The fifth-year residents return for the first day of a year that will make or break their careers: Meredith faces the consequences of tampering with Derek's clinical trial and is terminated at the hospital; April tries to step up to the plate as Chief Resident in the wake of a giant sinkhole in the middle of Seattle; and Cristina and Owen are still at odds over their drastically different feelings for their unborn child.

The chief makes a decision that shocks everyone at Seattle Grace; Owen and Cristina attempt to find normalcy; April struggles in her new role; the 5th-year residents receive their first solo surgery assignments.

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.