The Patient with Broken Wings

and her outside doctor

Dec 16, 2025

Welcome to Ask The Patient, a doctor’s love letter to patients everywhere. Together, we’re reclaiming the stories that make medicine human. If it speaks to you, share, like, or subscribe.

I didn’t really understand the significance of the titles inside doctors and outside doctors until I became the latter.

Having trained almost exclusively in academic centers and tertiary hospitals, I entered medicine as an insider. When we received phone calls from other hospital or clinic, it was always someone asking for our help: consulting a specialty they didn’t have, or transferring a patient too sick to be cared for where they were.

Being an inside provider means being the authority figure in a deeply hierarchical world. You don’t ask for help. You give help. Often, with judgment.

That judgment rests on the assumption that inside facilities don’t just have better equipment or more resources, but smarter, more capable people. What feels overwhelming to outsiders is actually easy…if only they were better clinicians.

Layered onto the intellectual condescension is an ethical suspicion: that by transferring their patients to the inside, outside providers are simply trying to “dump” trainwrecks so they can disappear from view.

So when the outside transfer phone call comes in, the tone is often predictable. The insider grills and drills. The outsider shrills and enthralls. Eventually, the insider accepts the transfer reluctantly, unconvinced it was truly necessary. The outsider hangs up relieved, having successfully argued that the patient really is that sick.

Both roll their eyes.

The Broken Wings

Irene was an introverted six-year-old girl who had stopped growing a year earlier.

Her straight, dark hair was pulled into a thin ponytail. When she smiled, only the corners of her mouth lifted. Her eyes didn’t follow. Instead, they stayed still and heavy, as if they were too tired to participate.

Irene had a vague rash on her face, knees, chest, shoulders, and hands. She tired easily. Slept a lot. While other kids ran nonstop, she moved slowly and carefully.

When I met Irene and her parents, it was clear they knew something was wrong. And when I saw her flattened growth chart and the sharp outlines of her collarbones, I knew it too.

Having learned the hard way of the weight of my own words, I tried to sound relaxed. I made small talks as I examined her. But inside, the dots were already connecting themselves into a picture I recognized: juvenile dermatomyositis (JDM).

Weight loss + Fatigue + Swollen knees + Signature rash + Abnormal cuticles + Muscle weakness. JDM is a multisystem inflammatory disease. Untreated, it can weaken the muscles used for swallowing or breathing. Children can become very, very ill.

As the picture sharpened, I grew quieter. That’s when I heard soft sniffing. I looked up at Irene: it wasn’t her. Then I looked around the room and saw the image that has been breaking my heart ever since:

Irene’s mother sat with eyes red and swollen, clutching tissues. Her husband held her, head bowed. And in the corner stood Irene’s teenage brother with his arms wrapped tightly around his own stomach, blinking rapidly to keep his tears from falling.

Irene lowered her head, peeking at her family. Tears slipped silently down her sunken cheeks. When she looked back at me, she still tried to smile.

Sweet little girl.

“I’m sorry,” I said, handing over the tissue box. “Did I do something?”

“No, doctor,” her father said quietly. “It’s just… in the ten minutes you’ve examined our daughter, you’ve touched her more than all the other doctors we’ve seen in the last year combined.”

Then, I understood the tears. More than fear, they represented relief, and the fragile beginning of the end of a long, lonely fight.

Moments like this weigh on me. I carry them home. I return to them often. Because when I close charts at the end of the day, families don’t get to close their worries with a click. Their fear goes home with them. It eats dinner with them. It lies awake with them at night.

And when the days are stormy, and the nights come down hard, it is up to us in medicine to make ourselves known to those who have been standing alone in the rain.

“Do you want to go sit with your mom, sweetheart?” I asked, resting my hand on Irene’s back. Her shoulder blade pressed sharply against my palm, delicate and angular, like the broken wing of a small bird.

A baby bird who never learned to fly before the storm came.

Irene climbed down from the exam table, tried to run but stumbled instead. Her mother caught her and held her so tightly her sobs became nearly soundless.

The room filled with a quiet, crushing sadness.

And I felt my own eyes burn.

The Condescending Voicemail

After a long conversation about what I suspected and the workup ahead, I placed an urgent referral to pediatric rheumatology.

Days passed, I called Irene’s family who said they hadn’t received any call to schedule an appointment. So much for urgent. I called the specialist’s office myself.

Don’t get me wrong, I do enjoy classical music. On my own terms. But Bach or Beethoven piped through a phone line as hold music, after three recorded messages and four button presses, twenty minutes into a packed clinic day? That wears thin fast.

Still, this was no time for irritation. I was now the outside provider pleading for help for a child who had waited long enough. When I finally reached voicemail, I delivered my best Ivy League patient summary with the 4C’s: Clear. Concise. Carefully crafted. At the end, I left my personal cell phone number.

“Please call or text anytime,” I said. “Whatever is easier.”

I turned my phone volume all the way up and waited. The next day, a voicemail appeared silently after being flagged as potential spam. I had left my cell phone number so the inside doctor could bypass the Beethoven. Instead, she called from the hospital line, which my overly smart phone automatically screened out.

“Hi, um, this is Dr. X. I was told to call this number about an outside referral? Apparently there’s a Dr. Jaw or Dr. Zah who wanted to talk? Anyway, call us back, I guess?”

I tried my best to ignore the condescension in the word apparently and the mangling of my one-syllable last name despite my careful pronunciation at the start of my message.

Beggars can’t be choosers, I told myself and dialed back immediately. Maybe she had called on a number that directly reached her office? I secretly hoped. And I was certain that once Dr. X heard Irene’s story in full, she would understand the urgency.

Then – Beethoven – again.

The same looping string quartet. The same recorded reassurances. The same sense of time stretching while a sick child waited. I began to suspect that some long-dead Classical composer had been condemned to become the background music of my sad life as an outsider.

Apparently, it was unreasonable for doctors across systems to talk to each other without an orchestra of waiting.

Apparently, I was just some outside doctor with an outside referral who wanted to bother someone more important.

Apparently, the inside/outside divide was wide enough to swallow both my name and a child with a progressive, potentially life-threatening disease.

The Red Phone Call

The red phone on the wall in our clinic was reserved for emergencies. It bypassed the music and rang directly into a nurse’s station, where someone always picked up.

And when it rang, it rang loud, like siren cutting through a storm.

One morning, just as I walked into clinic, it went off. I jumped at its old-school mechanical shriek, as if 1978 had called to warn us that everything must stop immediately or we would all perish.

“Dr. Zha, pediatric rheumatology is on the line for you!” A nurse called out.

This was a different rheumatologist. After weeks of silence and looping strings, I had placed a new referral.

“Hi, this is Dr. Zha.” I braced myself for the music (from a certain era).

“Oh hi! This is Dr. Y,” came a bright, warm voice. “How are you?”

Just like that, the tone shifted. We talked easily and efficiently about Irene. Dr. Y agreed the referral was urgent and promised to work her in within weeks. For pediatric rheumatology, that is remarkably fast.

Among the scarcest pediatric subspecialties in the U.S., there is only 0.27 pediatric rheumatologists per 100,000 children. After college, it takes roughly a decade of training to become one. As a nation, we produce only about 200 of them each year.

In contrast, over 1,000 new pharmaceutical sales persons are hired annually with zero prior training requirement. Apparently, we need more people to sell drugs than doctors to care for sick children.

“Can I give you my cell number?” I asked.

“Oh my goodness, yes. That would be so helpful!”

I read it off, and she paused. “Is that a New Hampshire number?”

“Yes!” I laughed. “How do you know?”

“I went to school there!”

“Me too!”

Turned out, we both graduated from Dartmouth. By then, it felt less like a consult and more like catching up with an old friend. We exchanged numbers and sent quick texts.

We need more friendly neighborhood pediatric rheumatologists, I wrote.

And good rural docs, she replied.

The Inside Attending Who Changed Everything

The intensive care unit (ICU) service was one of the most, well, intense rotations of my training. For ICU doctors, everyone is an outsider, and rightly so: The unit is its own hospital within a hospital, where patients are sicker, decisions move faster, and the margin for error is razor-thin.

Transferring a patient into the ICU is a big deal in every sense. Not surprisingly, the request-to-transfer phone call can be a dreaded one, heavy with risk, scrutiny, and judgment.

But one person during my training changed everything. I mean everything. Dr. D, a brilliant ICU doc, answered every transfer call the same way:

“Yes, of course. I’m eager to help.”

Before Dr. D, I had never heard anyone say that. Inside medicine or outside of it. Not at the bank. Not in a car dealership. Not even from a drug rep.

In fact, I had never heard the words eager and to help placed together in the same sentence at all. Hearing Dr. D say it felt like learning a new phrase in a language I thought I already spoke…

…one that shattered the invisible inside/outside caste system of medicine in an instant.

The truth is, if we want there to be a divide, there will always be one. Tertiary hospital versus rural clinic. Subspecialty versus primary care. Academic attending versus country doctor. Us versus them. You versus me.

And the implication is always the same: better versus worse.

This manmade medical hierarchy dictates how we speak to one another, including our tone, our patience, our generosity, our willingness to help. It inflicts moral injury on those who are dismissed while trying to advocate.

And patients feel this divide more urgently than clinicians ever will.

Because embedded within that hierarchy is patient care itself. The wider the divide between us, the farther the patient falls. Before we know it, care is blocked altogether.

Until one voice cuts through the storm.

Come inside. I’m eager to help.

Sometimes, that’s all a frightened family or a child with broken wings needs to hear.

If these stories resonate with you, if you’ve ever felt like an outsider in your healthcare, I’d love for you to stay on this journey with me. You can join Ask The Patient for free.

The Same Side

One of the first things I did after starting a new job was give my cell phone number to every clinician I met no matter where they sat in the system.

“Call me with anything,” I tell them. “I’m eager to help.”

Within a three-hour radius of my rural town, I’m now one phone call away from nearly every clinician I share patients with. Communication happens so easily that it has almost restored my appreciation for classical music.

Almost.

And Irene? She is now in good hands, being seen, getting the care she needed all along and growing.

Perhaps even the smallest bird can survive the storm, if someone is willing to hold it until it’s safe.

Irene’s story is proof that we, the healing profession, cannot afford to live in a world where collegial humility is a personality trait or the luck of shared alma maters. It must be a professional obligation.

Because there is no inside or outside of patient safety.

Patients are not just referrals.

They are not transfers.

They are not inconveniences.

They are simply trying to get in.

And our job, every single time the phone rings, is to be on the same side.

And honestly, it’s 2025. We can put Beethoven to rest and learn to talk to each other without the background music.