Sitting on the high granite ledge overlooking the fog as it drifted onto the valley floor, obscuring the golden headlights as they weaved on hidden roads, carrying hidden lives, I finally felt a semblance of peace.  I had come here to escape the tragedy that had rocked me, my medical school class, and the Stanford community earlier that week.

Maria Birukova was a fourth year medical and PhD student from Stanford.  She was also the only child of two physician-scientists from Russia, a Yale graduate, an avid climber, outdoorswoman, and great friend to hundreds, myself included. On September 18th, 2016, her footing broke loose while she was climbing un-roped on Bear Peak Spire in the Eastern Sierras in California, and she fell nearly 1000 feet to her death. From all reports, the terrain she was on was easy for her, like climbing a set of stairs. She had done similar ascents many times in the past. Of course, in the end none of that matters.  Over the course of medical school, I have witnessed many patients dying or near death, but this news felt different. I had too many memories, knew her too well. And suddenly, I couldn’t walk out of a hospital room and leave them all behind.

I met Maria on the SWEAT backpacking trip that kicked off our first year as Stanford med students.  She was short, barely 5 feet tall, with tan skin, dirty-blond hair, and a muscular body.  She was coming off of a 6 month climbing escapade that had capped her last year at Yale during which she lived in her van and, as she made very apparent and for which I immediately loved her, ate primarily cheese. She was friendly, easy to talk to, and, as I would get to know better later, incredibly non-judgemental.  She seemed to float through the mountains carrying her heavy backpack with ease, comfortable with herself, the world, and her place in it. I envied her that comfort, but was also sure it would fade under the pressures of med school.

I soon learned how wrong I was.  Maria never seemed to feel the pressure around her. Our first year we brewed beer together, with Maria carefully measuring the volumes and temperatures while I relaxed on the couch and cleaned her fridge out of cheese.  She came up with the name “Eye Opener” for our coffee stout, a reference to the CAGE questions we had meticulously rehearsed and then gleefully disregarded in our own lives. Our second year she shared in my joy at my wedding, and comforted me after I lost one of the most important people in my life, also suddenly, unfairly, and in his prime.  She patiently listened to my bitter ruminations on the injustice of death and responded as she always did, with wisdom beyond her years. Our third year I went off to the rigors of clinics, and she started her PhD work on combating biofilms.  I didn’t see her much during that time period, but I thought of her often.

I was walking out of neurology clinic when my phone lit up and I learned of her death.  I had cancelled plans to meet up with her just a couple of days prior, and it seemed impossible that those plans would now go forever unfulfilled.  Somehow it seemed that the fullness with which she had lived, the joy she had brought to life, would protect her against the possibility of death. She was nothing like the frail bodies that had slipped away in the hospital after months of struggling and multitudes of advanced medical interventions that prolonged quantity, if not quality, of life.  She was not at the end of her career with decades of stories and close calls, with most of her plans already lived.  There were no comforting words that could make sense of it. But that’s just the thing about death.  It strikes unpredictably, unfairly, with little discrimination, and is mostly utterly out of our control.

In our clinical years as medical students, we inevitably see a lot of death.  It is often at the end of someone’s time, when life might seem the crueler option.  But it often isn’t. I just spent the afternoon telling a thirty-something newlywed man with children that he had an inoperable brain tumor.  I recently came off of a service where we made a late twenty-something woman comfort care for her end-stage cervical cancer. Death is ugly. Maybe that is why we reflexively brush over its harshness with bland platitudes or falsely optimistic generalities. I have spoken these statements in an attempt to comfort many  grieving families.  Now on the receiving end, I realized how little they soothe the reality of a potential unfulfilled, of loved ones left lonely, of the injustice of it all.  Telling that patient that his brain tumor was inoperable, it struck me that what I would want in his situation is not inflated statements of hope, or put another way, the avoidance of realism, but simple acknowledgement of my humanity beyond my disease and some understanding of the past I had lived and the future that had been robbed from me.

With that sentiment in mind, what was most important about Maria, and what I think she would want to be remembered by is not her death, but her life.  I think she would want the world to know that she loved cheese and could brew a mean stout rather than the details of her fall. Or know that she lived creatively, independently, without apology, and did not postpone life today out of the misplaced pursuit of a better life tomorrow.   If I’m honest, I was jealous of her: jealous of her ability to forget the pressures of medical school and drive 8 hours after class to pull over alongside an old forest road and sleep under the stars.  Jealous of her willingness to try anything and everything without hesitation, from kayaking, to beer brewing, to mountain climbing.  Jealous of her humility, her ability to be wrong and ask questions, and be imperfect in the face of so many polished facades.  She was so much herself, so comfortable in her own skin, so happy and content to just exist.  

If I were a patient with end-stage illness, these are the details I would want my doctor to know. I also think they are the hardest to talk about, because they mean getting to know someone, really know someone, who is about to die. I know better now how much that hurts. But I hope I also now have a better understanding of just how important it is.