Derek is in a serious depression and refuses to go to work after losing his pregnant patient and being hit by a lawsuit.
Mark hasn't operated in days, because his hand is still swollen after the fistfight with Derek. Lexie urges him to talk Derek out of his funk and Mark points out he's hardly the right person to do that.
Cristina wakes Owen, who's napping on a cot at the hospital. Coming out of a nightmare, he shoves her violently, resulting in a cut to her arm. He bandages the cut and tells her to rest her arm and not do any work for the day.
Richard is cranky because he's now lost the services of Derek, Mark and Cristina. He's also mad at Miranda for having chosen pediatrics over general surgery.
Derek's depression deepens after he meets with his lawyers and they tell him he's lost more patients than he's saved. "Most of those were terminal patients," Meredith reminds him. "You were their last chance," she says, and urges him to look at the big picture.
"This is the big picture," he insists, staring at the far-larger pile of his patients who died.
Izzie gathers the interns to diagnose the case of a "Patient X," that they don't know is really her. The interns can't find anything wrong. "She's fine," they all agree, and Izzie shouts, "No, she's not fine!" She orders them to look over the case again. Lexie thinks that there's something in Patient X's brain that they've missed and Izzie tells her she's on the right track.
Miranda suggests closing a patient with staples, not stitches, and Richard snaps that since it's his hospital, they're going to do it his way. "I want all of you people to do what I say," he shouts.
"We have a diagnosis," Lexie announces to Izzie. "Metastatic melanoma." Izzie asks for their prognosis and the interns predict the patient will only live a few months. "The girl's pretty much toast," says one. "Survival rate is five percent," says another. Izzie doesn't let on, but she just says "good job." They want a prize, like last time and she tells them, "The prize is, you didn't screw it up this time. You were doctors today. That's the prize."
Lexie thanks Izzie for the diagnostic exercise. "How would you break the news to Patient X?" Izzie asks. "Screw the odds. My mother died of the hiccups," Lexie says. She decides she'd urge the patient to face the illness and fight.
Adele summons Richard and Miranda to the conference room. "Are you running a hospital here or a playground?" she yells at Richard, and demands he apologize to Miranda. She tells a smug Miranda she's no better, since she called Adele to "tattle on a grown man." They each apologize for the way they've been acting.
Alex makes a diagnosis that could potentially save or kill a high school student suffering from seizures when he decides it's her heart that's the problem. Despite Dr. Robbin's reservations, Alex is proven right. Arizona congratulates Alex on his success and says, "You fix that attitude of yours, you could be the future of this hospital."
Alex runs to tell Izzie about the unexpected praise. He advises her to stop "wasting her time with this Patient X crap," and that she could be a great surgeon. "I don't want to be the future of this hospital if you're not there with me," he says. She answers "Okay," and gives him a big kiss but her smile fades as he walks away.
Derek returns to the hospital, but only to tell Richard that he's not operating. Richard orders him back to work, but Derek just walks away.
After three days with no Derek, his patients begin to switch to other hospitals, so when Miranda tells Richard that the way he yelled at her in the OR is "not okay at all," he walks away without saying a word.
Richard asks for Meredith's help in bringing Derek back. "He's been planning to propose. That's not a man who's planning on being alone."
Lexie announces to Mark that the survival rate for their relationship is probably about "three percent," but that she thinks they shouldn't give up.
Cristina assigns herself back to trauama cases, although Owen wants to let her rest her arm. "I'm a big girl. I can decide when I've had enough trauma," she tells him. "It's going to take more than a bad dream to scare me off."
"It's more than a bad dream," he says and she answers, "I know."
Callie has been avoiding Arizona but ends up stuck in the elevator with her. Arizona tells her, "Sometimes I panic and I misjudge a situation. So, if you're up for it, I'd like to take you to dinner."
"Maybe," says Callie as she walks away. But then she stops the elevator and says, "How's tomorrow?"
Mereidth finds a drunken Derek playing golf at the site of the home he plans to build. He tells her, "I'm not hiding, I'm done. I'm done operating."
When she calls it "quitting," he says, "You wrote the book on quitting." She insists she's here for him now and he replies, "You wanted me out ever since the day I moved in." He tells her she lied to him when she said she was fine. "There's no fixing you. You're a lemon," he says bitterly. She reveals she knows about the ring and he bats it into the distance and yells at her, "Go home."
Izzie picks Cristina of all people, to confide in because she knows Cristina can handle the bad news. On the air vent, Izzie tells Cristina that she has cancer.