DAVE DAVIES, HOST:
This is FRESH AIR. I'm Dave Davies, in today for Terry Gross. In January of 2020, when the COVID pandemic was just appearing in news stories, Thomas Fisher says he knew the onslaught was inevitable, and he expected to be infected before it was over. Thomas is an emergency room doctor at the University of Chicago Medical Center, and his new memoir chronicles his experiences in the first year of the COVID crisis, struggling to stay safe while doing his best for patients. Thomas has been in emergency medicine for two decades, and he writes that he's made it his life's mission to care for his people, the Black population of Chicago's South Side. His book describes his frustration with a health care system that leaves him too little time and too few resources to meet all his patients' needs. And he writes about ways his patients' health is undermined by the world they live in, one of relentless gun violence and enduring impacts from racist practices such as redlining, employment discrimination, inequities in city services and police brutality.
Besides his work in the emergency room, Fisher's career includes time as a private insurance company executive and president of a managed care company. He holds a master's degree in public health from Harvard. And he spent a year in the Obama administration as a White House fellow for the Department of Health and Human Services, working on regulations for the Affordable Care Act and on the department's action plan for reducing racial and ethnic health disparities. Fisher's new book is "The Emergency: A Year Of Healing And Heartbreak In A Chicago ER."
Well, Thomas Fisher, welcome to FRESH AIR. You write that in January of 2020, you knew that COVID was coming, and it was going to get to your emergency room. And you say, no matter how you prepared, you expected to be infected eventually. What preparations did you make for working in this period?
THOMAS FISHER: What a crazy time that was. I made all kinds of plans from financial plans to plans that would help to keep my family safe like compiling what I thought might be appropriate PPE. I had no idea what those might be. And also made - included everything from my will and trust to what might happen if I became ill. It was both terrifying, but also something that in many ways we in emergency medicine prepared for since our residency training.
DAVIES: As the COVID crisis really set in, I'm wondering how it affected things in the emergency room. You obviously had a lot of patients. On the other hand, I imagine probably fewer people came in for some kinds of care.
FISHER: Things like elective surgeries were put on hold. The entire system aligned in order to get people from the emergency department into hospital beds as quickly as possible. When you called and asked for things, they happened with speed and intention, and I'd never seen anything like it. The hospital worked from the perspective of the emergency department in ways that it had never happened before. Then we went into a lull where we were between waves. And people who were chronically sick and often used the emergency department, we didn't see them. It's regular to see people with diabetes who are out of insulin or end up in diabetic ketoacidosis or, you know, people with chest pain coming to the emergency department with high frequency. Low back pain is one of our most common diagnoses, and we saw very little of it. There were periods between waves where it was a ghost town, which is very unusual in an emergency department on the South Side of Chicago or the south sides of cities around the country.
DAVIES: One of the things you noted was a lot of people were released from jails and prisons because of the threat, and then they got back on the street and started using drugs that they had lost a tolerance for. You started seeing them in ERs, too.
FISHER: Yeah. There was a period sort of early on where people were experiencing early releases, which was in order to protect their health, given the uncontrolled spread that we saw in jails across the country. One patient - a couple of patients I describe had experienced overdoses, and those commonly occur for two reasons. Sometimes we'd see more and more synthetic fentanyl being laced into heroin. And also, sometimes when people haven't been using for a while and go back to their old dose after losing their tolerance, that becomes an overdose experience as well. We saw that pretty regularly during, you know, sort of early to mid-2020 going into George Floyd summer.
DAVIES: You know, a lot has been written about skepticism of vaccines among communities of color, you know, rooted in part in a historic distrust of a lot of medical institutions. What was your experience in the ER? How did you deal with folks who were skeptical of vaccines?
FISHER: I saw less frank skepticism than more and more people whose lives were so busy they hadn't taken the time to sit down and think about it.
FISHER: And so in those moments, we were fortunate to have vaccines in the emergency department. And when I would ask people whether or not they'd been vaccinated, if they hadn't, I'd ask an open-ended question. You know, why not? What are your thoughts? And people would often say, well, you know, I wasn't sure or I'd heard that it had a microchip or, you know, many of the misinformation items that existed in the world. And I talked to them about it and addressed their questions and revealed how I had made my own decision based on what information that I used. Oftentimes people were not so much staunch skeptics in that they were convinced that this was not for them. They simply needed information to make a decision. And once they made a decision, they wanted it then. And I would often say, look. I got this vaccine. And they said, OK, well, I want the vaccine you got, which was often - and that would be exactly what they would get.
DAVIES: Right. You know, it's clear from your book that working in this emergency department on the South Side of Chicago was a constant struggle well before COVID. In fact, you take a moment, you check us in on a day in November 2019, just before the pandemic really hits. You say you walk in and there are 38 people waiting to be seen in your ER. Some have been there 6 hours or more. And you describe some of these patients, their issues, your interaction, what you were able to do. Every one of these stories is fascinating, actually. You want to pick maybe one and tell us about the experience, what was significant about it?
FISHER: Sure. I mean, I think it's important to point out from the beginning that these are aggregate stories. So they take common characteristics in a patient or two in particular and remove away their identifying information and bring them so that they are not, you know, I don't violate anybody's privacy. But one patient in particular that I talk about is a woman and her family who had been waiting in the emergency department waiting room for about 5 hours with critical illness. She hadn't been feeling well. Labs that had been drawn demonstrated kidney failure. And her family came to the door and said, look. We've been waiting too long. She's too sick to wait. Can we go home?
And in the process, I discovered the lab findings and tried to reassure them that we'd be seeing them soon. And could you just hold on a little longer so that we can both treat her problem and try to get to the bottom of why it occurred? And on that particular day, which is not dissimilar from many days, particularly pre-pandemic, we were just so full of sick people that I couldn't guarantee that she would be the next one back. There were other patients in the waiting room who were just as sick or sicker. We're constantly trapped where we want to be able to serve this person, which she has a real medical problem, one that needs to be managed. And yet so often we fall short and have to go back and tell them, please just try to wait a little longer.
DAVIES: So what happened to this woman with the kidney issue?
FISHER: I don't know what happened to her. I left that open-jawed with the recognition that she was waiting. In most situations, at some point we get them into a bay and we deliver the care that's necessary in order to ameliorate their issue. But oftentimes, folks like this leave and they go home or try another emergency department and often face another interminable wait.
DAVIES: You describe a case of a young woman who came in, maybe with her mom, and she had facial injuries. She had been jumped at school. You - so you typically have three minutes to talk to somebody. It's never enough time. And you could treat her physical injuries, but it left you frustrated. You want to tell us about that case?
FISHER: Yeah. This patient in particular was assaulted at school. And while she didn't have long-term injuries or anything that needed more than, you know, some Tylenol and pain relief, I didn't have a chance to ask if she was safe or being bullied or whether or not this was a pattern of violence that we - that - and this was a sentinel event that we could use to intervene. I just simply didn't have the time to ask those questions, which is indicative of so many times we are taking care of people where what they're coming to the emergency department with is a physical manifestation of some social trauma or being trapped in a dangerous workplace or being trapped in a violent relationship.
Oftentimes, if you sit and ask open-ended questions, they're waiting to tell you. But do you have the time to do that? In the book, I engaged our social worker to do some of that work for us, and I'm so thankful that we have social work embedded in the emergency department to pick up that slack when we are unable to. But what if we don't even realize we need to engage the social worker because we haven't taken the time to think about it? It's a conundrum we face every day.
DAVIES: You know, you say that you typically have three minutes to talk to someone, and this is typically someone who's been waiting a while and it's their one chance to have the attention of a doctor. And you've got a dozen things in your head about tests you're waiting for on other patients, you know, not to mention your own needs. You may be starved or exhausted. Is it hard to focus on those people and give them the undivided attention, even for the three minutes?
FISHER: When you're working that shift and you're right there at the front of the house and you're trying to sift through as many people as possible, it's extremely challenging. And what you realize is, look, you've got all this training and experience and you know how to do more and you want to do more, and you simply can't. And that creates this big yawning gap between what you'd love to do and what you are doing that lingers with us after our shift. What would you do if you saw somebody who had been - who is living, you know, in an unsafe environment and has a small, nagging medical issue but hints at something much deeper that you'd love to pull the string on and learn more about, but you very rarely have the opportunity to? It nags.
The fortunate component is not every shift reflects that challenge. We only work - that is one of the many places in the emergency department that we have the opportunity to work. And in those other places, we often have more time to sit down and listen if you take it, if you aren't shielding yourself from what you might hear, if you are open to it and not fatigued and not scared and not - you know, not yielding to the barriers that come from protective equipment or social distance and actually just sit down and open yourself and allow patients to open to you.
DAVIES: We're going to take a break here. Let me reintroduce you. We're speaking with Dr. Thomas Fisher. He is an emergency room physician at the University of Chicago Medical Center. His new book is "The Emergency: A Year Of Healing And Heartbreak In A Chicago ER." We'll continue our conversation in just a moment. This is FRESH AIR.
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DAVIES: This is FRESH AIR, and we're speaking with Thomas Fisher, an experienced emergency room physician at the University of Chicago Medical Center. He's written a new book about his experiences in the first year of the COVID pandemic. It's called "The Emergency: A Year Of Healing And Heartbreak In A Chicago ER."
I want to talk a bit about your background here. You write in the book that you're working at this emergency department by choice because you made it your mission to care for your people. Let's talk about that community and their connections. I mean, you write a lot about the history of de facto segregation in Chicago and redlining and inequities in public education and city services. Tell us a bit about your parents - how they got to Chicago, what they did for a living.
FISHER: My father's a physician and my mother is a social worker, and they met on a blind date in Detroit and moved to Chicago in order to start a life. They moved to the South Side of Chicago, a community that is full of Black folks that moved here during the Great Train Migration. Growing up in a household with those two instilled in me both the importance of investing and being a part of a community, but also the recognition that we're a part of something bigger. We're a part of a tradition that spans, you know, a couple of centuries in this country. And in many ways, that led me to see my work as an expression of a social justice agenda, which meant that taking care of the same population that raised me meant being, in many ways, like, a community doctor of the old-time kind, where you know the people in the community that come in. The references to, you know, when I fell on the corner of 47th and Lake Park, that's not simply, you know, a coordination on a map. Like, I have experiences on that same corner as well and can bring into that interaction, you know, a history and experience.
DAVIES: After you did your White House fellowship in Washington, that was when you went to work in the private sector, right? You worked for a health insurance company and then a managed care plan. And you describe this in the book and in particular, a place - I mean, I don't know how specific you want to get about this, but I mean, in the managed care plan where, you know, you really wanted to deliver effective health care for needy communities, and just the reimbursement streams and the timing by which payments arrived, particularly from governments, you know, state and federal, meant that it was just hard to provide the services, and there was a part where you actually had to lay people off, people who did important work, people that - health navigators who would help people get through the Affordable Care Act, you know, whistles and trips.
And I'm just wondering, you know, what conclusions you drew from the experience. I mean, we - I think most people believe it's an important - it's important for smart, public, spirited professionals to work in the business. I wonder what conclusions you drew about your experience there and whether that...
DAVIES: ...Was what you wanted to do.
FISHER: I had the notion that you get what you pay for. And if you start paying for the type of care that patients actually want and need, you would start getting better health outcomes. If you start paying for transportation to get to and from their appointments when that was an obstacle and start paying for the healthy food that's required to keep them healthy, start paying for the nonclinical inputs to their health that extend far beyond, you know, medications and surgeries, that we would have better health outcomes, particularly for those who need help the most. And what I confronted was a health care system that is working exactly as designed. And when challenged by the deeply ingrained obstacles that are ancient, I struggle just like every other administrator struggles to try to turn the system towards a different outcome.
And in the face of one of these cash flow challenges, I was unable to do better than what I'd hoped. And what I learned was not only - you know, there are no heroes, you know, no matter how hard I tried. And what I thought that I could bring to this challenge that I'd gleaned from research, from understanding patients in their clinical setting, in the emergency department, from watching leaders at the federal level, there comes a point where you just have to execute with the resources that you had available. And they - those resources didn't allow for us to incorporate all of these other very important inputs in a seamless fashion in order to address the obstacles that everyday people face when trying to get better.
DAVIES: So you decided the emergency department is where you belonged?
FISHER: I never left the emergency department. Throughout...
DAVIES: You kept...
FISHER: ...This entire trajectory...
DAVIES: ...Really, you kept doing shifts. Huh, wow.
FISHER: I kept doing shifts. I mean, it - I use a swear word to describe it. It's my bull**** detector...
FISHER: ...So that no matter what other rooms I'm in, I still have a pulse on what's really happening in the lives of individuals. I hear stories of people who say, look; I tried to get care for this broken ankle, but I couldn't find an orthopedist who would repair it for me, and that's why I'm still walking around in this splint weeks after I injured myself. Well, that's a systems problem. That's not a medical problem. Or I hear stories from patients who have, you know, had - I've had the opportunity to talk to the people in the waiting room who wait six or seven hours for needed services. That's a systems problem.
And I remain in touch with the patients who become a statistic in our crime blotter, but are, you know, shot full of holes on the South Side of Chicago. Well, they remain people to me when I take care of them; they don't become abstract. And I think proximity is so important to understanding these complicated problems because, otherwise, it becomes just so overwhelming that it's easier to think of folks who are suffering at the sharp end of these broken systems as abstract statistics and people you'll never meet. And then you take away their humanity, and you forget that they are no different than you are.
DAVIES: Let me reintroduce you here. We're going to take another break. We're speaking with Thomas Fisher. He's an emergency room physician at the University of Chicago Medical Center. His new book is "The Emergency: A Year Of Healing And Heartbreak In A Chicago ER." He'll be back to talk more after this short break. I'm Dave Davies, and this is FRESH AIR.
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DAVIES: This is FRESH AIR. I'm Dave Davies, in for Terry Gross. We're speaking with Thomas Fisher, an experienced emergency room physician at the University of Chicago Medical Center. He's written a new book about his experiences in the first year of the COVID-19 pandemic, treating what he describes as his people, the Black population of Chicago's South Side. The book includes stories of many patients and reflections on the inequities in the health care system and the impact of decades of racism on the communities the hospital serves. The book is "The Emergency: A Year Of Healing And Heartbreak In A Chicago ER."
There was one other patient that I wanted to ask you about among those that you describe. This was a gentleman who came in with a heart attack. You give him the name Mr. Thornton (ph). And you wanted to get him quickly up for a coronary angioplasty to open an artery in his heart. And things were moving slowly. And you had a disagreement with the doctor, the cardiologist, who wanted to do some other steps before getting him up for the angioplasty. You want to describe what happened here and what it tells us?
FISHER: Sometimes in the emergency department, there is a difference of opinion between what we in the emergency department believe is the right course of action and what our consultants experience and believe. This is pretty common. And in this particular situation, there was a patient who was extremely ill, having a heart attack based on their EKG, who was having trouble breathing. And what I hoped was that the patient would immediately go to the cath lab and have an angioplasty, open their artery and hopefully resolve their symptoms.
And in this situation, the consulting cardiologist wasn't so sure and thought it might be something else. And we had a disagreement around the best path of treatment at that time. And it seemed like the patient had a bad outcome. The challenge is, of course, that patient might have had a bad outcome no matter what we did. They were critically ill, and it's not clear that we were going to be able to save them no matter what. But the conundrum is sometimes what you'll find is there's VIP care. If you are a special patient or VIP for one reason or another, often there are no obstacles to care. Even sometimes they get people who are VIPs get care that they don't actually need and can even be dangerous. But having this side pathway for these common goods and resources that exist in almost every hospital, sometimes there are even VIP floors for patients, cast into question whether or not everybody gets the care that's required to them based on their health or based on these other variables.
DAVIES: Right. You described one case where a woman who happened to be the board chair of a significant organization came in with some pain, a lot of - what - you got calls. The medical chart actually had a different color code to indicate important person or something like that?
FISHER: Yeah. I mean, there's all these indicators and processes and workarounds for some of the normal snares that allow for VIPs to get services in a fashion that other people don't. But if you believe that, beneath it all, we all deserve health care and we all should have our pain relieved and our crisis solved, then shouldn't these same processes be held in common, particularly when so much of this is paid for by taxpayers and based on a nonprofit system that allows for many, many hospitals in the country to be supported by the communities that, you know, that they don't pay taxes to? If you both believe we have these resources in common and we need these resources in common, the idea of VIP care is worrisome.
DAVIES: Yeah. You slipped in an important point there. Are a lot of these hospitals are technically nonprofit, although executives make quite, quite healthy salaries. And they're exempted often from local property taxes. So there's a subsidy in effect here, right?
FISHER: Yeah. And that subsidy goes beyond just the property tax. Like, look. I trained to be a doctor based on public funds. I mean, Medicare pays for physician training. There's the non - there's the land - there's the real estate tax exemption. There - you know, Medicare pays for so many supporting resources in these institutions. NIH funding, which is federal money, gives indirect funding for all these university hospitals that are doing research, research that we all benefit from. But then when some of those resources that are needed are held aside for VIPs, the question of fairness can't be avoided.
DAVIES: You know, in the case of this heart attack patient, Mr. Thornton, where you wanted to get him coronary angioplasty quickly in an hour, the cardiologist was interested in other steps first. One of them was he said - one point wanted to put him on a ventilator. And in your conversation, he says to you, but if we put him on the ventilator, the door-to-balloon clock stops. Door to balloon means when you enter the door of the emergency room to what?
FISHER: To opening the balloon in the coronary artery that restores blood flow in a heart attack.
DAVIES: Right, which is the really effective intervention. And - but if he were on a ventilator, then at that point...
FISHER: At that point, you've satisfied the door-to-balloon time because this person gets excluded from the timing because they were too sick to follow the normal course of action.
DAVIES: So the numbers look better, but you haven't gotten the patient the critical care.
FISHER: In this particular case, one of the quality metrics that we use around heart attacks is how quickly do we perform the angioplasty, from the time we identify the heart attack to the time we open the affected artery? And we all race to meet those timeframes because we want to give high-quality care. And we've agreed that that is an indication of high-quality care. There are ways to stop those clocks that indicate that somebody was either too sick and we couldn't meet those time frames or other work arounds.
And in this point, I think that everybody involved in that care, the stand-in cardiologist in this conflict, I in no way believe that he didn't want to give the right care to this individual. I think that clinical uncertainty led to a more conservative path. And that conservative path included, well, would this impact our quality metrics? I mean, there's a whole body of research that I am not an expert on, but I've seen, that addressed many of these quality metrics that sometimes improve but often exacerbate health equity challenges.
DAVIES: At the end of a shift, does this stuff hang with you? Do you dream about it? I mean, do you mull over patients that - you wonder what became of them or wish you had been able to do more for?
FISHER: I constantly think about patients after my shift. Sometimes there are catastrophes that you wish you never saw and that nobody experienced that are nobody's fault. But I still can't let them go from my mind. Sometimes I worry that I've done the wrong thing, and when I went left, I should have gone right. Or maybe this medication wasn't the right choice. Or maybe they were going back into an unsafe environment, and I hadn't done enough to protect them. Sometimes people tell you things that are really unfathomable - a life that they live that are framed by a society that you just really never had an inkling of.
DAVIES: Can you think of an example of what you're talking about?
FISHER: One of the things that I hear often are the number of people who have had brushes with the criminal justice system and how that's reshaped their lives in ways that they didn't understand. There is a patient that was recently released from jail and now doesn't have a job or a place to live. And the depression led them to the emergency department for help. In that situation, I don't have a whole lot of help. I know that once you have brushes with the criminal justice system, the number of resources available to you, whether they be job or otherwise, become extremely limited. And it opens this yawning gap between what I can do and what's available. And that sticks with you, particularly when your job is to help people.
DAVIES: Dr. Fisher, you've been doing emergency medicine for how long?
FISHER: I started my residency in 2001, so I'm entering my 21st year.
DAVIES: So 20 years, give or take - that's - I just did some quick math - that's 4,000 or 5,000 shifts in an emergency rooms. You've - in between, you've done some policy work in Washington. You've worked in managed care as an executive trying to make systems work. What's your morale? What's your outlook these days? Are you optimistic? Are you exhausted?
FISHER: You know, I'm hopeful. I think that one of the keys is remaining close to these challenges. And I wrote this book to bring other people close to the challenges with me. I fundamentally don't believe we'll fix health care until we fix society. I mean, health care is just as sensitive to our racial caste and unchecked capitalism as every other factor in America.
And that said, I don't believe that we're going to solve it with one fell swoop in the next, you know, 90 days because everybody realizes that, oh, we've got to do something about this. But the first step has to be looking honestly and closely at what we see and what's happening to people across the country and the fact that, you know, health care is the biological platform on which everything we do relies. Our health is the most important component of our ability to love and create and learn. And so we owe to one another a health care system that reflects those values and our connections to one another.
DAVIES: Well, I salute your service and hope it goes well. Thomas Fisher, thank you so much for speaking with us.
FISHER: Thanks for this.
DAVIES: Thomas Fisher is an emergency room physician at the University of Chicago Medical Center. His new book is "The Emergency: A Year Of Healing And Heartbreak In A Chicago ER."
Coming up, John Powers reviews the new Apple TV+ series "Pachinko," based on the bestselling novel by Korean American author Min Jin Lee. This is FRESH AIR.
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