Happiness and physiology

“Man is an animal, and his happiness depends upon his physiology more than he likes to think … Unhappy businessmen, I am convinced, would increase their happiness more by walking six miles every day than by any conceivable change of philosophy.”

—Bertrand Russell

Dr. Kolhouse and the Cowboy

(Author: Mark Earnest, M.D., Ph.D.)

Published September 20, 2025 N Engl J Med 2025;393:1151-1153 

Link: DOI: 10.1056/NEJMp2501894 VOL. 393 NO. 12

It was my first day on the oncology ward as an intern, and Dr. Kolhouse, my attending, was telling us about the patients we were about to meet. It was the first time I’d met him, but his reputation preceded him. Everyone loved Fred Kolhouse. Shorter than I, with a stocky build and receding gray hair, he had a staccato, surging way of speaking. Words and phrases tumbled out in bursts, often punctuated with a sort of chuckle of one or two beats, usually when he was describing something personal and unexpected about a patient or acknowledging some irony.

“This guy has probably spent more nights sleeping under the stars than under a roof. I’m not sure he’d ever seen a doctor before he was diagnosed.” Dr. Kolhouse went on, “Just imagine that. You see a doctor for the first time, and he tells you you have a cancer on your penis. A few months later,” he said, shaking his head, “we’ve cut it off, and now we’ve got him locked up in a hospital dripping poison in his arm.”

The cancer was advanced when it was diagnosed and had since spread widely. This chemo regimen was the cowboy’s last option. It might buy him some more months, Dr. Kolhouse explained, but it would not be curative.

We moved on to other patients. Like the cowboy, most of them were there for chemotherapy, since routine outpatient infusions were still some years away. After we’d finished reviewing the patients, I made my own rounds to meet them all.

The cowboy was sitting on the edge of his bed when I entered his room. His back was straight, his hands resting palm down on his thighs like he was preparing to get up and go somewhere. The IV pole at the head of his bed held a bag of fluid with a single tube extending down to his left shoulder where it disappeared under his gown. He had cinched the ties of his hospital gown tightly in the back so it was drawn closely across his neck. Draped over a chair were a pressed pair of Wrangler jeans and a plaid Western shirt with white piping and pointed yokes. His boots sat neatly in front of the chair, and a gray felt cowboy hat rested on the bedside table. In place of boots, a pair of hospital-issued foam slippers covered his feet.

I introduced myself, explained my role on the team, and asked how he was doing. He answered my questions succinctly, calling me “sir” even though he was 15 years my senior.

“How are you feeling?”
“Fine, sir.”
“Is there anything you need? Anything I can do for you?”
“No, sir.”

As we spoke, I noticed a few more details. Across his forehead was a line. Above it, where a hat might sit, the skin was fair and smooth. Below that, his skin was dark, lined, and weathered. His dark hair was still damp from the shower and had been combed straight across from right to left — the teeth of his comb had left furrows running perpendicular to the part.

Despite my best efforts to engage him, our conversation was brief, and I soon left his room to make my way around the rest of the ward.

In the days that followed, I tried everything I could think of to get him to open up but had no luck. I never got more than a few syllables out of him, followed by a “sir.” Open-ended questions about his life and interests drew short, unrevealing answers. He had no complaints and no questions and was always sitting on the side of the bed in the same pose whenever I entered his room.
Toward the end of the week, Dr. Kolhouse threw out a new detail about the cowboy. “Did you know that he’s never been to the National Western?” he asked, shaking his head and chuckling. “He’s lived his whole life less than 100 miles from here, and he’s never been. Not once.”
New to Denver, I knew little about the event. Dr. Kolhouse explained that for nearly a century, Denver had hosted the National Western Stock Show. For 2 weeks every January, ranchers and cowboys from throughout the country would bring their prize livestock to Denver for show and auction and to watch the world’s best rodeo riders compete. Opening day was the next day, and it was a really big deal.

“I can’t believe it. It’s like living next to Mecca and never making the Hajj,” Dr. Kolhouse chuckled. “People come from everywhere for this, and he’s never been. It’s like cowboy heaven — like their best day ever. And it’s in his backyard!”

The cowboy was fully dressed when I knocked on his door the next morning — Wranglers, boots, Western shirt. The hat was on the bed, and he was putting a few stray items in a plastic bag. The IV was unhooked, a half bag of chemo still hanging on the pole.

“What’s happening?” I asked, knowing he had several more days of chemo scheduled.
“I’m going to the stock show,” he said flatly. He reached into his breast pocket, fished out two items, and held them out for me to see. One was a ticket to the National Western Stock Show. The other was a crisp $100 bill.

“That doctor came in this morning and gave these to me. He said there’d be a cab out front to take me over there” — he paused and looked up at the wall clock — “in about 10 minutes. I gotta get moving.”

“Which doctor?” I asked, though I thought I knew.

“The short one, with the gray hair.”

I shook his hand, wished him well, and watched him walk down the hall to the elevator, his hat tucked under his arm as his boots clacked on the polished floor.

Later that morning during rounds, Dr. Kolhouse paused by the cowboy’s empty room. He stepped into the open doorway and leaned against the sill. “Most people will take more days if you offer them. Our job is to be honest and do our best to let them know what those days will cost them. It’s one thing to give up a few days or even a few months of your life for a chance at a cure or a long-term remission. It’s another entirely if you’re just trading a few good days now for a few not-so-good days later. And if what you’re giving up is something really special.…” He paused as he looked over his shoulder into the room. “Well, if you’re giving up something special, you really need to be getting something great in exchange.”

Dr. Kolhouse shook his head. “We weren’t doing him any good.” He shifted his weight off the doorsill and moved into the hall. “No good at all.” He turned, walked to the next patient’s room, and resumed our rounds.

I never saw the cowboy again. Several months later, I stopped Dr. Kolhouse in the hall and asked what had happened to him. The cowboy, I learned, had recently died in a small Wyoming hospice, looking out on the chaparral he’d wandered through his whole life. Since that January morning, he hadn’t stepped foot in a hospital and, according to Dr. Kolhouse, hadn’t received “a molecule more chemotherapy.”

Dr. Kolhouse smiled and ignored the solitary tear that slid down the side of his nose. “You know, he was riding horses right up to the end, that guy.” He shook his head and chuckled. He nodded at me, said how good it was to see me, and walked away with the stride of a man in the midst of a good day.

Over time, I learned that Dr. Kolhouse’s care of the cowboy was the rule rather than the exception. His attention to each of his patients was deep and personal. He had an uncanny knack for uncovering the things that mattered most to them and took great delight in discovering the small details of their lives that revealed their character and each one’s unique definition of a good day. In the month we spent together, I never discovered a personal detail about one of our patients that Dr. Kolhouse didn’t already know. His secret, in part, was time and attention. He sat down alone with each patient every day, often early in the morning. His affinity for people with calloused hands and modest means and his tendency to beat everyone else to work each morning were perhaps unsurprising in an Indiana farm boy who had once finished his chores before school each day.

The greatest measure of his devotion to his patients, though, may have been his honesty about what each of them faced — and what he could realistically offer. His commitment was always clear: to ensure that each of his patients lived as many good days as they possibly could…even when that meant paying for them out of his own pocket.

Dr. Fred Kolhouse was diagnosed with advanced esophageal cancer in April 2010. He died at home 2 months later, after 67 years of mostly good days.

Avocado and Salt

(By Dr. Grace Yi, M.S.P.H.)

The first time I saw a man die in a trauma bay, it looked kind of like it does in the movies. He died gruesomely in front of his wife and teenage son, amid a flock of medical staff who’d come to rubberneck. Except the blood wasn’t fake, the family’s screams were real, and I didn’t know how to talk about it.

Over time, I learned some of the words I was supposed to say. On rounds, I cheerily greeted a man with an open wound bisecting his swollen belly up to his sternum. Peering at his insides through layers of bubblegum-pink flesh, I asked about his youngest daughter and documented his bowel movements. I gossiped about ex-boyfriends with a woman as a tumor scavenged her insides and gnawed tunnels through her skin. I told her I liked the freckles across the bridge of her nose; her daughter had them too. “I’m bulletproof,” she told me, as we waited for her to die. She was 2 years older than I was. As I saw more people die, I began to associate the experience less with movies and more with real life.

One man had come into the emergency department burning. His entire body was charred, even the inside of his throat; his tattoos, somehow, were not. Though death was inevitable, the medical team tried desperately to save him. That night, I showered twice to get the smell out of my hair and his screams out of my head.

I wondered if I could ward off trauma with good behavior. I started driving home more carefully at night, staying under the speed limit on wide-open roads, slowing down at yellow lights at empty intersections. I added my mom and my partner on Find My Friends, intermittently checking that they were where they were supposed to be and not in an ED or a ditch somewhere. I imagined a hundred scenarios for each call sent to voicemail. I went out of my way to recycle, in case karmic justice did too.

Around 1 a.m. one night, I sat alone with a dead man after he’d undergone a last-ditch thoracotomy. He was unnamed, presumed to be unhoused, and completely naked except for mismatched socks — green and neon pink. He had been struck by a car that had kept on driving. I, a medical student whose most laudable contribution was staying out of the way, had been tasked with sewing him up, “for the morgue,” the attending said. “It doesn’t have to be pretty.”

I had never been so close to a dead person, and I was afraid to look at his face. Someone drew the curtain shut, leaving us alone. I pushed his lung, still warm, back inside his skin, now cold. He fit together. When I finally looked, he was wide-eyed, as if he was just as surprised as the rest of us to find himself there. Reaching inside him felt like a deep violation, an uninvited intimacy. I gripped the hemostat clamp so hard that my thumb started to blister. I have never tried harder to get my sutures just right.

As I worked, I wondered: Had he suffered while alive, and did he suffer as he died? If you die and no one knows, what does your death mean? If no one grieves your death, what did your life mean? It took me 45 minutes. Someone more experienced could have done better, surely. But I tried to be gentle. I wondered if he could see us, from wherever he was, and I hoped he knew I was doing my best.

On the first day after a year of clinical rotations, I went on a silent meditation retreat.

For 7 days, there was no external stimulation: no phones, no books; talking was forbidden, even eye contact discouraged. We were to coexist with 60 other women with eyes downcast, willows wafting together in an imperceptible wind.

Just after a monthlong trauma surgery rotation, the newfound silence of the retreat was jarring. We had 8 hours of community meditation practice each day and a lecture on the Buddhist Dharma around dusk. Some women, already expert meditators, seemed to quickly find inner peace. With little prior meditation experience, I wandered the wilderness of my mind, wondering if the Buddha ever dozed off when he meditated, especially after lunch. Didn’t he ever get tired of sitting cross-legged? By the evenings, I struggled even to sit up straight. I envied his open hip flexors.

The meditation center’s campus boasted miles of loosely maintained wooded trails that branched and interweaved like cobwebs. I explored in my downtime. Whenever I thought I’d stumbled upon an untraveled path, a stone carving of the Buddha’s head would materialize — sometimes resting on a tree stump, sometimes embedded in the trunk. The frequency of these sightings felt intentional. Though only his head appeared, the Buddha always seemed to be in repose, his eyes never fully open. I wondered if half-lidded eyes permitted profound insights, or if he was just sleepy.

On my second day, following a new trail, I arrived at a stone structure on which dozens of notes and pictures had been taped. A laminated sign indicated that this was a shrine for the departed, who were honored in an annual ceremony. A few small figurines — a Mickey Mouse keychain, a baseball-player bobblehead — were tucked into cracks. I counted 27 notes addressed “to Mom.” It was gutting to contemplate the pain of losing a mother, my mother, and yet…here that experience seemed so ubiquitous, even mundane. How the world must have stopped for each of these people — how unmoored they must have felt when, somehow, life around them carried on.

I took to visiting the shrine each day, almost compulsively. I reread any visible letters and cried each time. I fought the urge to dislodge notes wedged in crevices, wanting desperately to see what words had been written without any intention of having them read. Though I encountered no one else, each day I discovered new additions: for a husband, a mother, a son. The silence in the meditation hall took on a new flavor — there was now sorrow, a sense of longing. One new addition to the shrine stood out: a note with a photo of an older couple. In the photo, I recognized the woman who sat behind me every day in the meditation hall. She wrote to her husband of 60 years, who had died 3 months earlier: “Rest, my love. The journey, for now, is done.”

I found myself drawn to her. Sneaking glances, I looked for signs of wear, anything that might betray an interior rotted from grief. How did she go on? When she sat across from me at lunch one day, I studied her. As she spread avocado on a piece of bread, I noticed the gold wedding band on her finger. She motioned for the salt and smiled when I passed it to her. I looked for tears as she chewed her toast. She finished eating and left.

The Dharma teaches that pain is inevitable but suffering is not. The cause of suffering is wanting the world to be different from how it is now. It’s human nature to want some semblance of control, some promise that life has meaning, things work out, good people prevail over bad. The more we cling to this lie, the more it shackles us.

Although I felt naturally inclined toward emergency medicine, my main hesitation was this: the more time I spent in the trauma bay, the more convinced I was that bad things would happen to people I love. Tragedy was like a rabid dog: as long as you didn’t look it directly in the eye, you might get out unscathed. I distanced myself from toddlers thrown through windshields, elderly couples horrifically rear-ended, a nameless man with unmatched socks who was cut open and stitched back together by my own fumbling hands so his heart wouldn’t tumble out onto the floor of the morgue. What a mess that would have been to clean.

But perhaps when we understand that pain is inevitable, when we reckon with our own mortality and the mortality of everyone we have ever known, some space opens up. I wonder if making physical contact with trauma every day gives us greater capacity to sit with others in their grief and not cower. I wonder if any form of contact with people — whether joyous or heart-wrenching — makes us feel more alive in our humanity.

On the final day of the retreat, hours away from being released back into the Real World, we were asked to create and share one-sentence mantras meant to anchor us to some truth. From behind me came the woman’s voice, revealing her mantra.

“It’s like this now.”

Notes

This article was published on July 19, 2025, at NEJM.org.

An extremely important lesson of life..

 

If a father can wish only one thing for his son!

 

Dichotomy of society

 

A teaching strategy

ایک استاد کہتے ہیں

میں ایک پرائمری اسکول میں منتقل ہوا۔ پرنسپل نے مجھے تیسری جماعت پڑھانے کے لیے دیا اور اپنے دفتر بلایا۔ انہوں نے کہا: "میں تم سے صاف صاف بات کرتا ہوں۔ ہمارے اسکول میں تیسری جماعت کی تین کلاسیں ہیں۔ اس تعلیمی سال ہم نے باقی اساتذہ کے ساتھ مل کر فیصلہ کیا ہے کہ ان میں سے دو کلاسوں میں بہترین طلبہ ہوں گے، اور جو تیسری کلاس تمہیں ملی ہے اس کے تمام طلبہ ناکام اور ناامید ہیں۔ اگر تم ان میں سے تین یا چار کو بھی بہتر بنا سکے تو تمہیں پورا احترام ملے گا، اور اگر نہ بنا سکے تو کوئی الزام نہیں، کیونکہ ان کے والدین بھی ان کی کمزوری جانتے ہیں۔"

استاد کہتے ہیں:

میں کلاس میں داخل ہوا اور ہر طالب علم سے پوچھا: "جب تم بڑے ہوگے تو کیا بننا چاہتے ہو؟"

کچھ نے کہا: فوجی افسر، کچھ نے کہا: ڈاکٹر، اور کسی نے کہا: انجینئر۔

یہ سن کر میرے دل کو بہت خوشی ہوئی اور میں نے کہا: "الحمدللہ! ان کے خواب اب تک مرے نہیں ہیں۔"

اگلے دن میں نے طلبہ کی نشستیں ان کے خوابوں کے مطابق بدل دیں: افسر ایک ساتھ بیٹھیں، ڈاکٹر ایک ساتھ، انجینئر ایک ساتھ۔ اور میں نے ان کی کتابوں پر ان کے خواب کا لقب لکھ دیا:

افسر محمد!

ڈاکٹر عبداللہ!

انجینئر خالد!

پھر میں نے اپنی تدریس کا آغاز کیا اور اپنے ذہن میں یہ بات بٹھا لی کہ یہ سب طلبہ دوسرے بچوں کی طرح ہیں، یہ کمزور نہیں ہیں۔

یقیناً ان میں سے کوئی غلطی کرتا، کوئی سستی کرتا، اور کوئی ہوم ورک نہیں کرتا وغیرہ۔

یہاں سزا دینے کی باری آئی!

لیکن میری سزا مختلف تھی۔ میں انہیں نہیں مارتا تھا، بلکہ صرف ان کا لقب چھین لیتا تھا، اور یوں ان کے خواب چھین لیتا تھا۔ پھر انہیں ایک خاص جگہ بٹھاتا تھا جسے ہم نے "گلی" کا نام دیا تھا۔ یہ انہیں بہت تکلیف دیتا، اور وہ اپنی پوری کوشش کرتے کہ دوبارہ اپنی کرسی اور اپنا پسندیدہ لقب واپس حاصل کریں۔

اس طریقے سے طلبہ کا معیار بلند ہوگیا۔ وہ روزانہ ہوم ورک کرنے لگے، دل لگا کر پڑھنے لگے، اور آپس میں اچھی مسابقت پیدا ہوگئی۔ میں کبھی کبھار انہیں تحفے بھی دیتا جو ان کے خواب کے شعبے سے متعلق ہوتے۔

پہلے سمسٹر کے آخر میں میری پوری کلاس کو پڑھائی، اسکول اور استاد سے محبت ہوگئی۔ اب شاذ و نادر ہی کسی کو "گلی" میں بیٹھانا پڑتا۔

سال کے آخر میں، الحمدللہ، میری کلاس نے باقی دونوں کلاسوں کو بڑے فرق سے پیچھے چھوڑ دیا۔

پرنسپل اور دوسرے اساتذہ نے مجھ سے پوچھا:

"خدا کے لیے بتاؤ، تم نے کون سا تدریسی طریقہ اپنایا جس نے ان بچوں کو اتنا بدل دیا اور ان کا معیار حیران کن حد تک بلند کردیا؟"

تو میرا جواب یہ تھا:

"میرا تدریسی طریقہ اور انداز تمہارے جیسا ہی ہے، فرق صرف اتنا 

ہے کہ میں نے ہر طالب علم کو اپنے خواب کا دفاع کرنے پر لگا دیا۔"

عربی سے ترجمہ شدہ 

On irrationality of human mind to manage money

In 1971, Yale professor Martin Shubik invented a game that highlighted one of the most powerful psychological traps.

He auctioned off a dollar bill to students with simple rules: the highest bidder wins.

But there was a twist that proved just how irrational humans can be. 

Here’s how it worked: 

The highest bidder wins the dollar, but the second-highest bidder must pay their bid and receives nothing.

Everything seems rational until the bidding hits 95 cents.

Now, the second-place team faces a choice. 

They’re at 90 cents, so if they stop now, they lose 90 cents.

But if they bid $1, they only lose 5 cents (so they bid $1).

Now the other person is at 95 cents.

This is where psychology takes over.

The person at 95 cents thinks: “I can bid $1.05 and lose 5 cents instead of 95 cents.”

The other bidder at $1 thinks the same thing: “I’ll bid $1.10 and only lose 10 cents instead of a dollar.”

Back and forth they go.

Shubik regularly got students to pay over $3 for his dollar.

The record in his class was $204!

Two students spent over $200 combined so one could “win” a single dollar bill.

Three forces create this trap:

First is loss aversion: Losing $95 feels twice as painful as winning $5 feels good.

Second is commitment escalation: Each bid makes you more invested in winning. You’ve come this far, so why stop now?

Third is competitive arousal: Once someone else is bidding against you, it becomes about beating them, not the dollar.

Your brain simply stops calculating value and just wants to win.

Marketers use these exact triggers every single day.

Here’s how this get used in your ads :

Create micro-commitments before the sale with quiz funnels, email captures, free trials, and more. Each step makes backing out feel like a loss.

Show competitive dynamics like “387 people bought this today,” or “Just 99 left in stock.”

Add escalating bonuses like “Spend $50, get 10% off. Spend $100, get 20% off.”

Sex and Love making

"It was a good sex." - I quipped

Us ne bister pe lete lete cigerette sulgaya, aur kash laga ker boli:

 -  Jise tum sex kehte ho, main 'love making' kehti hun !!

The leader

 

Parents are the best role models

 

Father of thousands of orphans

عبدالستار ایدھی صاحب سے پوچھا گیا کہ مغرب میں بے حیائی بہت ھے ‏کنواری عورتیں ماں بن جاتیں ہیں - ‏انہوں نے کہا  شاید بنتی ہونگی مگر میں تو اتنا جانتا ہوں کہ ادھر پاکستان  میں بائیس ہزار بچوں کی ولدیت کے خانے میں میرا نام لکھا ہے۔

 

On "Fallen Youths"

 “Why are we worn out? Why do we, who start out so passionate, brave, noble, believing, become totally bankrupt by the age of thirty or thirty-five? Why is it that one is extinguished by consumption, another puts a bullet in his head, a third seeks oblivion in vodka, cards, and a fourth, to stifle fear and anguish, cynically tramples underfoot the portrait of his pure, beautiful youth? Why is it that, once fallen, we do not try to rise, and, having lost one thing, we do not seek another? Why?”

~Anton Chekhov

Sharpasand

 Someone asked to see a Pakistani TV drama: Sharpasand as I love Nauman Ejaz. What a spontaneous actor he is.

Due to my work's heavy schedule, I was able to see only the initial 3/4 episodes - but I realized:

"Hum sab ke andar aik farasat ali khan rehta hai'

Teacher

 As someone beautifully said - and has been told in all cultures across the globe:

"A teacher is equivalent to a father, as he is the only person in this world who want to see you more successful than him or herself"

Muhabbat ka hisaar

 Suna hai,, bohat ziyada mohabbat bhi saamne wali ki jaan le leti hai

Aadmi kisi ke gird muhabbat ka hisaar zaroor rakhe, magar itna bhi obsessive na ho jayye ke agle ka dum ghut jaaye..

Messiah (vs doctors/physicians/providers/MDs etc)

 Lately, as modern medicine has advanced, many terms have been invented for medical care providers. There is only one thing that distinguishes any medicine man or healer from run-of-the-mill physicians/providers..

"A Human Touch"

Unfortunately, now I see fewer and fewer doctors touching the patient. The warmth, healing power, connection, or even, call it a placebo effect—all have been lost in modern medicine by the loss of just one small gesture.

We are now more and more treating numbers, charts, labs, and computers. AI is making it even worse!

AH!

An important peace of Karachi's history

 

He who stands up for an ignorant people...

It is often said that when Che Guevara was finally captured in his Bolivian hideout—betrayed by a shepherd who revealed his position—one of the astonished soldiers asked the shepherd:

 “How could you betray a man who spent his life defending people like you and fighting for your rights?”

The shepherd, unmoved, calmly replied:

 “His battles frightened my sheep.”

This story reflects a tragic reality in history: many who sacrifice for the oppressed are ultimately abandoned by those they defend.

A similar episode took place centuries earlier in Egypt, during the French invasion led by Napoleon Bonaparte. The Egyptian commander Mohamed Karim (1751–1799), who valiantly resisted the French in Alexandria, was captured after a long struggle.

The French court sentenced him to death, but Napoleon intervened, saying:

 “I regret executing a man who defended his homeland with such courage. I do not wish history to remember me as a killer of heroes. I will pardon you—if you can pay 10,000 gold coins as compensation for my army’s losses.”

Karim laughed and replied:

 “I have no such wealth, but the merchants of Alexandria owe me more than 100,000 gold coins.”

Napoleon granted him time to collect the sum. Karim, still in chains and surrounded by soldiers, was taken to the marketplace. There, he pleaded with the wealthy traders—men for whom he had sacrificed everything—to contribute to his ransom.

Not one merchant stepped forward. Instead, they coldly accused him of being responsible for the city’s devastation and their financial troubles.

Heartbroken, Karim was led back to Napoleon. The French commander then declared:

 “I will not kill you because you fought against me, but because you sacrificed yourself for a cowardly people who love trade more than freedom.”

Years later, the reformist scholar Mohamed Rashid Rida (1865–1935) reflected on such tragedies, writing:

 “He who stands up for an ignorant people is like one who sets his own body on fire to light the way for the blind.”

Three Lessons of Life