When Meredith greets Derek in the elevator, Cristina realizes that they're back on. Meredith feels guilty about it, since Cristina has lost Burke, and tells him they have to keep things between them a secret. Cristina pretends to be severely depressed about her breakup and gets Meredith to swap a surgery for a shift supervising interns in the pit.
Derek complains to Mark about the secrecy with Meredith and Mark is surprised that Derek didn't really break up with her. He tells Derek that he's foolish for hoping they'll officially get back together and is skeptical when Derek says he's not expecting that.
A chatty patient, Cathy, is told she's going to have to lose 60 percent of her tongue due to cancer. She's devastated to hear that the reconstructive surgery planned will leave her nearly unable to talk. Richard decides to try an innovative new surgery that would reactivate the nerve in her tongue. Mark is convinced, although George worries that neither of them has ever done it before.
Izzie anxiously waits for George to see if he's told Callie, but he hasn't. Izzie takes him aside, into the room where the semi-comatose Really Old Guy is, to ask him why not, but they're interrupted by her interns.
To everyone's great surprise, the elderly patient, who's been in a coma for a year, wakes up and objects to being referred to as Really Old Guy. He announces his name is Charlie and that he's only woken up because he's plans to die today. While Izzie examines him, he reveals that he knows everything about all the residents, after the year they spent lunching and gossiping in his room. He insists that George isn't going to leave his wife for Izzie because men never do. She freaks out and insists that George tell Callie tonight but he says he's going to do it in his own way.
Charlie starts pulling his tubes and wires out to help expedite his death and Izzie is so annoyed with him, she helps him, until an intern points out that he's stopped breathing. They manage to bring him back, but he begs Izzie to stop saving his life. Izzie tells him he's probably right about George and then she realizes that Charlie has died, just like he said he would. She calls the residents and George to say some nice things about him in tribute. Izzie declares that he was a bastard, but one who knew what he wanted. And that gives her hope that you can get what you want, eventually.
Alex is saddled with a middle-aged intern named Norman and wants to dump him on the clinic. Miranda insists that she first needs a favor from him: He has to treat a teenage boy whose mother has brought him in because she suspects he's on drugs. Alex tries to explain that his altered behavior can have a variety of causes, but Norman sides with the mother, praising her intuition. The drug test comes back negative and it looks like the boy is just going through normal teenage moodiness, until he starts spouting gibberish. Alex orders a neural exam. The boy has hydrocephalis, which is impacting his speech.
During the tongue surgery, Mark isn't sure what to do next as he's never done this before. They realize they need an extra set of hands and send George to fetch Derek. The teenage boy collapses and Alex runs to get Derek, who's busy with the tongue surgery. He tells Alex what to do: He needs to stick a needle behind the patient's eye into his brain, which saves his life.
Meredith has to supervise Lexie and when the paramedics bring in a man who's not breathing, Meredith has Lexie perform her first intubation on him. The man dies and Lexie is horrified that Meredith didn't do more for him. Meredith explains that the man was already dead when he came in and that her responsibility is to teach Lexie. Since Lexie seems unwilling to learn from Meredith, she orders her to go to the clinic. Miranda is upset that the clinic is being treated as a dumping ground and orders her to go back, but Lexie begs her to stay since Meredith obviously hates her.Miranda tells Meredith that Lexie thinks she hates her and her mother, Susan -- who died under Meredith's care. Miranda insists that Meredith's job is to help Lexie be a better doctor. Meredith tells Lexie that she was very fond of Susan and then explains every detail of what went wrong on the day she died.
Richard frets that he's left Adele waiting because of the surgery. Derek advises him to tell her the truth about how much he's missed her.
Meredith overhears Cristina boasting about the cool tongue surgery and realizes she's been faking her sadness. She confronts her and Cristina says she's dealing. And that she doesn't need to be "protected" from the news that Meredith's back with Derek.
The new batch of interns, who have no idea that George is repeating his internship, consider him "the best intern ever," until Alex points out that George is a repeater and that if they really want to learn from someone, they should learn from a resident.
Miranda updates Callie, who's been doing paperwork all day, on all the residents' dumping of interns, but Callie couldn't care less. Callie says she knows Miranda better at her job but she doesn't want to fight her, or anyone, so she's just going to do paperwork. Miranda admits she's having trouble with being #2 when she used to be #1, but she's going to help Callie since she obviously needs it. Callie accepts, with relief.
That night, George finally tells Callie about Izzie.