EP. 16: THE (TRUE) COSTS OF ILLNESS AND HEALTH

WITH EMILY MALONEY

Jun 21

WITH EMILY MALONEY

An essayist shares her experiences facing the financial and personal costs of health care, from the vanage point of both patient and caregiver.

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Episode Summary

Essayist Emily Maloney offers a wholly unique vantage point when it comes to American healthcare. At 19 years old, a suicide attempt landed Emily in the hospital for an extended stay, which then saddled her with a massive 5-figure load of unexpected medical bills. In an attempt to pay off her debt, Emily became an emergency room technician and began working in the very same system that was crippling her financial life. In today’s episode, Emily discusses her experiences as both patient and caregiver, and shares her insights on the true cost – financial and personal – that the flawed US medical system exerts on everyone involved, from patients to physicians.

Emily Maloney is the author of Cost of Living, an essay collection that chronicles her journey from patient to emergency room technician, set against the backdrop of the failure of the American healthcare system. At the age of 19, Emily was hospitalized for a suicide attempt and upon discharge was confronted with a 5-figure hospital bill, She would spend nearly a decade trying to pay off this debt, working in various roles in health care and, along the way, learning about the true financial and personal costs of being ill in America.
Her work has appeared in the Washington Post, Glamour, Virginia Quarterly Review, The Atlantic, the North American Review, and the American Journal of Nursing. She has also worked as a dog groomer, pastry chef, general contractor, tile setter, catalog model, and has sold her ceramics at art fairs. Emily is a MacDowell Fellow, a 2019 Illinois Arts Council Fellow, and a 2015 graduate of the University of Pittsburgh MFA program.
In this episode, you will hear about:
• Emily’s motivation for writing her recently published book of essays, “Cost of Living” - 2:33
• How finding herself in suffocating medical debt changed Emily’s life - 10:24
• Why the true costs of medical interventions are impossible to know under the current system - 18:20
• What drew Emily into the medical profession despite her negative experiences as a patient - 24:43
• Emily’s ideas on how healthcare in the US should be reformed - 37:28
Henry Bair: [00:00:01] Hi. I'm Henry Bair.

Tyler Johnson: [00:00:03] And I'm Tyler Johnson.

Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are, by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Henry Bair: [00:01:03] Our guest today is acclaimed essayist Emily Maloney. At the age of 19, Emily was hospitalized for a suicide attempt. Upon discharge, she was presented with a five figure hospital bill that she would spend the better part of the following decade trying to pay off. She would eventually find herself working as a technician in the emergency department, as an ambulance technician, and in various other roles in health care. Along her passage from patient to health care provider, Emily discovered shocking realities of the financial and personal costs of being ill in America. She learned the surprising ways our health care systems fail its patients and experienced moments of genuine connection with those she cared for. She chronicles all of this in her recently published collection of essays, 'Cost of Living.' In this episode, Emily shares with us her story and her lessons learned from having experienced both sides of the hospital bed.

Henry Bair: [00:01:57] In contrast to previous episodes of this program, this episode focuses in large part on the flaws of medicine as it is practiced today. But only through these reflections can we strive to imagine and realize a better, more humane future of medicine. Over the course of our conversation, Emily offers us glimmers of hope and optimism of what this brighter future might look like.

Henry Bair: [00:02:19] And now we welcome Emily. Emily, thank you very much for joining us today to kick us off. I'm wondering whether you can briefly tell us the origin of your book, 'Cost of Living.' What motivated you to write it?

Emily Maloney: [00:02:33] I knew it was a book a long time ago. A lot of the original scenes date from when I was working in the emergency department, where I would come home from a shift. I worked second shift usually and often on the fast track side, but often also on the trauma side. It really depended. And you know, I would see someone or have an interaction and think maybe I should write this down. So that was the sort of initial thinking. "Well, this, this is interesting. Maybe I'll write an essay about it, maybe I'll write something about it, about my experience." You know, there's a lot of pieces out there and books written by physicians. There's a few written by nurses. There's maybe one or two memoirs written by EMTs. Most of them are actually paramedics, though. So as someone who interacted very directly and physically with patients, I found it really important to to detail my experiences because I didn't see that reflected on the shelves at Barnes and Noble or whatever.

Tyler Johnson: [00:03:45] One thing that I'm brought to think about when you mentioned that - let me mention briefly two experiences. One is mine and one is that of a colleague. And then I'd love to get your thoughts about this. So, one is you mentioned being physically close to patients working as a technician in the emergency room. I had never realized how strong the cultural mores around that were until when I was just finishing medical school. I worked in a hospital in Argentina for six weeks and I was working in a bone marrow transplant unit. And as is often the case in teaching hospitals, there was the attending who was in charge of the team and then all of the little ducklings trailing behind him wherever he went, right, to go see the patient. And I was like the lowest of the ducklings. So we went to see a patient one time who had been in the hospital for a long time, had been down in bed, and her muscles had just grown very weak because she had been in bed for so long. And we needed to get her up and out of bed because the main task of that day was to encourage her to get up and to walk around. So we told her that she needed to do that and then immediately the attending went over and in a way that's a little bit hard to describe, basically leant over, helped her to sit up and then wrapped his arms physically around her and physically helped to sort of pick her up out of the bed and then steady her onto her feet so that she could then take a few steps and walk around. And the thing that struck me so much was that when I watched him do that, I realized in the moment that I was shocked because I had never seen an attending physician touch a patient that much. Right? Like attending physicians have this sort of arm's length relationship for the most part with their patients. Right? They almost never get closer than the length of their stethoscope.

Emily Maloney: [00:05:31] Right.

Tyler Johnson: [00:05:31] And so that struck me. And then similarly, I have a colleague. I didn't know this until recently, but at Stanford Hospital, the different members of the health care team in the hospital, except for attendings, all have different assigned colors of scrubs. So the respiratory technicians wear color X and the nurses wear color Y. And the emergency room technicians wear color whatever. Anyway, so one of the attendings at Stanford Hospital decided that he would do an experiment. And he spent a few weeks during the pandemic putting on different colors of scrubs and then just going around the hospital with his badge, not in obvious view, basically, to see how he was treated. And the good news is that for the most part, it was not just a litany of horror stories, which he was kind of afraid that it might be. But he said that it was really remarkable in some instances, inappropriately, and in some instances actually in a good way, how differently he was treated by people, by not being sort of the doctor in charge. Right? Like people just related to him in a completely different way. And so all of that is to say that I think that the health care system is so doctor-centric in many ways, and the narratives that we tell about health care are so doctor-centric that I imagine writing about this from a person who actually in many ways is more in the center of the actual care that gets delivered, but whose viewpoint is not as often expressed. It has to be bring a really distinctive vantage point. And I guess I'm just curious, having worked in that capacity for a long time, what about that strikes you as you look back on it, having that role that is maybe not as often presented?

Emily Maloney: [00:07:13] Patients told us all sorts of things and I don't think they realized that we could then turn around and tell the doctor or the nurse or whoever else, like as a patient care tech. You hear all sorts of things from patients there. It's weird because on one hand, I think the treatment from patients is both a little bit egalitarian in that they just see you as a medical professional. They don't know how much training you have or haven't had, especially if they don't have a lot of experience being in an E.R. dealing with that kind of life. They think, "Oh, you're you're the nurse." There's no distinction between nurses, techs and PAs or MPs. I think for patients, especially, like patients who are not familiar, patients who have a complex medical history and have that experience, they do treat you differently if you're a patient who if we're dealing with someone who we see on a regular basis, whether they're a frequent flier or not. That's another story. But we would get stories very different from the nurses report or from the physician's experience that sometimes they would be more honest in funny ways. I think that they thought, "Oh, like I can maybe confide in you because you're the one who's here who's dealing with the things that need to be dealt with." You'd have these, you'd strike up these conversations because you know, the ER techs, they're also pushing patients to see, they're also at our small hospital.

Emily Maloney: [00:08:57] It's very... We did a lot of different roles or you were performing EKGs or you were there were a lot of like little, little tasks that people were trained on. And so if you're if you're sitting there waiting in line for the CT machine, there's all sorts of funny things that patients will tell you in line. And I think that that kind of relationship can be really intimate and that intimacy can happen really suddenly, right? Because they're so vulnerable. But yeah, I mean, I think that it's important to tell stories of techs and to have that experience.

Emily Maloney: [00:09:35] A lot of the people I worked with went on to become physicians. We were making doctors where I work. So there were a lot of a number of people who went on to medical school. A few people became pharmacists. A few people became podiatrists. That bridge was there. The idea that we could provide flexible scheduling and provide that emergency department experience. So that way they would be able to go out and say like, "Oh yeah, you know, I worked at this level two trauma center and let me tell you the stories I had," and could be good for their medical school applications. So we did make plenty of doctors, but at the same time, there was there's definitely an intimacy that happened on the part of patients disclosing information to us.

Henry Bair: [00:10:24] Thank you for sharing those insights. I'm sure we will delve deeper later on in this conversation into your time working in the ER. But for now, I want to turn back the clock a little bit. In your book, you write about how you underwent a terrible experience while you were in college, which served as the catalyst that triggered the series of events you would later weave into a narrative in your book. For our listeners who may not be aware, and to the extent that you are comfortable with, can you share with us what that event was?

Emily Maloney: [00:10:56] Sure. Yeah. So I attempted suicide when I was 19, and that resulted in a boatload of medical debt. I took close to 8000 milligrams of lithium, which landed me in telemetry for a number of days. Which is not as expensive as ICU, but it was not... I ended up with five figures of medical debt, in the mid five figures, as a result of my stay and I later went on to try and pay off that debt working in the ER and then later in the pharmaceutical industry. I was depressed in college, but a lot of people were depressed and I only realized sort of what was going on, the extent of my relationship with my psychiatrist and the many drugs she tried to put me on. It turned out that I was not actually bipolar or anything like that, but I was treated for bipolar disorder for over five years and was given 26 different medications while under the care of my psychiatrist. I think that a lot of people, particularly in psychiatry, there's this sort of biological revolution in psychiatry where we have starting in the late seventies, we thought, "Well, we can treat patients the way that we deal with diabetics," that there's this sort of 1 to 1 relationship between medication administration and symptom improvement. And I don't think that's necessarily true. I was sort of subject to the care of a perhaps overzealous psychiatrist who had been educated in a particular way around medication administration. And I just wanted to be a good patient. So I took all the drugs that had been prescribed to me. I later came into the E.R. thinking that I took a class at community college, like an EMT basic class. And I thought, "You know, this is cool. I just... I don't know. The human body is this really, really fun puzzle." And I didn't think I could necessarily pass the classes to go to medical school, but that I knew that my experiences could provide me with both a source of income and a way to sort of make sense of the world that I had seen from another angle.

Tyler Johnson: [00:13:26] So I'm a medical oncologist, so I give chemotherapy to patients with cancer. And there has been, I would say, something of a quiet revolution over the last 5 to 10 years in oncology, where cancer occupies a place, I would argue, kind of right at the apex of the medical hierarchy, like for some reason, cancer commands a lot of respect and honor, right? If you have cancer, like it's okay if people know about it, is what I'm saying.

Emily Maloney: [00:13:53] Right.

Tyler Johnson: [00:13:53] Right. And I think a sort of an outgrowth of that is that there has been this feeling among patients for a long time, that there's almost this, like, moral obligation, that if the cancer, doctor says you need pill X. If you have to mortgage your house or you have like whatever you have to do, you just get the money so you can get the medicine, so you can fight the cancer. Right? And I think that because that's largely been unspoken, oncologists have kind of not really been aware of what now is often called financial toxicity of the treatments that we that we give. And I just am hoping that you could talk through a little bit. The moment when... So here you've had this very complicated psychiatric history. You've been on all these different medications, and then you become so desperate that you try to take your own life. And then I'm sure there are lots of doctors and nurses and whatever working to save your life and make sure that you're okay and bring you through this very difficult episode. And yet then a few months later or whatever it was, here comes this bill to your house for $50,000 or whatever. Can you just talk a little bit about that moment of getting ,I don't know if it was the bill or many bills, whatever, but sort of that what that was like?

Emily Maloney: [00:15:09] Yeah, I... I didn't know what to do. I had received a kind of financial education from my parents and from my family. And I in some ways... I knew a lot about what things cost because that was the environment I had been raised in. And so I had... I modeled as a small child. I had access to some of that money and bought stock with it like I was... I was like a in some ways a financially precocious young person. I had a credit card. I had a checking account. I paid for a lot of daily expenses. Starting when I was like much younger than a lot of people would normally start paying for those expenses, especially in my neck of the woods, having grown up in a in an area where just generally surrounded by incredible wealth and an incredible privilege. So I was not educated about what I was supposed to do with this particular information. You know, the idea of medical debt was new to me. I didn't really understand the ramifications of what I had gotten myself into. And so that experience for me, I just I opened the bill and I thought, wow, is my life worth that much money? I don't know. It was a real... It was a disorienting time.

Emily Maloney: [00:16:44] I put... I ignored a lot of bills. I just thought, "Well, you know, at some point, insurance is going to pick some of this up. Right?" And they didn't. And so I don't even remember the original bill. I just got the balance forwarded from the collection agency, but I didn't understand what could be covered or not. Ultimately, it's really actually the fact that EMS brought me to one hospital instead of the public hospital that actually ended up dictating this debt. I didn't know at the time. I knew that my psychiatrist had privileges at the Catholic hospital and not at the other hospital... At the public hospital. So I think that that was something that I only realized much later. Receiving the bill, I just thought, you know, my rent was $500 a month and I was working a variety of different jobs in college. Looking at that bill, I did not even begin to comprehend what that meant. I just thought, "Wow, that's a lot of money." I put it aside thinking that maybe there would be some kind of health insurance would kick in for some amount. And it just... They never did. You know, there was some amount of health insurance that I had at the time, but it would not cover psychiatric care. So I learned that the hard way, unfortunately.

Henry Bair: [00:18:20] I would argue that most people working in health care, most clinicians probably are also unaware of the true costs that the care they are providing exerts on their patients. And it's... It's just something that doctors don't really talk that much with patients, do they?

Tyler Johnson: [00:18:38] No. Well, I would even go farther than that. I would go so far as to say that there is no such thing as the concrete cost of anything in health care. The system... And I'm no health care business executive, but the system is so Byzantine and so opaque and so multilayered that occasionally we will have patients who say, "Oh, well, but if I get that scan instead of that scan, how much does it cost?" Or, "if I get this done at this place rather than this place, how much more will it cost?" It's not just that. I have no idea, right? I mean, that would be one thing as a doctor, maybe you shouldn't have an idea. People have argued that. And it's not even that. I don't know how to find out. It's that literally, I don't think there is a way to find out.

Emily Maloney: [00:19:26] There's no way to find out. A lot of that information, the agreements that are made between middlemen, is protected information. And so, yeah, there's absolutely no way I know that some medical schools have done more to educate their medical students about the true costs associated with certain things and to try and help keep costs down. The PA that I worked really closely with most of our days were sutures on the fast track side, right? So I would set up suture trays all day with him and he would clean and return the instruments from the suture tray, which he would otherwise discard to his patients, saying like, take these out in 7 to 10 days, don't cut yourself. Because the fact is, otherwise they were returning to our emergency department. They were clogging and already clogged. I mean, we were we were on bypass on a semi-regular basis anyway, number one. And number two, he didn't want to pass that cost onto his patients if he could. And so that was one way that one person was able to address that, at least somewhat. But absolutely, you know, the costs themselves can be totally opaque and billing itself is Byzantine. So there's really a lot of the time just absolutely no way to find out. And in fact, oftentimes even pharmaceutical companies don't necessarily know because the pharmaceutical company has an agreement and then the PBM has an agreement. The pharmacy benefit manager has an agreement with the health insurance company, and that information is private and protected. And then the insurance company or the PBM has a relationship with the retail pharmacy, or it might also be a retail pharmacy, which is a whole other problem. And so there are patients who are saying, "Well, you know, my drug costs a zillion dollars." Why? Why is this? And on the pharmacy side, we're like, "Well, we have patient programs to try and limit the cost of the drug." But at the same time, we don't necessarily know, depending on what your insurance is, how much that cost is actually going to be. So.

Henry Bair: [00:21:41] Yeah. So... So you receive this this giant bill and it's absolutely... It comes out of nowhere. So, how did you eventually resolve this?

Emily Maloney: [00:21:51] Well, I ignored it for a really long time, and then eventually I started paying on it, which is not something you're actually supposed to do if you've ignored it for a certain amount of time. Just keep ignoring it. Eventually, after seven years, it's supposed to fall off your credit report. I did not know this, so I started paying on it and I paid as much as I could afford to pay, which was usually somewhere in the neighborhood of $25 to $50 a month. Because I was living a very monk like existence. I couldn't afford a lot of things during that point in my early to mid twenties. So that was something that I just... I paid on it. And then it turned out that apparently after a certain point, the collection agency can't collect that money from you anymore. And so I... But I didn't... I didn't recognize this. It just happened in the form of a phone call where I called the collection agency because my bank had been acquired. And I thought, well, maybe the routing numbers have been changed in the acquisition or something. I need to set up something new. And the woman on the other end of the phone said, "You know, this is beyond the statute of limitations." And that was the first time anyone had said those words aloud to me. And I thought, Okay. And she said, "Well, you know. We're not going to collect on it anymore. I'm just going to close your account. Have a great have a great weekend." She's like, she's got this Iowa accent. She's got these, like... flat vowels and I thought, "Okay," and that was it. And it was, it was. So, I don't know, it was like really anticlimactic, right? Because, you know, like I've been I've been paying on this bill for so long and I've finally fallen into line and I'm like, "Okay, I'm just going to, like, pay the minimum every month.

Emily Maloney: [00:23:42] You know, the good news is now legally, legislation has changed just in this year to where we are not... Technically people are not going to have medical debt reported on their credit report in the United States. Whether or not that actually ends up happening, we'll find out. I don't know what that means for people whose medical debt is already on their credit report and to what extent people will try and bend this law or just assume that people don't know about it. But it is apparently now illegal to report that to credit bureaus. So hopefully in the future people will not end up with with my problem, which was... It's really hard to rent an apartment when you have a lot of medical debt. And it's not just... It doesn't look good. That was like one of many issues that sort of plagued me throughout my twenties.

Henry Bair: [00:24:43] So to pay off your medical debt you entered the health care profession, which might seem surprising to some, given your less than ideal past experiences as a patient. You first tried getting an EMT license, and I think you eventually did get it. But then, you were also working in the emergency room in various capacities. Aside from the paycheck, was there anything in particular that drew you to health care?

Emily Maloney: [00:25:10] Bodies are so cool. I'm a huge nerd. I don't know. It just... It seemed like... It just seemed so interesting. I always love science and I always loved math. Actually, English was my worst subject in school. It's kind of ironic that I became a writer because I was really bad at it for a really long time and I had to work at it. But I think that that pull... The sort of the science, pull the interest in bodies, the interest in people's stories. People have all sorts of crazy things they say to you in the ER. I mean, sometimes they disclose and it's like it's an intimate setting and they they tell you the truth. But normally they don't, right? Or they don't know what's wrong with them. They're not very good historians. They can't account for what's actually happening to them. And so because they're bad historians, we get bad information and then they end up being subjected to a battery of tests that they wouldn't have to be subjected to if they had better health literacy. I think that's a real big problem in this country is health literacy.

Tyler Johnson: [00:26:18] So, you know, here you had had this experience where you received very needed care, but then as a consequence of it had this absurd debt. And anyway, the whole thing that you explained, how did the experience of having been a patient and the aftermath of having been a patient inform the way that you approached delivering care when you were working on the health care provider side? And/or the way that you interacted with other health care providers, in terms of the things that doctors were doing or not doing, and all of that?

Emily Maloney: [00:26:50] There's an essay in the book where I sort of disclose my status because at the time I was still taking lithium. Well, I was also working in the emergency department and one of the physicians I worked with maybe started looking at me differently once I disclosed this information. I worked in an area that had very old and just incredibly elderly sick patients. We were the oldest and sickest patients per capita and the state of Illinois. And that kind of work was mostly medical, right? It's like people have sepsis and they have CHF and they have COPD and they have like 30,000 other things. And it's just, you know, they leave to go back to their nursing home and then they come back. It's just like this catch and release program. And like, everybody gets blood cultures, you know, like everybody was like all I did all day was drop blood, you know? But a lot of the patients that we saw who were not elderly and septic were psychiatric patients. And the reason for that is because I worked at a hospital with a locked psychiatric ward. You know, we didn't have the helipad, so we didn't get any of the cool trauma.

Emily Maloney: [00:28:09] You know, we had we had psychiatric patients get referred and diverted to us on a regular basis. And I would see patients whose behaviors were maybe not too far from my own lived experience, and being confronted with that can be alienating. You think, "Do I look like that? Do I respond that way?" You know, "Am I?" I felt like I always had to be extra careful around my colleagues and around the people who became my friends and around patients because I thought, one wrong move and I'll just give it away. And I know that a lot of that has to do with the inherent stigma associated with psychiatric issues and the fact that I think overwhelmingly, unless it's a dedicated psych E.R., Emergency departments are ill suited for treatment of psychiatric patients. It's like, ER Docs don't want to treat psych patients because they're boring and there's nothing that they can really do except give short acting drugs and then admit them. And I think that there is a lot of stigma around that. I'd love to see that change, but I don't see that changing any time soon.

Tyler Johnson: [00:29:31] So as I'm sure you're aware, there is, as terrible as it often is being a patient in the health care system, there's a lot of evidence that doctors themselves are increasingly burned out and the doctors themselves are having a hard time in the same health care system. And so we recognize that that probably operates on at least two levels. One is this very complicated macro level that has to do with the way that health care is set up and the way that doctors are used within the system and all of those things. And then also there is, I think on a micro level, there is a personal just sort of a disconnect where doctors themselves have kind of many of them have lost touch with the stuff that brought them into medicine in the first place. Right? I mean, as a writer, I'm sure you can imagine that every aspiring medical student writes an essay about how they want to help people and has these very high minded ideals about why they want to be a doctor. Right? Sure. And I have read like hundreds of these essays so I can talk with confidence about the themes, but then they get 10, 20 years into practice and it's like they have forgotten the version of themselves that even wrote that essay.

Emily Maloney: [00:30:36] I keep referring people back to there was an op ed by an emergency department physician a couple of months ago in The New York Times where he's like, "We're running out of people."

Tyler Johnson: [00:30:51] I remember that.

Emily Maloney: [00:30:52] Basically that was the gist of it was like. "We're running out of people to provide care. Like and with this next wave, like, we don't know what we're going to end up seeing." And it's very COVID focused. But obviously like having written my book, I worked in the ER starting... When I was starting in 2008. So we've been running out of medium gloves and short staffed for a really long time. You know, it's not just in the recent past that I think this has been an issue. It's something that's that's really been a problem for physicians and other health care providers for a very long time. But I know that it's sort of come up in the pandemic more than more than ever.

Tyler Johnson: [00:31:37] You know, one thing, Emily, that you might be able to speak to almost uniquely, there was an op ed in The New York Times that was written a couple of years ago, and the headline was something like 'The business of health care is built on the exploitation of health care workers.' And the thesis of the op ed was that you have this untenable pairing because on the one hand, health care, the business of health care, like any business, wants to maximize profits. And at the same time, health care workers for the most part, are really driven by high ideals. Right? They want to help. They want to do good. They want to make people better. So then what ends up happening, though, is that the health care system has this insatiable appetite and just sort of keeps consuming and consuming and consuming the most valuable resource, which is the time and goodwill of the people who are working in the health care system. And it's never clear like where that should stop, right? Because the appetite is insatiable. And so I guess what strikes me is that you end up with a person, a patient who feels like they're in this terrible place of moral hazard. Right? Because here you get the care that you need and then you're saddled with, whatever, $50,000 in debt, which you pay diligently, even though you have almost no money until the moment that it magically and without solicitation disappears. Right? Like that whole thing is.

Emily Maloney: [00:33:10] I called them!

Tyler Johnson: [00:33:11] It's like some axis between cruel and absurd.

Emily Maloney: [00:33:14] Right? Right.

Tyler Johnson: [00:33:15] But then on the other hand, you have health care workers who often feel a great degree of moral hazard because they feel like they're operating in a system. Right? Like the doctors who took care of you. It's not like they wanted you to have $50,000 of debt. They sure had no idea that you had $50,000 of that.

Emily Maloney: [00:33:29] Right. And they probably have their own debt for medical school, which is like, you know, like which is...

Tyler Johnson: [00:33:34] ...This whole other Thing.

Emily Maloney: [00:33:35] ...Whole other like demented practice, I think.

Tyler Johnson: [00:33:38] But I guess, though, that the thing I'm wondering is, is as the rare person who has so intimately experienced both sides of that equation. Did you identify a way to try to still operate with a measure of grace? Like, to cultivate some kind of genuine kindness or something> even working within what often I'm sure felt like a broken system. And if so, what? What did that look like?

Emily Maloney: [00:34:08] I think compassion fatigue is a huge, huge thing, right? Especially now, because if you manage to survive working in a hospital in the last couple of years and you're still working in a hospital, there's not a lot of you just so I do think... I think it's important to mention that the compassion fatigue that we're all. I think in both... I think practitioners are in that space. I think patients are in that space. I think the general public is in that space, which is why people are like, "Well, the pandemic is over. We're just not going to wear masks anymore." Compassion is a funny thing. Something I felt was true of our emergency department in particular is that it seemed like the line sometimes between patient and provider was thinner somehow. There were people we saw in our emergency department who worked at other hospitals. There were people who I worked with who were seen at other hospitals. One time I had a colleague who got whatever zoonotic disease that the patient had brought in. And he's a tech. He's in the next room. It's hard to sort of identify how to move forward. Right? But I know that. The people I worked with and the patients we saw, there's not... There's just not much difference between the two.

Emily Maloney: [00:35:50] And I think that if you're... if you're a well person, if you're a healthy person, the difference between being a healthy person and being a sick person is also, especially now, not so far away. Given that now we have all these people who have long-covid and who are dealing with the sort of extended experience of what might become an autoimmune disease in some patients. So yeah, I don't know. I'm not sure entirely how to answer that question because of the fact that, yes, did I want to provide quality care for the patients I saw? Absolutely. But I can absolutely at the same time understand the kind of compassion fatigue that makes people burn out. And that experience of compassion fatigue, of course, predates COVID. One of the ER docs I had previously worked with went into administration. It's not uncommon I think for ER in particular to go into administration because they just can't see patients anymore, but they need to keep working. So there are different ways to handle it. A lot of the ER docs I worked with had like really elaborate hobbies, too. That was the other thing. They all, like, rode their bicycle like 20 miles to work or whatever, you know, and they also like scuba dived and jumped out of airplanes on the weekends.

Tyler Johnson: [00:37:17] If you haven't followed Dr. Glaucomfleckin on Twitter.

Emily Maloney: [00:37:20] I do on TikTok. He's great.

Tyler Johnson: [00:37:23] So that's all right. That's the doc is the person with the bike helmet? Yeah.

Emily Maloney: [00:37:27] Yeah.

Tyler Johnson: [00:37:28] So now switching lenses completely. If someone handed you the controls to the US health care system and said, okay, do whatever you want, it's your system, fix it.

Emily Maloney: [00:37:41] So many things. So many things.

Tyler Johnson: [00:37:43] What would be like a few of the top things that you would that you would try to fix.

Emily Maloney: [00:37:47] Universal health care? I think that health care should be a right and not a privilege. I think there should be a single payer health care system. I know that there are problems in lots of countries that offer single payer health care system. I understand that the NHS is not a perfect system. I understand that the Canadian health care system is not a perfect system. I know people who have worked in both systems, but the system we have now is untenable. We've entered this era of late capitalism, where like no one can afford to see a physician anymore. So...

Tyler Johnson: [00:38:23] Is that a problem? Just kidding.

Emily Maloney: [00:38:26] Well, I mean, if you're talking, you don't want to see that many patients. Maybe not. Right? But so... I think that's first and foremost, I think there should be more residency spots in this country because there's a shortage of physicians and there's so many people who don't match and are forced into a scramble. And some of those people don't even scramble. And like these are people who had decent scores and who are still not matching and like, I don't know, maybe they should become pathologists or whatever. Like, maybe there's some other reason why they're not matching. But like, generally speaking, we are... We're at this critical juncture. We have an extraordinary shortage of qualified physicians. Nursing school, same deal. Also the idea that you go to medical school after four years of undergrad and then you go to four years of medical school and then you have your intern year and then you have your residency and then you have your fellowship. And all the while you're making like $50,000. Like that's an untenable situation. Like in the UK, a medical degree is an undergraduate degree, not a graduate degree. So there are different ways to handle this, but I think medical school should be free. It would be really easy for the government to subsidize this because money has no meaning anymore anyway, so. Right? I mean, it does. It does. It absolutely does. But I know that there are lots of people who are like, well, that's going to cost a lot of money. But the system we have now is so expensive. It's so expensive to run the system. They're the most expensive health care system in the entire world. And I think there's a way that we could make a better system, still pay physicians and health care providers to do their job. And also be able to actually provide care to people who need it.

Emily Maloney: [00:40:21] The final point is increased health literacy in the US. I think health literacy is really low. I think that we should be able to figure out better ways to educate and empower patients to navigate the system and to be able to provide information about themselves and their care. I think we should have like a nationally standardized universal EMR. A lot of these are just really big, big things, big things that need to be done. But health care literacy is way up there because I think that a lot of people, their initial experience in health care for the very first time is in the E.R. You know, they're having the worst day of their life. They have no idea what to do. And so they're struggling. And I feel that that is something that really needs to be addressed more than anything.

Henry Bair: [00:41:11] This last point you made reminds me of a joke between my medical school friends and me early on during our clerkships, after particularly difficult patient encounters. Difficult in the sense that the patients had trouble conveying what they really meant or could not grasp the significance of a particular piece of medical information or would not heed our recommendations. After these encounters, we would turn to each other and say something like, "We spent so much time in medical school learning all the right things to say and the right things to know to be good doctors. But what we really need are classes that teach patients how to be better patients." And yes, this irreverent comment in large part stems from a place of frustration. But I think that what that was really getting at was better patient health literacy.

Emily Maloney: [00:42:04] Right. Because that's the thing, like seeing a standardized patient, you know, they've been trained. They know what to say. They know... They have the information. You're working with that patient. It's for your training. But there are ways in which I think we could absolutely educate the general public on just basically, don't go to the E.R. Don't go to the E.R. We'll find you a primary care provider who can see you in an office. You know, unless you're in imminent danger of dying. And you should be able to also recognize that that's an educated patient. Right? You know, sometimes people make mistakes, but for the most part, I do think that people go to the emergency department for the wrong reasons. That starts a process after admission that becomes an increasingly complicated and bureaucratic.

Henry Bair: [00:42:52] Yeah. Many of our listeners are medical trainees, pre-medical students, considering a career in health care or early career clinicians. So as someone who has been on both sides of the hospital bed and through all of your lived experiences, what one piece of advice do you have for people starting out?

Emily Maloney: [00:43:11] Get a really good support system so that way you can continue to practice medicine. If you need to see a therapist, see a therapist. If you need support in other ways, find those support. Be able to have friends who you can commiserate with and who can understand where you're coming from, or your family. I think that that's really the most important thing, because people are burning out of the medical profession at an alarming rate, and we need to be able to provide people with the skills just to be able to manage themselves and to be able to take care of themselves as people, so that way they can be better providers.

Henry Bair: [00:43:51] Well, with that, I want to thank you very much, Emily, for your time and for sharing your story, for being so open with your ideas and your personal experiences.

Emily Maloney: [00:44:01] Thanks so much for having me. This is great.

Henry Bair: [00:44:06] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.thedoctorsart.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.

Tyler Johnson: [00:44:25] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.

Henry Bair: [00:44:39] I'm Henry Bair.

Tyler Johnson: [00:44:40] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.