Richard performs a monumental surgery in his career; Derek and Lexie attempt to work miracles for a patient with an inoperable tumor

Amelia arrives at Seattle Grace to beg Derek to help with the gliosarcoma case; Cristina and Owen have heated arguments during marriage counseling; Alex realizes he needs to improve his people skills in order to be a good doctor.

The residents agonize over their oral boards, reliving every answer they gave during their exams; Arizona's close childhood friend comes to Seattle Grace for medical help; the doctors work on a patient who is missing one third of his skull; and Julia asks Mark to start a family with her. Meanwhile Catherine tells Richard that one of his residents has failed.