The Epilogue Girl Asks the Question

I'm writing this from the desk where my suitcase is half-packed.

Tomorrow I leave town for a few days, and the rhythm of the leaving has the same shape it always does — patient call-backs squared away, the practice covered, prescriptions sorted, my wife reminding me where I packed the chargers, the dog Lilly suspicious of any luggage that isn't hers. It is May 1, 2026. In a week, I will have been a physician for thirty years.

May of 1996. That's when I crossed the line.

Thirty years is a strange number to hold in one hand. It is most of someone's working life. It is more years than I had been alive when I started. And it is, depending on the day, either a long time or no time at all — sometimes both inside the same clinic visit.

I bring it up because I have spent the last few weeks revising the epilogue of the novel I've been carrying around. The Last Doctor is a post-apocalyptic story about a young physician named Deborah, and I just polished it for the Black List — that meant tightening four pivot scenes, including the very last one. https://blcklst.com/

In the epilogue, Deborah has survived the world that ended. She is older. Quieter. There is a girl with her — a child she's been teaching, a child who follows her on rounds the way I used to follow my attendings on rounds. The girl asks a question. It is a small question. The kind a child asks when she's working up the courage to ask the larger one.

And Deborah answers her using the words of a man who has been dead, in the story, for many years.

She doesn't know she's doing it. She just opens her mouth and Michael's words come out.

When I wrote that scene I thought I was writing fiction. I'm not sure anymore.

Here is what nobody tells you about thirty years.

You do not remember most of the patients. You remember a handful, the way a pilot remembers a handful of landings — usually because something about them was hard, or rare, or beautiful, or because it was the day you finally understood what the textbook had been trying to say. You remember some names. You remember more faces. You remember almost no last names.

But you remember the doctors who taught you. All of them. Even the difficult ones.

I remember the resident who showed me how to break bad news without breaking the family. I remember the attending who let me do my first lumbar puncture and then bought me a sandwich because, he said, I had earned it. I remember the family physician in residency who told me, almost casually, that the most important thing I would ever do for a patient was come back the next day, and the day after that. He said continuity was the only intervention with a perfect safety profile.

He was right. Family medicine evidence keeps confirming it: continuity of care is associated with reduced mortality, fewer hospitalizations, lower costs. https://bjgp.org/content/68/673/e428 https://www.aafp.org/pubs/afp/issues/2024/0700/longitudinal-care.html

I have used that line about continuity, in clinic, more times than I can count. I told it to medical students. I told it to my own residents when I was a residency teacher. I told it to the AAFP membership during the year I served as president of the Arizona chapter. https://www.azafp.org/

I never once told the man I learned it from that I was using his line.

He died before I thought to.

Most physicians don't know whose voice is coming out of their mouth on any given morning. We are walking around speaking sentences our mentors gave us, in the order our mentors gave them to us, often using their exact rhythm — the pause before the diagnosis, the soft okay that signals the family it is time to listen, the way to say I don't know without losing the room.

My residency program was in family medicine. By the time I finished I had absorbed maybe eight or ten distinct voices and patched them into something that sounded, to patients, like one voice — mine. https://www.aafp.org/students-residents/residency-program-directors/program-directors-handbook.html

That's how it works. That's how it has always worked. Medicine is an oral tradition with a paperwork problem.

The paperwork is what we fight about now. Prior authorizations, MIPS, the RUC, the codes that are someone else's intellectual property, the dashboards. https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/ https://www.mgma.com/advocacy/regulatory-burden-report

The oral tradition is what we sometimes forget to defend. And it is the more important of the two.

Every family physician practicing today learned to do this work from someone. Most of those someones are not famous. None of them have publications named after them. They taught in clinics that nobody in administration could find on a map. The system did not pay them for the teaching, except in the indirect way the system pays for anything important — by quietly counting on it never to stop.

It will stop, of course, if we keep treating primary care as a downstream cost center instead of an upstream investment. The shortage projections are not subtle. HRSA's 2024 primary care workforce report projected a shortage of 87,150 full-time-equivalent primary care physicians by 2037; the 2025 update revised that to 70,610 FTE by 2038, with family medicine running at 76% adequacy. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/State-of-the-Primary-Care-Workforce-2025.pdf AAMC's most recent projection puts the overall physician shortage at up to 86,000 by 2036, with primary care making up 20,200 to 40,400 of that. https://www.aamc.org/news/press-releases/new-aamc-report-shows-continuing-projected-physician-shortage AAFP has been ringing this bell for a decade. https://www.aafp.org/about/policies/all/workforce-reform.html

But the shortage isn't just a head count problem. It's a transmission problem. You can't run an oral tradition on attrition.

The epilogue scene in The Last Doctor almost didn't make it into the novel.

For a long time the book ended earlier — with Deborah making her vow, with the world still uncertain, with Michael's death fresh. My instinct was that the reader would do the rest of the work. They would imagine the future. They would fill in the silence.

It was a reader I trust who told me the silence wasn't the ending. They said the ending had to show that something had been passed down. Otherwise Michael's death was just a death. It needed to become an inheritance.

So I added the girl. I let her ask the question. I let Deborah answer the way Michael would have.

When my editor read it, she said: this is the best scene in the book. And I thought — well, of course. Because it isn't a scene I made up. It's a scene I have lived dozens of times, on the other side. I am the girl asking the question, in this scene, in every clinic, every time I borrow a sentence from a teacher who is no longer here to hear it.

Thirty years in, that's most of what doctoring is. Borrowed language. Working at someone else's bench, repeating someone else's gesture, until the gesture becomes yours and you have a chance to hand it to someone else.

It is also why I got into the writing in the first place. There are doctors who will never get a publication, never get an award, never get a Substack post written about them. The Last Doctor is, in a way, my attempt to put one of them on the page anyway. Michael isn't real. But he's also every attending I ever loved.

If the book ever gets made into something — and the Black List process is a long shot, I know that, every working physician knows that, the odds are bad and the readers are honest — the line of dialogue the girl gets in the epilogue is borrowed. It is a line an attending of mine said to me in a hallway in 1995. He said it once. He probably forgot. I have used it for thirty years.

That's what I want to mark, this week. Not the anniversary itself. The chain.

Tomorrow I'll be on a plane. I'll have A Taste for Lunacy open on my laptop — the screenplay rewrite is close to done, v6 under 120 pages, Stanley moved into the mentor-archaeologist role he was always supposed to occupy. Mentors. It's apparently a theme. https://blcklst.com/

And if a young doctor asks me, this week or next, why I keep doing this — the practice, the AAFP work, the writing, the reading, the teaching, the showing up — I will probably say something that isn't fully mine.

That's okay.

It was never supposed to be fully mine.

The whole point is to give it forward, in someone else's voice, and trust them to give it forward again, in a voice you'll never hear.

— Andrew