Author: Maria Yang, MD

The alarm began to ring. Refusing to acknowledge the morning, he reached over and patted the nightstand. Only when his fingers wrapped around his cell phone did he finally open one eye. He squinted. Then he groaned.

After plodding through his morning routine, he put on a dark suit and light necktie. The leather laptop bag bumped against his hip as he exited the apartment. He reflexively looked down, only to remember that he had cancelled the newspaper a month ago.

As he walked into the deli, the man with the funny hair walked out. They waved to each other. This is what they did every weekday for the past four years. He knew that the elderly woman in front of him would order—

“Small coffee, cream, no sugar, and an egg bagel with butter.”

As she shuffled away, he wondered if any of them noticed the change in his routine.

“Good morning, chief,” the man behind the counter said. “The usual?”

“Yeah, thanks.”

He fished a five dollar bill out of his wallet. He knew that he should make his own breakfast and stay at home. He couldn’t do it. Routines were difficult to change. He hoped that things would return to normal again soon.

“Have a good day,” the man behind the counter said as he stuffed napkins into the white sack. “See ya tomorrow.”

From the deli, he usually walked three blocks north and entered the skyscraper. He hadn’t gone there in over three months. His boss had said, “Look, I’m sorry, you’re a good guy and all, but we just can’t afford to to pay you.”

So now, he instead walked five blocks east with his coffee and muffin to the public space with free WiFi. While he was setting up his laptop to review classified ads online, a man in sagging jeans and a soiled sweatshirt walked past. In his hand was a tall aluminum can in a brown paper bag.

Taking a sip from his coffee, the other man thought, It’s five o’ clock somewhere.

The man had bought the aluminum can in the brown paper bag from the bodega around the corner. He was celebrating his morning’s success.

His day started at 3:30am because he knew that the sanitation trucks would arrive around 6:00am. He also wanted to avoid the morning rush. People in the neighborhood often yelled at him and threatened to call the police. His cart, when full, was bulky and difficult to maneuver in the crowds as they streamed towards the subway.

This morning, the superintendent of a high-rise apartment building saw him pushing his cart.

“Hey, Papi!” the superintendent said, waving at him. “Take my bags.”

The five overstuffed bags could not fit in his cart. He was delighted.

Aluminum cans and plastic bottles earned him five cents a piece. He was smiling as he pushed the cart forty blocks uptown. On a good day, he could pull in $100. With this donation from the superintendent, he got close to $200.

“Thank you!” he exclaimed when the grocery clerk put the cash into his hands. He stuffed the wrinkled bills into his tattered wallet and walked into the bodega. When he reached the back of the store, he opened the refrigerator case. Instead of plucking out a single can of beer, he decided to splurge.

“A case today, huh?” the bodega clerk murmured.

“It’s a good day,” he said.

Routines were difficult to change. He knew that things would return to normal again soon.

The nurse saw the little girl standing in the hallway. She was holding her mother’s hand.

“Hello, Clara! Look at you! You’re so cute in that pretty dress.”

“Thank you,” Clara said, looking down. Her feet swiveled against the tiled floor like windshield wipers. “Where’s my daddy?”

“He’s still seeing patients, but he’ll be back soon.”

Clara’s large eyes saw a clot of doctors in the arterial of the hospital ward. A few of them dislodged and floated into patient rooms.

Smiling at Clara, her mother asked, “Do you want to be a doctor like Daddy?”

Clara grimaced. “No. I don’t wanna be around sick people all the time.”

Wesley, how about you? How is your mother doing?”

He looked down. His fingers began to pick at the hem of his maroon jacket. Nearly two months had passed since he last spoke in the group. The other people sitting in the circle looked at him.

“About the same.” Wesley cleared his throat, then gave his usual report. “She still gets up in the middle of the night and tries to leave the house. She hasn’t figured out how to unlock the door. That’s good. Most of the time she recognizes who I am, but sometimes she gets upset when I try to get her back into bed. She screams at me. I’m surprised the neighbors haven’t called the police yet.”

A few people snickered.

“Dad passed away ten years ago from a stroke, but she still thinks he’s at work and will be home any minute. She looks out the window day and night.”

Wesley folded his arms in front of his chest and sighed.

“She thinks I steal her things. I can her hear right now: ‘Why do you keep taking my watch? You can buy your own! I’m going to call the police if you try taking it again!’ She gets so upset. She just doesn’t remember.”

People in the circle nodded in sympathy. Someone offered, “I’m sorry. My mom does the same thing. Sometimes I get so angry that I scream right back at her.”

There were more murmurs of recognition.

“Who’s with her right now?” someone asked.

“The housekeeper. She’s been with us for about fifteen years. She comes on Monday evenings. That’s how I can come here.”

“So you get a clean house and a break from your demented mom,” someone commented. People quietly laughed.

“I’m all she’s got now,” Wesley said.

The support group ended about twenty minutes later. An elderly man who recently joined the group put his hand on Wesley’s shoulder.

“You’re a good son. I wish my kid was as dedicated to his mom as you are to yours.”

Wesley reflexively turned his shoulder away, but smiled at the old man.

As was his habit since he joined the group nine months ago, Wesley took a cup of coffee with him for the walk home. The cup was empty by the time he reached his studio apartment.

After unlocking the three locks, he stepped inside. First he took off his shoes and jacket, then he put the cup next to the pile of mail on the table.

“Yes, Ma, I’m back.”

Wesley turned the bolts in the three locks. His foot nudged the stack of old newspapers closer to the wall. He sat down on his unmade bed.

“No, Ma, I didn’t take your watch.”

He peeled his socks off and tossed them onto the heap of clothes spilling out of his closet.

“No, Ma, did you hear what I said? I didn’t take your watch. I have my own watch. See this? This is my watch. I only have one watch.”

He grabbed the remote control and turned on the small television across the room. While rolling his eyes in annoyance, he pushed the button to increase the volume. The laugh track of a sitcom roared through his empty apartment.

The doors to the pet shop are open. Empty fish tanks are stacked near the entrance. Brightly colored fish that could never fit into any of the tanks are painted on the shop windows. Paper birds, all smaller than the painted fish, dangle from the ceiling.

Next door is a dental clinic. Blue scaffolding and nets obscure the windows. Two people wearing scrubs and holding clipboards stand next to the entrance. A woman pushing a simple baby stroller—holding only a quiet child, not a beverage or a heap of toys—stops, nods at the child, and asks one of them a question.

A man leans over the table he has set up on the sidewalk. He restacks the baby shoes that are teetering near the edge of his display. Belts dangle off of the table like parched leather tongues. A small cardboard sign advertises that all items cost two dollars each.

A city bus approaches the intersection and pulls away from the curb to make a right turn. Pedestrians in the street begin to jog: The bus has not slowed down. While turning, it passes within one foot of the people still in the crosswalk.

Across the street, 20-story brick buildings loom overhead. In each window is an air conditioner. Torn plastic bags, sheets of newspaper, empty beverage cups, and other detritus collects in the corners between the buildings and chain-link fences. Only the afternoon breeze visits the blue slides, green monkey bars, and yellow animal sculptures.

The kids are crowded in the ice cream shop, many looking at the menu affixed to the wall. Firehouse is the flavor of the month. The boys jostle each other; the girls point at the buckets of ice cream in the glass case. The city traffic drowns out their laughter.

Five of them exit the ice cream shop. Puberty has begun to play with their body shapes. Their school uniforms cannot hide this. One of them, a young man, looks over his shoulder and remarks to the group, “We’re in the ghetto. Downtown, that’s where all the white people are.”

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.