Empathy Without Infrastructure

I first saw medicine’s limits at seventeen, volunteering alongside local EMTs during the Afghan refugee crisis in August of 2021. One night, we were dispatched to the Dulles Expo Center–where families were being housed–when a man who had just received the COVID-19 vaccine experienced painful side effects. He only spoke Pashto yet was trying to communicate with us, and even though we were medically trained, we were not able to offer emotional support in his language. We relied on body language and tone. His breathing steadied but the rest of the ride was silent – that stayed with me.

I quickly learned that even competent care can feel inhumane without communication or cultural understanding. That patient’s pain was not physical – it was linguistic, and most definitely avoidable. Our failure was not a lack of clinical skill or compassion, but a lack of funded language access in the emergency response structure. If a Pashto translator was available, knowing that we would likely be repeatedly dispatched to the expo center, the whole experience would have been profoundly different. That was the first time I learned something I keep relearning: empathy without infrastructure leads to incompetent care. In medicine, equity fails not because physicians do not have compassion, but because equity work is mostly unpaid, unsupported, and excluded from metrics related to promotions, funding, and surviving in this institution. I am now a first year medical student. The ideals that brought me here – empathy and a commitment to equitable care – are taught, but rarely rewarded. This contradiction is structural.

Barriers to language access – what the Afghan refugee in the ambulance experienced – is a clear example of this disconnect. Despite federal mandates requiring that hospitals provide language access for LEP patients, there are very few clinics that offer timely access in any form (in-person, video, or by phone). Most physicians rely on family members, which increases the risk of medical errors. LEP patients face longer hospital stays, increased readmission rates, and lower satisfaction. This is evidence for how these communication barriers translate into health disparities, despite being supported by federal mandates but having failed implementation. This raises the question of why, and one possible answer is that equity in medicine is sometimes treated as a vague moral idea instead of core work.

Making this issue more complex is burnout. Equity-related labor competes with the productivity metrics for reimbursement, so is seen as too costly regarding time or energy. It can feel easier to stay neutral instead of questioning these systems perpetuating harm. But real care asks the exact opposite: for us to confront these questions even when it would be easier to turn a blind eye. This dissonance is one of the most significant causes of burnout affecting over half of physicians in the U.S. Moral distress – when clinicians feel that they are not able to provide care aligned with their values. Medicine, of all fields, demands that kind of moral courage. Its culture is rooted deeply in hierarchy and tradition, making it very resistant to change – and sustained by the quiet ways in which people justify harm when it protects a world they are familiar with.

Conviction is easy when it’s theoretical, but much harder when it means questioning the people or institutions you love. But love for this institution does not mean accepting it as it is. It means challenging it so that it lives up to its own ideals.

And now, that courage is more necessary than ever. Medicine today is caught between its social mission and political reality. There are attacks on diversity, equity, inclusion, and justice (DEIJ) programs and laws that criminalize gender-affirming care. When institutions scale back equity efforts, they reduce the numbers of faculty who come from marginalized backgrounds – leading to, for example, the persistent gaps between male and female representation in medical institution leadership roles that we see now. In addition, when the mentorship and service work already being done is not funded or recognized, it demotivates the physicians doing it which shrinks the pathway of clinicians committed to equity in the future. These policies affect the medical training we receive, the kinds of patients we’re allowed to help, and the doctors we become.

These contradictions in medicine don’t come from students or faculty – they come from structures above us, such as funding pressures, productivity metrics, and reimbursement models that define what success is in both clinical and academic medicine. These shape how we practice and also “why” we work.

As a first-year student, I do not have much institutional authority. But, I wanted to understand whether medicine could be rebuilt from within – not through top-down policy but through the people who face these contradictions everyday. So I started working with Dr. Maranda Ward to design a module for residents with self-identified DEIJ values to pursue a career in academic medicine.

Residents are the closest to care but farthest from institutional power. Many of them already have strong convictions about equity, but few pathways to operationalize “values”. Our module – From Values to Action – Using Residents’ DEIJ Values to Shape a Career in Academic Medicine – was designed to translate residents’ values into tangible academic roles like mentorship, research, or leadership. It’s built for translating reflection into practice, where residents can design small projects, such as a language justice curriculum, and track their outcomes over time. It is a pilot framework for transforming moral intent into institutional participation. By using measurable outcomes such as curricula and mentorship structures, it lets equity work be evaluated using the same criteria applied to other efforts. Frameworks such as this also support accreditation standards that require institutions to show a commitment to equitable care and DEIJ, but currently have limited guidance on how to do so.

This is the core argument. Medicine’s social mission depends on whether we can make equity measurable and fundable. Empathy cannot survive a system that only rewards efficiency, so structure has to accommodate it. A single module won’t fix these contradictions, but it creates a space for residents to reconnect with their values and translate them into academic roles, which is one way to start aligning what medicine teaches with what it rewards. When equity-related work is rewarded with higher budgets, promotion criteria, and accreditation standards (the same standards used for research and clinical productivity), it starts becoming a part of the institution.

DEIJ efforts cannot survive as a top-down initiative. They have to grow from lived experiences of the people closest to care. That brings me back to the Afghan patient in the ambulance – the helplessness that results from systems that are not equipped to listen, and to the culture of medicine where conformity and efficiency are often rewarded over conscience. I’m still learning what it means to choose between these. Medicine requires both the comfort to sit with suffering and the conscience to challenge its causes. Right now, equity work is seen as optional and based on goodwill – it must be resourced like other core aspects of academic medicine. The question is not whether equity is valued in medicine, just whether medicine is willing to build systems that can sustain it.