribed.

For a time, her scans improved.

She brought stories from school to the infusion unit.

The child who drew her with a superhero cape and the parents who kept asking whether she was really okay.

We celebrated small radiologic changes as if they were assurances, although we both knew they were not.

Eventually, the reports changed tone.

New lesions appeared, and words such as progression and limited options entered our conversations.

Her handwriting on the symptom sheets became smaller and less steady.

We spent less time talking about medications and more time talking about what she wanted her students to remember.

One day she asked, almost casually, "When you write about me later, will it just be numbers?" I answered with the only honesty I had.

Well in the file, yes, but not in the quiet place where I keep the patients I cannot forget.

There you remain more than numbers.

On the day she died, I was in the same hospital, but not in her room.

I was upstairs obtaining consent from another patient when a nurse called and said simply, "She has passed." I signed the death certificate, dictated a brief summary, and went back to clinic.

Oncology demands that kind of forward momentum.

The schedule leaves little room to stop.

Yet that evening, driving home, I realized that this thirty-two-year-old teacher had taken her place in the small cemetery Lariche described.

She was no longer just deceased due to disease progression.

She had become part of the inner landscape that would accompany every future conversation with patients and families facing advanced disease.

Our professional lexicon makes these transitions appear deceptively orderly.

We say disease progression instead of dying and limited response instead of this isn't working anymore.

These terms are precise and often necessary, but they also create a distance that is easy to overlook.

In conferences, we discuss hazard ratios and Kaplan-Meier curves and how many patients were censored at last follow-up.

Each downward step on a survival plot represents a person whose absence is now felt at a family table.

Yet nothing in the figure or table reflects that absence.

Within these formal descriptions lies a disciplined silence.

It appears after we say there's no further curative treatment.

When the room becomes very quiet as families search our faces for one more sentence of hope.

It appears in the corridor after a code has been stopped, as everyone walks away at slightly different speeds.

It appears late in the evening when the infusion chairs are empty and the printer is already generating the list of patients for the following day.

This silence does not mean that we have failed to communicate.

It's the place where our professional roles and private emotions meet and do not quite align.

Working in a public hospital in Turkey, I see how systemic constraints deepen this tension.

Clinic days are crowded and visits short.

Some families travel long distances with limited resources, hoping that the university hospital will provide answers that smaller centers could not.

When I have nothing new to offer, I confront not only the limits of medicine but also the accumulated weight of social and economic inequities that no protocol can correct.

These, too, leave their marks in the internal cemetery.

Yet alongside loss, there are moments of unexpected grace.

A father, after hearing that his daughter will not recover, says, "Thank you for walking with us this far." A widow returns months later with a box of homemade sweets, explaining, "This ward was where he felt most respected." A young man with lung cancer jokes with the nurses about the hospital food even as his strength fades.

Such gestures do not change survival statistics, but they transform the emotional landscape of the day and remind me that presence can be as important as efficacy.

They also add color and texture to that inner cemetery, turning it from a place of only loss into a place of meaning.

Over time, I've come to see Larish's cemetery not as a burden, but as a kind of school.

Each patient has taught me something.

The consequences of delaying hard conversations, the power of sharing silence without reaching for another drug, and the importance of acknowledging uncertainty rather than offering polished but hollow reassurances.

These lessons never appear in continuing education credits, yet they shape every new encounter more than any guideline update.

At the end of most days, I perform a small ritual.

Before leaving the hospital, I hang my white coat on a hook by the office door and allow myself a brief moment of reflection.

During that pause, I think of one patient from that day and one from the past.

Sometimes that same thirty-two-year-old teacher, and sometimes another whose story has quietly stayed with me.

I do not recite a formal prayer, but for a moment the usual clinical vocabulary falls silent and their names are present.

Perhaps this is what Larish intended.

Not a cemetery of defeat, but a place of remembrance that keeps us from becoming mere technicians of protocol and helps us remain, even at the busiest moments, not only clinicians managing treatment plans, but also witnesses accompanying others through fragile times.