When I first met Maria during her primary care visit, I, a medical student, was struck by her independence at 90 years old. Her frosty hair was brushed into neat curls. Her glasses rested on the tip of her nose. Her reusable grocery bag was frayed at the corners from carrying years of paperwork from doctor’s appointments.
Speaking only Spanish, Maria explained to me every medication she took morning and night and shared her hesitations about continuing them. If her blood sugar was well managed, she asked, why did she have to keep taking her diabetes medication? As I explained the role of each medication, Maria diligently jotted down the risks and benefits in her little black notebook — a notebook that, I later realized, had become her lifeline as she navigated our broken health care system.
I met Maria while taking part in a unique program at the Cambridge Health Alliance, a safety net hospital. At Harvard Medical School, 12 second-year medical students each year have the opportunity to participate in the Cambridge Integrated Clerkship (CIC). Rather than rotating through specialties in monthlong blocks, we follow a panel of patients longitudinally — learning clinical medicine as our patients receive care across specialties such as OB-GYN, neurology, pediatrics, and surgery. We attend expecting mothers’ prenatal visits and deliveries. If one of our patients is diagnosed with colon cancer, we scrub into their surgery, check in during chemotherapy sessions, and attend follow-up visits. Between appointments, we call to inquire about medication adherence, arrange transportation, and help navigate insurance coverage. Care coordination becomes a natural, and arguably crucial, aspect of guiding our patients through a fragmented health care system.
David Hirsh, the program director, founded the longitudinal curriculum 21 years ago in efforts to tackle the “ethical erosion” that occurs in medical training. Ethical erosion is a well-documented phenomenon where empathy and moral integrity decline throughout medical training due to emotional and physical fatigue and systemic pressures. The CIC program is built on two essential pillars of medicine to combat the erosion that occurs during training: clinical knowledge and relationships.
This longitudinal model exposes medical students to the deeper structural gaps in the U.S. health care system. It’s a kind of training that every future physician should receive.
As my year progressed in the CIC program, Maria’s health declined, and I frequently visited her in the hospital. During one overnight shift, I got an alert that she had come to the emergency department for heart failure. When I found a free moment, I ran down to the ED to check on her. Comforted by a familiar face, she pulled out her notebook and began detailing her symptoms. Maria was caught between the complexity of medical language, the barrier of not speaking English, and digital health records that were impossible to navigate on her basic phone. Her notebook offered her a rare sense of structure and organization.
Over the year, she was readmitted to the hospital four times. Each time, I met her and her family on the fourth floor of the hospital, witnessing their despair and pleas to nurture her back to health. I could not stop wondering: Why was her health deteriorating so rapidly? Was it simply the course of her illness — or were we missing something?
When Maria passed away, I mourned with her family and her health care team. But I also was devastated by what her story revealed: the compounding failures of our health care system. In the weeks after her passing, I scoured her health records, piecing together disjointed electronic health records and re-reading clinical notes and emails. I began to understand that what happened was revealed not in the written words, but in the delayed coordination amongst specialists, the miscommunications due to the language barrier, and the providers who were stretched thin for time and attention. Her death was not the result of any single provider or major misstep; it was the outcome of a system fraught with inefficiencies, all entwined with the imperfect art of medicine and unpredictable force of life itself.
In traditional block rotations, systemic failures often announce themselves in obvious ways: insurance denials, rushed discharges, unaffordable medications. Medical students rotating through the month encounter them as snapshots — a brief glimpse into the patient’s life. The moment it happens is also the moment it passes as medical students whiz onto their next team and next rotation. A patient becomes their “problem” and “task” for the day or week.
In the longitudinal curriculum, a quieter kind of injustice reveals itself: the medication instructions that seemed clear in clinic but led to missed doses at home, the interpreter whose muddy audio left key details miscommunicated, the delayed test result that eroded the patient’s trust. I would witness the consequences during follow-ups — or in the emergencies that came when follow-ups didn’t happen. Following Maria over time, I saw how these seemingly harmless “inconveniences” and subtle “missteps” layered onto one another, silently accumulating until they became embedded in her illness. The continuity offered by the CIC exchanged a single encounter into a lived narrative of decline not just shaped by disease, but by the invisible thousand cuts of the health care system.
The CIC program was created to solve a problem in medical education regarding ethical erosion. But it is addressing something much larger. It is training future physicians to recognize the structural failures and the multiplying drivers embedded within our health care system — and to confront them with compassion, creativity, and humility. Ensuring that all medical students have access to this training is more important than ever, especially as the fluctuating socio-political landscape directly impacts a patient’s social, physical, and emotional well-being.
The administrative burdens that frontline health care providers face are not only operational challenges but also reflect deeper systemic issues that must be addressed. Programs like the CIC offer a model of education that is grounded in continuity, relationship-building, and real-world complexity. Medical students not only learn to diagnose disease. They also begin to see the quiet forces that determine which patients receive treatment, who falls through the cracks, and why.
Serena Wang is an M.D./M.B.A. student at Harvard Medical School and Harvard Business School.
