The patient was hacking sputum into a tissue when the resident and I entered his room.

“How long have you had that cough?”

“Oh this? As long as I can remember.”

“But it’s been worse lately?”


“Worse how?”

“More stuff coming out each time. See?”

He opens the tissue.

"How much sputum is there?"


"The stuff you cough up."

"I don’t look that close.”

“More than two spoonfuls?”

“Oh yes. Definitely.”

“And the color?”


"Ever see any streaks of blood?"


"And how long have you been smoking?"

“About 20 years.”


“Maybe closer to 30.”

“How many packs a day?”

“I don’t know.”


“Maybe two and a half.”

"That's a lot of cigarettes."

"I know."

"Have you tried quitting?"

"Once or twice. It didn't work."

He laughs, and with a few chuckles, his laugh morphs back into a cough.

"Alright, Mr. S. We’ll give you the usual: some medications to open your airways and help you breathe better, and some antibiotics. Most likely you’ll be here a few more days.”

"Thanks, doc.”

Outside the room, my resident showed me the patient’s chest X-ray. "Look at that sh*t" he said, pointing to the screen, where increased lung volumes and flattened hemidiaphragms were classics signs of chronic obstructive pulmonary disease. There was also a white density at the base of one lung, suggesting a pneumonia.

He went on. "Smoking is literally the worst thing someone can do to their body," he said. He shook his head at the screen, seeming to be disgusted with it all.

I said nothing, feeling vaguely annoyed by the resident's questionable sensitivity. We had a few lectures on motivational interviewing in medical school, and I had once written a paper on alternative methods of smoking cessation. I wondered if and how other doctors had spoken to our patient about it.

“Maybe I can talk to him about long-term strategies for quitting,” I ventured.

“Don’t bother,” the resident said. “It’s his own fault."

For the next several hours, the resident and I turned our attention to other patients. We wrote admission orders, responded to pages, and prepped discharge summaries.

Around 9 PM, we went over our patient list. "You go home," the resident said, seeing my work was done for the night. And then: "I'm taking 10 minutes," to no one in particular. I was grateful to go home, and I sympathized; I knew he was going to have a much longer night.

I gathered my things, bundled up in preparation to face the frigid Boston air, and turned past the hospital. The dim lights of a 24-hour convenience store cast shadows on the pavement, and I noticed another person in scrubs leaning against the wall, lurking beneath the shadows. Before I could get a closer look, I smelled smoke and glimpsed dark ashes dropping to the ground, vanishing on the snow-soaked sidewalk.

As I walked past, the set of scrubs and I made brief eye contact, and I was surprised to recognize the person who had just told me to go home. This was his 10 minutes. We nodded at each other, and I continued home.

It never came up again.


(Certain details of this story were altered slightly to protect privacy)