You Are Not Alone.

I recently spoke with some people about medical systems—the actual processes involved in providing health care to patients. Story ideas involving systems sparked in my head: What about the guy who makes your sandwich at the deli? What if he had to grow the tomatoes? and cure the meats? and chop down trees to fashion the cutting boards? and weld the freezer parts together? etc.

All the ideas looked much better in my head than they did on the computer screen.

I then considered the systems that train physicians.

“Back when I was your age,” many pre-med students said that they wanted to become doctors so they could “help people”. They had the fantasy that they could help people with only their intellect, work ethic, and selflessness. Doctors, in this view, were self-contained healers that needed only their brains—and their brains alone—to solve medical mysteries.

This just isn’t true.

The path to a medical degree does little to dissuade this worldview. Students receive individual grades. Grades are often based on a “curve“, which can foster competition instead of cooperation among students. The Medical College Admission Test (MCAT) is an exam that doesn’t involve teamwork. The student sits in front of a computer. Alone. (“Back when I was your age, I had to fill out a Scantron sheet for the MCAT. Do you even know what a Scantron sheet is, kid?”)

To be fair, many medical schools now incorporate teamwork and group learning in the first year. Some students easily make the transition from striving alone to striving together; others struggle or frankly resist joining the group. Some fear that the group might dilute his brilliance (“regression towards the mean”); some lack patience to work with others; a few believe that they are always “right”.

Perhaps this resistance is developmentally appropriate. Pre-med and medical students must first learn the content of their studies. This requires individual concentration and dedication. As they progress through their education, they then learn the process of medical care. It doesn’t matter if you know that Streptococcus pneumoniae is the most common etiology of lobar pneumonia if you don’t know how to order a chest X-ray. (And what’s the best way to maximize the likelihood that the radiologist will read your film as soon as possible?)

With time and experience, medical students and resident physicians learn how the system does and does not work. Most physicians soon stumble upon this realization: You can have the best intentions to “help people”, but if the system blocks your efforts, it doesn’t matter what your intentions are. You won’t be able to help them. To do the work properly, physicians must rely on other people and systems.

To be clear, this does not mean that the intelligence and talents of the individual are trivial. A system arguably works “better” (more effectively? efficiently?) when it is comprised of smart, dedicated, and diligent people. The complexities and complications inherent in health care, however, demand the attention, care, and energy of more than one person.

All of us who work in medicine must constantly remind ourselves that we cannot provide health care by ourselves. We must explicitly teach this to our students. Physicians, in particular, must remember that “ancillary staff”—nurses, clerks, janitors, technicians, phlebotomists, scribes—help us in many ways that we take for granted. Without them, we could not do our work.