I recently observed a neurologist. As a high school student on the verge of applying to college, I thought I would spend the day quietly watching: seeing labs being ordered, hearing terminology I’d look up later, perhaps witnessing the human aspect of medicine from a close distance.

However, nothing can prepare you for witnessing someone gradually lose their chance at life—not due to their diagnosis, but because two segments of the medical system weren’t communicating.

The patient, whom I’ll refer to as Mr. D, was in his sixties. He suffered from advanced kidney disease. Everything about his profile made him an excellent candidate for a kidney transplant: he was mentally alert, physically stable, and eager. Except for one significant detail.

A stent.

Not in his heart. In his iliac artery, extending into the external iliac, a crucial vessel used to connect a donor kidney. That stent rendered the transplant nearly impossible. It severely compromised the procedure.

It had been placed by a cardiologist a year prior to alleviate swelling in his feet. However, it proved ineffective. It had exacerbated the situation.

The neurologist meticulously reviewed the scans again, searching for a possible solution. There wasn’t a simple one. And I sat there, shocked, recognizing what we were truly observing: not merely a poor outcome but a failure in the system.

No one had communicated. No one had anticipated what might occur downstream. A decision was made, likely with the best intentions. But without context, collaboration, or reflection.

And now Mr. D was nearly disqualified from a transplant that could have extended his life.

It’s easy to cast blame. To assert, “Well, that cardiologist should’ve known better.” Or, “Someone should’ve identified this sooner,” but such instincts overlook the core issue. The reality is even more unsettling: no one possesses the complete picture anymore.

In an era of referrals, EMRs, and consult inboxes, care resembles a relay race. Yet sometimes the baton is dropped, and no one looks back. We excel at managing individual body parts in isolation. But when it comes to integrating whole-person care, the seams start to unravel.

I’m merely a student. I don’t claim to comprehend the intricacies of medicine. But I do understand this: Mr. D did everything correctly. He showed up. He adhered to instructions. He placed his trust in the experts.

And somehow, that trust was violated. Not through malice, but through inaction.

There’s something profoundly troubling about that.

I keep reflecting on how this wasn’t a dramatic failure. No alarms, no malpractice, no media headlines. Just a quiet failure. A non-conversation that altered everything. Somewhere along the way, the system valued silence. Whether due to overconfidence, neglect, or simply the rush to act. Ethics weren’t absent, but they were delegated. Everyone performed their roles, yet somehow the overall picture was lost. In the end, it wasn’t just a stent that obstructed the transplant. It was a system that couldn’t pause long enough to question, “How will this matter for the next step?”

And who assumes responsibility for that?

No one, truly.

We claim “medicine is a team sport,” but what occurs when the team isn’t on the same field? When specialists are playing different games, relying on different scorecards, while the patient is the ball?

I don’t possess answers. I can’t say if this story would have concluded differently if someone had made a phone call. But I do know this: I can’t erase the expression on Mr. D’s face when he understood the implications of that stent.

It wasn’t rage. It was a sense of resignation. As if he’d encountered this scenario before. As if he’d already learned the difficult lesson that in medicine, even when everyone cares, no one truly leads.

That moment transformed something within me. I entered hoping to witness the future I desired: white coat, assured decisions, lives saved. But I departed with something weightier: the realization that medicine isn’t solely about curing. It’s also about acknowledging the ways we let down one another and our patients.

Perhaps that’s the initial step toward learning how to improve.

Cesar Querimit, Jr. is a high school student.