I’ve been an ER doctor for 11 years.

Friday nights in a hospital Emergency Department on the South Side of Chicago can take many different forms. Some nights bring waves of ill people who drench the ER with their cries. Other nights it’s the frenetic energy from the mentally ill, or the shouts of frustration from those in the waiting room who have been stranded for hours. And other nights the tension comes from the anxious care teams attempting a therapeutic plan to help a gasping patient breathe. Most nights lead to hours of nonstop questions. Who is closest to dying? What resources do we have tonight? What’s the most efficient plan of action? What can we, as a team, do right now to make this person’s life better?  And, finally, can we prevent this person from being back in ER tomorrow night?

One recent Friday was a welcome change. Although people packed the waiting room, the evening was calm.  Almost every person was black. They sat watching television, waiting, staring blankly or peaceably chatting with neighbors. A nice change of pace that allowed me to reflect on my city, my community, my work and my patients.

I walked into one room and met a woman who had fallen and injured her knee. Hers was a very simple and familiar story. She had taken the bus to Walgreens to pick up a prescription, one of many that drained her pocketbook. She had sore knees even before the fall.  She had poorly managed diabetes, despite medication and long-standing efforts to lose weight. Given the many things weighing on her mind, she was a little distracted when an uneven sidewalk conspired with an untied shoelace to let gravity take control.

She was uninsured.

After an ambulance ride to the hospital, she waited hours for an X-ray that calmed her fears but had questionable medical necessity. This was a simple case; I knew what to do here. But so would any grandma who cleaned a skinned knee or coach who has put ice on a sore shoulder. As we prepared to discharge her, I inquired how she’d get home. With nobody to pick her up and $2 in her pocket, a cab was out of the question. Although her medical presentation is common across race and socioeconomic status, her circumstances are not. How will this limping woman get home? Is that my problem? If getting home from the hospital is a problem, what other issues does she have?

In Chicago, where segregation, poverty and race are inextricably linked, my patient confronts situations that make staying healthy challenging and accessing health care confusing. Obvious issues like food stability, poor education and violence have become overwrought health challenges to the point of cliché. Beyond those issues my patient’s health is also impacted by a community with a less cohesive transportation network, fewer green spaces and fewer places for public gathering. Her health care options are limited, pharmacies are close yet understocked and her providers have different training. As many Chicago doctors will tell you, none of this is an accident. But who starts the process of fixing a broken system? What resources are available? How do we get the other stakeholders involved?

The accumulation of politics, policies and suburban flight has concentrated poverty and segregated races in measures unlike any other U.S. city. For example, Chicago has black communities with such high poverty, concentrated segregation and disadvantages that no white communities in Chicago can be used for comparison. My patient makes decisions for her health and health care through the lens of this poverty and segregation. How can we replace entire hips and knees, but not make sure individuals have access to the basic medications that prevent heart failure exacerbation? How can we create complex health systems but not meet simple needs?

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No institution is more representative of America than its health care system: advanced, creative, expensive, unequal.

Our system has fostered the brilliant minds and technology that lengthen life, transplant organs, visualize brain activity and ended a mandatory death sentence from HIV/AIDS. Such successes have changed the course of history and garnered Nobel prizes. Those successes, unfortunately, have not benefited all Americans and have come at a great expense. As a result, our system is amid a dramatic and controversial reshaping. But who is benefiting, and more important, who is being left behind?

Those are my questions. Those are my patients.

Maybe most important to my patients is the huge expansion in the number of people who will purchase health insurance in the near future. Millions who were previously uninsured will soon have opportunities to access the health care system. By definition, many of these people will be impoverished. These are the members of our society who frequently have no regular source of health care despite being in poor or fair health and having high rates of chronic illness. They have benefited the least from American’s lengthening life span and have the most to gain from change. They take two busses and a train to appointments; they work at minimum wage jobs that put their health at risk; and they are injured by uneven sidewalks. They worry about being experimented on and about how they’ll afford their medications.

While it remains valuable that we solve exceedingly complex medical challenges, my patients also need issues addressed that are not controversial in other communities. How will this system be reshaped to meet their needs? Will it help or harm those providers who have always provided care to those most in need? How do we create a system where patients share decision making with their doctors who make significantly more income and live in enclaves a world away? How do the new systems overcome mistrust, the crutch of color blindness and decades of inertia?

As our system rapidly evolves, we will all have to think differently about health care.  Equitable care will not occur by accident, it requires active engagement.

My shift ended soon after my patient was discharged from the ER last Friday. I left through the ambulance bay, past spent liquor bottles on the sidewalk, the whine of motorcycles in the distance and inhaled Chicago’s summertime thick humidity. A block and a half ahead I noticed my patient’s awkward leg swing balanced between her new crutches. I went to get my car and circled back to offer her a ride. These are my patients.

Thomas Fisher is board certified in emergency medicine and practices in the same neighborhood he grew up. He worries that the Chicago Bears will break his heart again this season.