“None of us have seen anything like this,” Thomas Fisher observes of the Covid pandemic, midway through his eloquent, propulsive The Emergency: A Year of Healing and Heartbreak in a Chicago ER. “The coronavirus is making us relearn medicine.” With immediacy and candor, Fisher’s book captures his turbulent challenges as an attending physician in the emergency department of the University of Chicago Medical Center, on the city’s largely Black and disadvantaged South Side, guiding us through scores of dramas, and bringing into sharp relief the gross racial and socioeconomic inequities that stymie better health for all our citizens.
Equal parts policy manifesto, philosophical treatise, and nonfiction thriller (with a splash of autobiography), The Emergency frames 12 critical months—November 2019 through November 2020—as Fisher and his team cycle through their usual trials—gunshot trauma, pulmonary embolisms, cancer—while also playing 11-dimensional chess with a relentless microbe. He finds pleasure and pride in their work: “As the attending physician, I supervise the care of each patient in the emergency department,” he notes. “Like attending physicians in EDs across the country, I don’t get involved with every decision, but I meet and examine each patient, and I am ultimately responsible for their diagnosis, treatment plan, and outcome. The residents are the ones who put their hands on every patient.… The nurses and techs spend more time with patients than any doctor does. If anyone on the team is off their game, the whole choreography falls apart. But when the dance is flowing as it should, it takes on a kind of frantic beauty.”
The ED (also known colloquially as the ER, as in the television series) bridges two worlds; or as Fisher writes, “We work right where the community and hospital connect.” The advent of the pandemic ushers in novel measures, additional layers of precautions and preparations, from face shields to laundry drops to pop-up decontamination units. It’s tough to connect with patients when they can’t fully see his face, but Fisher pushes past the barriers. His cast springs to life: Janet, injured in hail of gunshots; Nicole, a teenager jumped at school; a 34-year-old man struggling with mental illness, “who speaks in the idiom of lockdown.” Their accounts form the flesh and bones of The Emergency. It’s a wonder to see Fisher the writer follow in the tracks of Fisher the clinician, rounding on patients in absurdly brief examinations, pondering which steps to take, stricken by the cruel limitations imposed by an unjust, profit-hungry system.
Born and raised on the South Side, Fisher headed to Dartmouth but then circled back to the University of Chicago for medical school. (He also holds a degree in public health from Harvard.) His zeal for his community draws us in as he blends riveting storytelling with a righteous anger: “Even on the segregated South Side, we serve Black and white people, executives and laborers, young and old, men and women, people with plans for the future and those who know the end is near…illness and injury shape each of our lives. But if our human frailty brings us all together, our specific pain and its possibility of relief can be very different.”
He recently spoke with Oprah Daily about his experiences as an ED attending in a year of crisis.
How did this book evolve from your clinical shift to the printed page?
Fisher: For many years, I’ve been journaling. There are often moments that emphasize the gap between what’s needed and what I can do, gnawing at me. Sometimes it’s something that’s totally out of my control, when people are too sick and there’s nothing we can do to recover them. Other times there’s an opportunity that’s been missed. And there’s a whole other category where it’s just confusing: Why are these young people so sick? Why do people have to wait five hours with critical illnesses? What am I doing wrong? Those things would often enter my subconscious and emerge in dreams. That led me to journal, and to think more carefully. And you have to recognize that, at the same time that I’m embarking on this clinical arc, now 20 years in duration, I’ve also been working outside the emergency department to try to resolve some of these conflicts. All of that culminated in a period with me stepping back to understand: What have I seen, and what did I learn? And that’s what I tried to put on the page, in ways that would be informative to the patients themselves, those who are trapped, those who often have nowhere else to go and come to me for help. And when I can’t help them, what I can tell them to help them understand why we’re both involved in this trap.
Why should readers care about the grim realities and exhilarating triumphs of an emergency department?
One of the benefits of taking readers into the emergency department is revealing what we see, things people don’t otherwise have exposure to. When people are in their worst state—when they’ve had their heart attacks, when their infections have gotten out of control—they’re not out in the community, they’re in our healthcare system. In those moments, they’re no longer the CEO of the hospital or a homeless person: They’re just a person. Those of us in healthcare have the opportunity to see others stripped of their social edifices, to see those underlying components that we have in common.
Can you suggest potential solutions for the structural discrimination you’ve portrayed so beautifully on the page?
First of all, we only reconcile this with a grand restructuring of society that no longer elevates profit over people, and sees our shared humanity as the fundamental component that links us all together. That would then restructure society toward one that keeps us healthy, or at least doesn’t identify who gets to benefit at the expense of others. We’re all in this together. I don’t believe that’s going to happen in my lifetime, but that doesn’t mean I shouldn’t point out: That’s where we need to go.
Short of that, there are components of moral leadership that, when we do reconcile the conflicted organization, we see the people at the end of the budget—at the end of our hiring, at the end of our decisions—as fully human, and make decisions accordingly. That look at systems, rather than individuals, as the locus of our change.
How can we reinvent health infrastructure when there’s so much strain on our political institutions right now? We’re barely holding on as a republic.
It’s easy to talk about change, and then once you hop into the tactical details, you realize: This is going to be incredibly difficult. I do think there’s wisdom in democracy; when you hold decisions in common, that every individual can participate in, you start to make good decisions about what public health looks like. Shared resources that support us all: basic medication, basic emergency services, basic child healthcare and maternal care. The Affordable Care Act started to make steps in that way. But we’re going to have to build new things to fill in gaps. Part of why the healthcare system is currently misorganized is because our payment system tilts toward those who pay the most. And if we balance this out and hold some things in common, we might be able to create a floor for everybody.
Now again, that’s going to be incredibly challenging—I really don’t see this book as a policy proposal, but rather a step back and says, “If you believe that there’s shared humanity, and if you believe that when we are sick we owe something to one another, then let’s get around the table and start to think through the problems.” In 2003 Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare was published. It aggregated all the work on health disparities, the inequities and injustices in the system. It was around 250 pages. We’ve made no progress. I don’t think the challenge is a lack of good ideas. I think the challenge is of will. What I’m trying to argue is to gather that will, to see one another differently, and to start to enact those changes.
How do you enlist the public in becoming partners in their own care?
One of the pieces is recognizing how much of this is within the control of patients, and how much is the systems and structures in which patients live. For example, I practice medicine on the South Side of Chicago, a diverse community with all kinds of different subsets; but one of those neighborhoods near the hospital is Englewood, where 25 percent of people are unemployed and 12.5 percent or so have no health insurance. Neighborhoods like that simply don’t have a lot of health consciousness. Communities like Englewood don’t have a lot of primary care services available to them. Guns are rampant. The opportunities to safely exercise outdoors are few. The onus is on society in restructuring so that people can be healthy, so that somebody from Englewood could be just as healthy as somebody in a North Side neighborhood like Streeterville, where only 2.5 percent of people are uninsured and 2.5 percent of people are unemployed.
Those two vast differences of experiences—it’s not that people in those different communities have different will, or different interest in their own healthcare. People want the same things—everybody wants a certain level of peace and joy and to be connected to something larger than themselves, to have a future for themselves and their families. But when you’re in Streeterville, your opportunity to achieve that is high, compared to in Englewood. And you wouldn’t be surprised that those two communities have the largest life-expectancy differences in the country: It’s close to 90 years in Streeterville and about 60 in Englewood. Thirty years of life—that’s not an individual choice; those are systems that have created those differences.
In your opinion, is medicine overly siloed?
That’s a good question, a very interesting question. I work in a setting where those silos are broken down, where I take care of rich and poor, I take care of men and women, I take care of young and old, I take care of broken ankles and gunshot wounds. Much of what we see is both siloing across specialty but also the same sort of caste and segregation we see in society. I worry more about the latter than the former. When you enter the healthcare system, the people who share that setting with you influence your outcome.
So if you go somewhere where everybody is rich and well cared for and affluent, you’ll find things like waterfalls and fluffy pillows and attentive physicians and more nurses than you need, compared to when you go to places where people are lower-income and uninsured, less likely to speak English and more likely to be Black. That kind of segregation is more dangerous, to me, than the technical siloing.
How does the clinical expertise you’ve acquired on Chicago’s South Side, an urban environment, translate to underserved rural communities, from Indigenous reservations to backwoods Appalachia? How do we get the big picture beyond the city?
When I was a younger man, I worked at a free clinic in Vermont, which couldn’t be more dissimilar to the South Side of Chicago: It’s rural, it’s white, it’s tucked up in a corner of the United States. And yet their context also influences the healthcare of those around—if you’re poor and rural, your opportunities to stay healthy are fewer. The jobs you work in are more dangerous. The food available to you is constrained. Those folks also fell ill earlier and had fewer places to seek care. There’s a lot of thought on figuring out how to create a more cohesive healthcare system for those in rural environments who are most vulnerable. They also have the challenge of distance. The stories I share in The Emergency are about people who need help the most and are least likely to receive it; and I don’t think that’s dissimilar from my experiences in rural Vermont, reservations in Oklahoma, and other rural environments across the country.
How should we prepare for future Covid waves?
[Whistles] I really shudder at the prospect, but it’s an inevitability, right? BA.2 is on the horizon, right? Numbers are up in Europe. There are pandemics every few years—there was a time before HIV, right? That became one. And then Ebola hit. Flu comes every year. So much of this is deeply investing in a public health system, and also in the way we communicate about public health.
And yet with Covid waves over the past two years, there have been mixed messages about what to do, how to lower risk of transmission, even from our most thoughtful, informed epidemiologists.
This is so hard because we’ve never had Covid; we’re learning as we go. Even the scientific method is a process by which we understand the world, the source to test and retest, so that we come to a version of the truth, but it’s not like the Gospel. It’s not infallible. Mistakes are made. Some of it comes from both a level of candor about how we’re getting into the same decisions and reshaping them honestly, and clarity on what our policies are trying to accomplish. Are we trying to open schools? Are we trying to protect the economy? Are we trying to maximize lives protected? Let’s be real explicit about that so people can participate in the public conversation. I just really, really worry about the way in which social media has been detrimental to the public good.
The advantage of social media is you can get actionable information out there quickly; the disadvantage is that 48 hours later, new data comes in to refute what you’ve just put out there. The more conventional channels of communication used to streamline; now it’s just a crazy Wild West of debate.
There was also accountability. In traditional lines of communication, there are certain things you cannot do on radio, on television, in print. There is no accountability on social media. A lie can be promoted and amplified, and everyone is, like, Well, it wasn’t my fault, you have to learn the truth for yourself. If that’s the case, you’re relying on every individual to be an expert. There needs to be better social media, if that means regulations, if that means carrots and sticks. The total lack of accountability is untenable, considering that there are lives on the line.
I’m arguing some very different pieces about how America needs to live up to what it says it is, related to care for one another.