Published September 20, 2025
N Engl J Med 2025;393:1151-1153
Link: DOI: 10.1056/NEJMp2501894
VOL. 393 NO. 12
“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.
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