Reader’s Guide

The Reader’s Guide for my novel Death’s Pale Flag consists of a series of questions about the book. The questions are designed to support readers, book clubs, and study groups in exploring some of the book’s central themes. The guide is broken up into two sections. The first is short and takes on major elements of the book, whilst the second gets more into the nitty gritty of each chapter. I would be delighted to discuss any and all questions with individuals and/or groups of any size. Please contact me via email to arrange such discussions at:

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Reader’s Guide

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Ryan Brenan has the world on a string. He is seen as one of the best brain surgeons in his state. He routinely takes on the most complex of cases at his medical center. There’s nothing the natural world can throw at him that he can’t handle.

Unfortunately, it’s not the natural world that he has to worry about. For no obvious reason, Ryan encounters an escalating array of ghosts. That is: spirits, specters, the undead. And they are not about to leave him alone.  

In this novel, the reader is swept up into the high stakes world of modern day neurosurgery — attached at the hip to Ryan as he runs between bleeding brains, relentless tumors, and severed spines. And then we experience with him a whole different world of unspeakable horrors…

Discussion Points


Were the ghosts in this story real?

Do you believe in the possibility of ghosts/spirits/the undead?

What would the affect be on you if you believed you experienced a ghost?

If the ghosts are real, what is their intention?

What was the nature of the Kelly ghost?  An angel? A demon?

What was more unsettling — the ghosts, the surgery scenes, or the stories behind the patient’s injuries/illnesses?

How did the sheer volume of real life carnage, mayhem, and tragedy experienced by the patients in the novel affect you? Do you think it is a realistic reflection of what is seen at a modern medical/trauma center?

How did the stories of the patient’s injuries and illnesses affect you? Did the manner in which they sustained their illnesses/injuries affect your response?

Was Ryan mentally ill?

What will the next five years of Ryan and Kelly’s relationship look like?

What kind of father was Ryan? Husband?

Why do people become workaholics?

Did Ryan’s Afghanistan experiences play into his later breakdown?

What did the appearance of a John Lennon ghost mean to you?

Why couldn’t Ryan ease up on his work?

What else could have/should have Kelly done to bring Ryan back to a more normal existence?

What were the scariest scenes in the novel?

What kind of effect would that much exposure to death and tragedy have on you?

If you were a surgeon, how would you deal with losing someone on the operating table? To harming a patient badly through your ministrations? To being an “accidental killer?”

If you were a marriage counselor, how would you begin with Ryan and Kelly at the worst of their times?

How have you handled making a major mistake in your own work? Does it eat at you? Do you ruminate about it? 

How much do you separate your work life from your home life?

How are you affected by the grace and bravery of the many patients and their family members depicted in the novel? Do you think this is an accurate depiction of most?

By Chapter

Chapter 1

How would it feel to operate on a dying child?

Do you believe in ghosts?

Do you ever scare yourself around your own home?

Chapter 2

What do you think of Ryan’s days?

How many hours a week should a physician work?

How do you function after a lost night of sleep?

What is a “resident?”

Chapter 3

Does the Halloween season make you think of death more than normal? Does it make you more or less sensitive to frights?

Chapter 4

Why was Ryan so incensed by the fire truck driver’s comment about his drinking?

 How would you go about telling a family that their teenager had killed him/herself?

How real are your nightmares?

Chapter 5

How hard is it to leave work at work?

How often doe problems at home affect your work?

Why do you think Ryan enjoys the childish mischief night pranks?

What regressive activities do you enjoy?

How much are people changed by their work and other life circumstances?

Chapter 6

What kind of intelligence is needed to be a superlative physician? Would it need to be different for a surgeon?

How do “book smarts” differ from “street smarts?”

What do you think of how Ryan handles Ernest?

What would it be like to speak to a large group of bereaved family members?

How do you think Ryan did in delivering the bad news? Was he too direct?

How hard would it be to separate oneself and one’s concerns for one’s own loved ones from the tragedies that are witnessed in the hospital?

Chapter 7

What if anything should Ryan do about his nightmares?

What do you think of Ryan’s level of drinking alcohol?

How would your sense of risk change if you were in Ryan’s work?

Chapter 8

What would bother you the most in the care of severely ill or injured people?

How would it feel to look at the brain of a young person that has been decimated by injury?

Do you ever consider how fragile life is or how vulnerable you or your loved one is to injury or illness?

What are your thoughts about how arbitrary injury, illness, and death can be?

Chapter 9

Should Kelly have pursued her conversation with Reverend Ron further? Should Reverend Ron have pursued the conversation further?

How often have you spooked yourself in the dark?

Chapter 10

What spooks you?

Chapter 11

Should Ryan have declined to care for the child?

What do you think of how Kelly handled Ryan’s news about the surgery? Should she have handled it differently?

How do you feel about the suffering and arbitrary deaths of children? Of anyone?

What do you think of how Kelly handled Ryan’s news about the nature of the tumor and the child’s prognosis?

Chapter 12

What do you think of Cara’s apparent nonchalance about the two brain dead trauma patients? 

How invested should a surgeon be in his/her patients? Can they be over-invested?

What would it feel like to watch a child die?

Chapter 13

Why won’t Ryan share his experiences with Kelly? Should he?

How hard should/could Kelly push?

Do you do menial tasks to divert your attention from things that are bothering you? Is this helpful? What tasks do you chose?

Chapter 14

How is your sleep hygiene? 

Do you ever have realistic dreams as you are falling asleep? Can they be difficult to distinguish from reality?

Is Ryan mentally ill?

Chapter 15

Do you ever miss opportunities to savor the golden moments of life? How can you make sure they don’t pass you by?

What simple pleasure bring you the most joy?

Chapter 16

What do you do with your evenings? 

How creative are you with your free time?

Chapter 17

Is Ryan a hero? Was he “brave?” What is brvery?

How might an experience like Ryan’s affect you throughout your life?

If you went through something like Ryan, how would you feel about talking about it in years to come. 

Chapter 18

Why does Ryan frequently ask the residents what they want to do for a patient?

How often are serious mistakes made in the hospital care of a patient?

How can medical errors be minimized?

Should have the nurse and fellow been punished? How should they be handled?

What sort of bad outcome would be easier to take — one in which an identifiable error was made or one in which an error could not be identified?

What do you think of Ryan’s inability to fully trust the other members of his care teams?

Chapter 20

What should Ryan do about his hallucinations?

What should Kelly do about her unravelling husband?

Chapter 21

What do you think about Kelly’s assessment of neurosurgeons’ egos?

Should Kelly expect more commitment from Ryan? How might she address the issue?

What is your experience with workaholics? What would be our advice to their spouses?

Chapter 22

What kind of couple are Ryan and Kelly?

Chapter 23

What is your response to picturing yourself in Cara’s position?

How sustainable is Ryan’s professional lifestyle?

Would you try a dreamcatcher? 

Have you gone with superstition over science at certain times? What were the circumstances?

Chapter 24

How would you respond to Arianna’s concerns?

Chapter 25

What do you think of Ryan enjoying the attractiveness of the young woman at the game?

How do you think you would respond in Ryan’s shoes?

Chapter 26

What do you think of Ryan’s “evidence” for the existence of ghosts? Was he succumbing to the power of suggestion?

What would the existential implications be to you if you firmly believed you had encountered a ghost?

Who, if anybody, would you tell about the experience? How would it impact your mental map of the world? Of life? Of Death?

Chapter 27

How could/should Ryan be sharing his hospital experiences with Kelly?

What would the impact of being around so much death have on you?

Chapter 28

What would Kelly think about Ryan’s ghostly experiences if he told her about them now?

Chapter 29

What would you think of a partner who was behaving like Ryan? How would you handle him/her?

Chapter 30

Why are people so cavalier about risk-taking? 

Are the behaviors described in the chapter a form of child abuse?

Chapter 31

How would you feel as a surgeon if so many of your patients sustained their injuries from ill-advised behaviors?

Does modern medicine keep people alive for too long?

Is the father responsible for Alex’s death? How would you treat him if you had to interact with him as the treating physician?

How would you decompress after a weekend like the one Ryan was experiencing?

Chapter 33

Why does Ryan continue to resist sharing his supernatural interactions with Kelly? Is this a male thing?

What are your feelings toward Ryan at this point? Do you feel frustrated or angry with him? 

Is Ryan’s medical OCD justified? Is his partner at fault? What should be the limits of a physician’s duty to a patient?

Chapter 34

What do you think of Matt’s assessment?

How would you respond to being called a “serial accidental killer?”

How should Matt have responded to Ryan’s admissions about supernatural occurrences?

What do you think Ryan’s response will be to his discussion with Matt?

Chapter 35

How would you feel being exposed to so many awful freak accidents? How vulnerable would you feel? How worried might you become for your loved ones?

Why do you think Cara responds to the patients the way she does?

How challenging would it be for a physician to like and respect all their patients? 

How does a physician’s opinion of a patient affect their care of the patient?

How would the arbitrary nature of horrible patient outcomes affect you? How would it affect your faith?

Chapter 36

Why can’t Ryan separate himself from his work?

What do you think of how Mr. LeBlanc was handled in Ryan’s absence. Was Ryan right in being so infuriated?

What are your thoughts on physician-assisted suicide? On euthanasia? On “accelerating” a patient’s demise? 

How should Kelly have handled the situation?

Chapter 37

What do you think of Kelly’s perception of what is most important to Ryan?

Is Kelly more angry or worried about Ryan? What are her options?

Chapter 38

How cautious about the inherent risks of life would you become in Ryan’s job?

Is Ryan losing his mind? What should he do?

Chapter 39

What do you think of Reverend Ron’s assessment of Ryan’s supernatural problems?

What do you think about Ryan’s admission to how he responds to patients with bad complications?

What do you think of Reverend Ron’s thoughts on Ryan sharing the worst components of his work life with Kelly?

Is ego a major driver of Ryan’s problems?

What do you think of Reverend Ron’s advice?

Chapter 40

What do you think of Ryan’s choice of gifts? Does it suggest anything about his current state of mind?

Chapter 41

How vulnerable do you feel to terrible accidents or disease on a daily basis? How about with respect to your loved ones?

How do you reconcile the notion of  a loving God with the arbitrary nature of tragedy?

How would Clarice’s death affect you?

Why do you think Ryan was more affected by Rick and Jonathan’s response to him visiting them than by Clarice’s surgery or death?

Chapter 43

Could Ryan’s encounter with the Dark Lady be a form of sleep paralysis?

What do you think of Kelly’s response to Ryan’s confession?

What do you think of Ryan’ insistence on continuing to work in spite of what he was experiencing?

Do you believe Ryan can hold it together?

Chapter 44

What do you think of Dr. Larkin’s assessment of Ryan?

What, if any, actions should Dr. Larkin have taken with Ryan?

What other options should Kelly explore?

Chapter 45

What would motivate a physician to act as Dr. Woodfield did? Was Ryan’s reaction to him justified? How could he have handled the situation under ideal circumstances?

How close is Ryan to getting fired?

How often do you think hospitals/healthcare systems tolerate “disruptive” physicians? Do you think the individual physician’s productivity is considered?

How should hospitals/healthcare systems handle disruptive physicians? Nurses? How about underperforming physicians or ones with a lot of malpractice suits or patient complaints?

What can hospitals/healthcare systems do to assure a collaborative atmosphere for all its providers?

Chapter 46

What did you think when Ryan bolted out of the van?

Chapter 47

Have you ever been fooled by the power of suggestion?

How plausible was Kelly’s explanation to the girls?

What would happen if she did discussed the video with Ryan? How would Ryan have handled his daughters if he was notified?

Chapter 48

How do you feel about the patients who sustain terrible injuries or illnesses through their own negligence?

Is a physician ever justified in losing his/her temper with a patient?

Is Ryan a functional physician at this juncture? What stops him from taking himself out of the work rotation?

Chapter 49

How would Ryan’s meeting with Mia affect you?

How much exposure to human tragedy is too much for anyone to bear?

How common do you think Mia’s bravery and grace is in the medical world?

Chapter 50

Why is it so hard for Ryan to be open with Kelly?

Is there any implication to Ryan now seeing the ghosts of former patients?

Chapter 51 

What do you think of Reverend Ron’s assessment of the lot of partners of physicians?

Does Ryan deserve Kelly’s love?

Chapter 52

What are the chances of Kelly and Ryan’s marriage surviving?

How else might they have addressed the ski weekend?

Chapter 53

What should Ryan have done when he began seeing ghosts in the hospital?

What do you think of him continuing to care for patients?

Chapter 54

Are the ghosts real?

If they are real, what do they want from Ryan? Why are they stepping up their harassment of him?

What does the dark lady want Ryan to do?

Chapter 55

What do you think about Kelly’s assessment of the relationship between love and memory?

Does Kelly still love Ryan?

Chapter 56

Why does the Dark Lady take on the appearance of Kelly?

What motivates Ryan to attack the ghosts?

Chapter 57

What do you think of Ryan’s medical evaluation at U Penn? Was anything solved?

If the ghosts were real, what was the nature of the Kelly ghost? Of all the ghosts?

Is Ryan better?

What do you think of Reverend Ron’s seeing Ryan as an addict?

Should Reverend Ron be giving supernatural explanations of Ryan’s experiences greater consideration?

How will Ryan do in the future? How will his marriage fair?

Chapter 58

What is your reaction to both Kelly and Ryan seeing the John Lennon lock-a-like? Was he a ghost? What are the implications?

What will happen from here?

Gary Simonds is a neurosurgeon who has treated tens of thousands of patients with devastating illnesses. He is a professor at the Virginia Tech Carilion School of Medicine and the Virginia Tech School of Neuroscience. He has published three nonfiction books on burnout and psychological distress in healthcare providers and routinely writes about, and gives talks on, neuroscience, neurosurgery, medical socioeconomics, medical humanism, medical ethics, and burnout.

Gary grew up in New Jersey and in England, is an avid soccer fan, a guitar and banjo player; and lives with his wife, Cindy, and border collie, Hamish, in their log cabin in Black Mountain, North Carolina.