The coffee was bad. It was always bad. The pot had been sitting on the warmer since 5 AM, and the cup I poured into had a chip in the rim that caught on my lower lip every time I lifted it. I drank it anyway.

My first patient was at 7:15. Frank "Deacon" Maloney, 67, came in at the same time every morning, same chair, same complaint -- his knee hurt, and he didn't know why, and he wasn't going to X-ray it because X-rays cost money and his knee had been hurting for twelve years and if it was going to hurt forever, he might as well save the twenty dollars.

"Deacon," I said, pressing on his knee. "Your meniscus is shot."

"I know what a meniscus is, Raymond."

"Then why are you here?"

"Because you're the only doctor within thirty miles who doesn't charge me fifty dollars to tell me what I already know."

I wrote him a prescription for ibuprofen. He couldn't afford it. I told him to buy the store brand. He bought the store brand.

Karen Voss came at 9:00. She was 52, had stage IV pancreatic cancer, and refused to die because she had "too much to say." Every visit began the same way:

"I'm not dying, Raymond."

"Karen, we've talked about this."

"I'm not. The tests are wrong. The doctors are wrong. I'm going to live to see my granddaughter graduate."

"Then let's make sure you're comfortable while you wait."

I examined her. Her liver was enlarged. Her abdomen was tender. Her eyes were bright, defiant, furious at the universe for suggesting that she should be anything less than immortal. I prescribed morphine for the pain and told her to eat small meals. She nodded without listening.

At lunch, I ate a sandwich at my desk and read the newspaper. The factory had laid off another hundred people. The pharmacy in Lima had closed. The church was doing a food drive. Nothing extraordinary.

Nurse Janet came by at 1:00. "The Cleveland clinic called back," she said.

I didn't look up. "And?"

"They want an interview."

I finished reading the headline. "Tell them no."

She hesitated. "Raymond—"

"I'm not going anywhere, Janet."

She left. The office was quiet except for the hum of the refrigerator in the corner, which had been making a strange noise for six months and which I hadn't fixed because fixing it meant buying a new compressor and the clinic couldn't afford it.

My 2:00 patient was a teenage boy -- 16, overweight, with the early signs of type 2 diabetes. I explained the diet. He listened politely, nodded, and I knew he would do none of it. I prescribed metformin. His mother couldn't afford it. I told her to pick it up at the pharmacy that had the coupon program. She picked it up.

At 3:30, I performed a minor procedure -- removing a cyst from a construction worker's shoulder. The procedure went fine. The patient was fine. I cleaned up the instruments.

At 4:15, there was an emergency. An elderly man, 78, had collapsed in the waiting room. I ran out. He was on the floor, conscious but confused. His blood pressure was 80 over 50. His pulse was thready.

"Call 911," I told the receptionist.

The ambulance would take 18 minutes. We didn't have 18 minutes.

I started IV fluids. I checked his airway. I asked his name. He told me. I asked his address. He told me. I asked if he had any medications. He handed me a paper bag with three pills inside. I recognized them: a beta blocker, a diuretic, an aspirin. He was on heart medications. His heart was failing.

The ambulance arrived at 17 minutes. I had stabilized him enough that he wouldn't die in the waiting room. That was the job. That was all it was.

At 5:00, the last patient left. I locked the door and sat at my desk and thought about what I'd seen today. Frank with his knee. Karen with her cancer. The teenager with his diabetes. The old man with his heart. Twelve patients. Five serious conditions. Zero cures.

I picked up the phone and called the sanitarium. My sister's voice when she answered was the same as always -- clear, warm, slightly distant, like someone speaking from another room.

"Raymond," she said. "How was your day?"

"Fine," I said. "How was yours?"

"Same as always."

"Good."

"Raymond, are you coming home?"

"Maybe this weekend."

"Okay."

I hung up. I sat in the dark office and listened to the refrigerator hum its broken note. I thought about Cleveland. I thought about the hospital there with its MRI machines and its specialists and its chance to do something -- anything -- that would change my life.

Then I thought about Frank. About Karen. About the teenager who would come back next week and nod politely and do none of the diet I'd prescribed. About the old man whose heart was failing and who would die alone in a hospital bed three towns over because he couldn't afford to live here.

I thought about twelve years. Twelve years of bad coffee and broken chairs and patients who needed me more than they needed a specialist in Cleveland.

I stood up. I turned on the light. I went to the cabinet and took out the schedule for tomorrow. I had ten appointments. Five of them were follow-ups. Three were new patients. Two were emergencies that someone else's doctor had sent me because I was the only doctor.

I put the schedule on the desk. I turned off the light. I locked the door.

And I went home, because tomorrow I would open the office at 7 AM, and the coffee would be bad, and the chair would still creak, and the patients would still come, and I would still be here.

Nothing had changed. And everything had.