regimen. It wasn't that she was rebellious. She just wanted to live like a normal person and was having too much fun to pay attention to the directives. But the severity of her disease was going to ruin her eyes, kidneys, and heart before she reached middle age.

Like many interns before me, I sought an explanation from her. "You know that you're killing yourself. Why don't you take your insulin like you're supposed to? Why do you drink so much?"

"Because I'm a human being, or haven't you noticed?" Wink, wink. She was attractive, but the disease was taking its toll. She had scars from poorly healing skin ulcers, and her complexion was sallow. "Besides," she added, "I'm going to die, one way or another. I prefer to enjoy life." My inexperience with chronically ill patients made me stupid. "But you're cutting years off your life," I told her.

It was her turn to educate me. "Oh, you doctors," she grinned. "You don't know so much. If I listened to you, I wouldn't eat anything I like, go outside, or have sex. What would be left? Work? This   hospital?"

The more she spoke, the more I liked her. "You know, I'm going out with a doctor," she said. "He's really cute. He never tries to tell me what to do. I just want to feel good. Can't you see that? It's my life." She wiped her eyes, then smiled and asked, "So, do I have to stay?"

"I'm afraid so. Your blood sugar is over 600 and you have ketones in your blood. You know what that means."

"Sure do. Okay, get me out of here quick. But I'll only stay if I get to eat cake," she asserted.

"What?"

As sick as she was, she was mischievous. "I know what you're gonna do. I don't want that ADA diet," she said, referring to the guidelines put out by the American Diabetes Association. "It's like eating cardboard. I want to eat cake."

"The food here stinks," I said. "You can have cake when you go home. I'm not allowed to give it to you."

It was the patient's turn to
educate me. "Oh, you doctors," she grinned. "You don't know
so much."

"Then sign me outta here. No cake, no deal."

I thought about it for a moment. We were going to be replacing her body fluids and electrolytes with aggressive IV therapy and infusing her with repeated doses of insulin. We didn't have any chance to change her attitude, which was all that stood between her and despair.

"Cake it is."

"I don't really have a boyfriend," she said. "Are you interested?"

I walked from the room, laughing and shaking my head. I found out later that she wound up dating a medical student.

Hope isn't just about total success or failure, or about living or dying. It's about gradations of success, about things working out a little bit better than they might have. Hope is about a child suffering less pain or a wound healing with a smaller scar. It's about chest pain not being a heart attack or being a smaller one. At the very least, it's what I mean when I say, to every patient, "I hope you feel better."

There's always room for hope. Attitude counts for a lot in life, but never more than when it gives you strength during difficult times. In my opinion, being sick in the ER qualifies as hard times. In these moments of misery, you must strive to be strong.

As a patient, you should realize that it's much easier for a doctor to care for you when you are trying to get well, when you are making your best effort to understand your situation and to cooperate in the approach that your doctor has chosen to return you to good health. Everyone roots for a trooper. When you are either passive or negative, your doctor may misinterpret your mood as meaning that you don't care that much or even that you are angry.

In most of what any of us do, there is probably a desired outcome. When you walk on the beach, you hope for majestic waves, breaching whales, and magnificent sunsets. When you take a test, you hope for a good score. When you sleep, you hope for peaceful rest devoid of interruption. Think of any situation in which you are a participant, and you hope for something. Even when you have no expectation of achieving what you hope for, you are still hoping. That's a good thing, because it usually means that you care about what happens.

When you give up hope, it should be because you have come to peace, even if in surrender. If someone with you is giving up hope, then try to bring him or her to peace so that the ending is not a failure. And once you have accepted something as being in your past, then begin as quickly as possible to hope again.