EP. 24: PURPOSE AND JUSTICE ON THE PANDEMIC FRONTLINES

WITH THOMAS FISHER

Aug 16

WITH THOMAS FISHER, MD

An emergency physician and author discusses life on the frontlines of COVID-19 and healthcare as a foundation of social justice.

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Episode Summary

Imagine showing up for work every day for a year, knowing full well that each day you risk contracting a potentially devastating disease with unknown long-term consequences. That's exactly what Dr. Thomas Fisher went through, as he documents vividly in his recent book, The Emergency: A Year of Healing and Heartbreak in a Chicago E.R., which delves into what it was like fighting COVID-19 on the frontlines in 2020. Dr. Fisher, an emergency physician at the University of Chicago Medical Center, former healthcare executive, and former White House Fellow, has dedicated his life to caring for his community, the black population of Chicago's South Side. In this episode, he recounts harrowing stories from the emergency room, gives an impassioned critique of a health care system with too little space for doctors to provide the care their patients need, and shares a renewed vision of healthcare as a foundation of social justice.

Thomas Fisher, MD, MPH, is a board-certified emergency medicine physician at The University of Chicago. He has worked to improve health care as an academic, health insurance executive, and White House Fellow in the first term of the Obama administration. His path includes training as Robert Wood Johnson Clinical Scholar, being honored as a Crain’s Chicago Business 40 under 40, and being included in the Aspen Institute’s Health Innovators Fellowship. For 20 years he has been an attending physician in the emergency department that serves the same South Side Chicago community where he was raised. His book, The Emergency, published by Penguin Random House, was released in March 2022.
In this episode, you will hear about:
• What motivated Dr. Fisher to write his book, The Emergency, a riveting first-hand account of the first year of the COVID-19 pandemic - 2:09
• The uncertainty and terror physicians faced at very beginning of the pandemic - 5:29
• An intimate picture of how emergency physicians approached the first COVID-19 patients - 9:45
• How an upbringing in Chicago’s South Side propelled Dr. Fisher into a career in healthcare, and how the reality of inequitable systems has shaped his medical practice - 13:10
• A discussion of the concept of “heroism” in the context of frontline healthcare workers - 20:35
• How Dr. Fisher used letters addressed to patients as a narrative device in his book to explore social injustices that affect individual health - 30:50
• Dr. Fisher’s reflections on maintaining a connection to the meaning of his work despite the seemingly insurmountable systemic challenges that he recognizes - 35:57
• Practical advice for clinicians on making space for patient care within a rushed healthcare environment - 42:28
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: [00:01:04] Imagine showing up for work every day for a year, knowing full well that with each day you risk contracting a potentially devastating disease with unknown long term consequences. That's exactly what Dr. Thomas Fisher went through, as he documents vividly in his recent book, The Emergency: A Year of Healing and Heartbreak in a Chicago E.R., which delves into what it was like fighting COVID 19 on the front lines in 2020. Dr. Fisher is an emergency physician at the University of Chicago Medical Center and was previously a health care executive White House fellow and a Robert Wood Johnson Foundation clinical scholar. He has dedicated his life to caring for his community, the black population of Chicago's South Side. In this episode, he shares harrowing stories from the emergency room, gives an impassioned critique of a health care system that allows for too little space for doctors to provide the care their patients need, and discusses how health care inequities are a manifestation of entrenched social injustices, from redlining to employment and discrimination to biases in city services.

Henry Bair: [00:02:09] Dr. Fisher, welcome to the show. I'd like to start with your book titled The Emergency. In it, you go through month by month, the year 2020 and what it was like to confront COVID 19, this new disease entity with no known treatment at the time, and how the uncertainty and terror impacted you, your colleagues and your patients. What motivated you to write this book?

Thomas Fisher: [00:02:37] First of all, thanks for having me on. And yeah, it's a year from November to November of 2019 through November of 2020, which gives you a little bit of a suggestion that I began writing before COVID. I have been working in health care for 20 years and at the beginning I was an academic and I was deeply invested in trying to understand the roots of the challenges that my patients face and create solutions for them from an academic perspective, that meant study and intervention. And very quickly, I ran into the reality that what amounts to evidence for decision makers is often very different than what amounts to evidence for physicians and those of us on the provider side. And the book was an attempt for me to help my patients in particular understand what I've learned about the health care system. And then as I started writing, COVID descended and it became this incredible natural experiment that truncated the time frame that it takes for society to create health from decades into weeks. And so it was just a really cool opportunity that serendipitously happened to occur while I was writing.

Tyler Johnson: [00:03:52] So can I can I take you back a little bit? You were in this kind of unusual position where you were already in the process of trying to both illustrate and draw out larger lessons to be learned from problems that you were seeing in the health care system even before the pandemic hit. But we'll get back to some of the larger lessons in a moment. I wanted to first ask you, though, I think all of us have memories of what February and March of 2020 were like. Right. I think we can all sort of remember the beginning rumble of things in China and then in Italy. And then we started to read about Manhattan. Right. And it felt like there was this sort of growing sense of dread. And then the NBA started to call off games. The NCAA, like there were all of these things. Right. That were sort of this cumulative. And then most of us, to some degree or another, all of a sudden ended up on house arrest. Right. Like I remember picking up our kids on a Friday, being told they'd have a school to go to on Monday and then on Saturday getting the email that no in fact, no schools are going to be open. Right. Like I think we all have that narrative, but. Whatever all of us remember about that. You are on medicine's frontlines, right? Whatever containment systems we're going to be able to put in place wherever the patients are going to be housed, once they got into the hospital, whatever triage system they were going to use to try to figure out who might have COVID and who didn't. A lot of that stuff doesn't even apply for you because you're the first person you and your team are, the first people who meet the patients when they come into the hospital. Right. And back then, when we had no diagnostics, you had no idea if they had COVID or not.

Tyler Johnson: [00:05:29] So I guess I'm just wondering, can you just give us a visceral sense, what was it like to be on the ground in those days? Sort of waiting for the tidal wave to break, like waiting for this thing that I think the whole world was pretty terrified of, not even knowing exactly what it was going to look like or when it was going to arrive.

Thomas Fisher: [00:05:54] You know, in sum, it was both terrifying and also deeply meaningful. Look, we didn't know what we were going to face. We had very little information, as you described already. We had no testing. So, you know, by the time a test was positive, the person was far out of our care, either because they went home or they'd been admitted to the floor of the ICU. We were flying blind. We knew on the front lines that our colleagues in China and Italy and New York were dying. We knew this. We knew that they were falling sick. I mean, the first physician who identified it was dead by the time it had gotten to Chicago. And what that also does is it creates a certain amount of crystallizing focus, because if you're going to participate, why are you doing that? Right. For me and for many of my colleagues, it was something we'd been training for. We knew that we're on the front line and many of us chose this profession for that reason.

Thomas Fisher: [00:07:01] And also there was a component of this where we've been preparing for pandemics our entire professional careers. We practice donning and doffing during the Ebola scare. We did the same thing when anthrax threatened us in the early 2000s. We. It's on our board exams. What what's the difference between smallpox and chicken pox? These are the things we've sort of been drilling for. While all of a sudden it's no longer practice. This is the game, right? You've been practicing for 20 years and now you're in the Super Bowl. It's game time. And so that is really a purposeful moment. Now, do I wish we had more support in that process? Yeah. Do I wish that we'd had more information? I mean. You guys remember those times you already quoted a number of these experiences? Like, I remember there being no planes in the sky all of a sudden, like you used to having a normal din of the occasional aircraft going overhead, and all of a sudden not there's no rush hour, the streets never filled with people where people are washing mail off when it gets home. We've been explicitly told by leaders, don't wear masks. That's I mean, ostensibly it was to save it for first responders. But we were being told not to do some of the things that were explicitly going to protect us. And so we were being told we didn't need to use an in 95. A surgical mask was sufficient so long as the patient had a surgical mask and we'd be in a closed door with somebody who was coughing and febrile and sneezing with simply a surgical mask on.

Thomas Fisher: [00:08:33] It was it was terrifying. Emergency departments are already one of the most collegial. And you're working alongside the same techs and pharmacists and nurses and doctors in fast paced decision making. But now we're a part of the equation, too. We are also at risk and we have to protect each other and remind each other and console and comfort. And look, we all know people who got very, very sick and some of whom never returned to the clinical setting. And we know that some of those people caught it at work. Also, the last thing I'll say about this is we also had this cohesiveness because we knew that other folks in the hospital were both relying on us and respected what we were doing. But also some of them were afraid to come down to the emergency department. You know, they would much rather know what that test showed before they did their procedure or admitted that patient. And we're doing everything in their power to ensure they had that piece of information before they were exposed. And we never had that luxury. Never. And so it's a it's a time that I wouldn't want to recreate, but I'm one that I'm glad I went through.

Tyler Johnson: [00:09:45] One small detail that I want to draw out from what you're talking about health care workers, those who are working during the pandemic will know exactly what you meant when you talked about donning and doffing. But can you just tell people, first of all, what do those words mean? Because they're not very commonly used except for in this setting. And secondly, can you talk a little bit about what's it like, like the way back when there are no tests, you don't know, like everybody who has a fever and a cough might have it. They might not. You don't know your protective gear is whatever it is, depending on whatever. But like talk about that experience of getting ready to go into a room and then coming out of the room afterwards. Sort of what was in your heart and mind during and actually what you physically did?

Thomas Fisher: [00:10:27] Yeah. When a patient had a fever and a cough and they were really sick, we would put them in one of the rooms that had negative pressure. So it had a door, usually a double door. And before we would go in, we would don protective wear. So we put it on in a specific sequence which included a gown, gloves, mask, hair cover and eye cover. And then on the way back out, we would doff them, take them off in a sequence that allowed for us to protect ourselves in the most effective way.

Thomas Fisher: [00:11:02] So taking the gown and gloves off in the room and waiting to get out of the room to take our mask and and I wear off. And if we were reusing the mask, we wouldn't take the mask off at all. And it was very regimented. In fact, on each room we had in dry erase, or maybe it was a waxed pencil written on the glass. Here's the sequence so you wouldn't have to think about it. You could just refer to the glass. What's next? Oh, I wash my gloves and then break the seal and then wash my gloves again and then take them off. And then you open the door, and then you leave, and you do it in such a way to both protect yourself and also to protect the room. The notion that you could have these sterile and protected, clearly delineated boundaries between where people are infected and where people are not infected was not possible in America's emergency departments in general when we were in the middle of the waves, I think you could do it more effectively up on the floors. You already had information you knew. But you also have to keep in mind, a lot of people are asymptomatic. We would see people come in for a trauma.

Thomas Fisher: [00:12:07] They're in a car accident. They've got a broken leg. Well, before you can take them to surgery, you've got to do a COVID test. Will they have COVID? Or you're in a car accident and they're largely uninjured and you're doing a scan of their chest, abdomen and pelvis in order to screen for many of the traumatic injuries that might not be apparent on a physical exam. And you see the ground glass pattern on their lungs that's consistent with COVID pneumonia. And that was happening with some regularity. And so even in places where you thought this is the Non-covid section of the emergency department, these are just people who came in with a sprained ankle. They had COVID to. And so we had to maintain a certain amount of vigilance throughout until wearing universal masking and eye protection became the habit. The habit was to wait until you thought you were in a situation of risk and then put it on. So at the very beginning, that was a challenge. I think now we've adjusted to the fact that wearing a mask is just the way it is in the clinical setting, which is a big change from the first, I don't know, 18 years of my practice.

Henry Bair: [00:13:10] Dr. Fisher, one of the things that you said earlier, very early on in this conversation was you need to know why you're here. If you are telling yourself that you're prepared to be on the front line and facing this potentially lethal, very unknown entity, this disease entity, that brings me to many moments of your book where you interweave stories of what was happening in 2020 with reflections of what brought you into medicine, your upbringing, your childhood, your education, your family. So I was hoping that you could tell us a little bit about about that, about what first drew you to medicine and why emergency medicine in particular.

Thomas Fisher: [00:13:56] I grew up on the South Side of Chicago and practice in the same community where I work. And the journey that led me there began by having a physician as a father and a social worker as a mother who on the one hand gave me a sort of approach to thinking and the understanding that being a physician is not out of reach or a strange and elusive goal, but something tangible. And there was a community of black doctors on the South Side that I had access to that made it real. Like, these are just people. Like me, I could do something like this. And also having a school social worker as a mother helped to instill service and the understanding that people are facing all kinds of different situations. And in the end, they are challenges that any of us could face. And those folks, despite the context in which they're in, have the exact same goals, desires and hopes as you do. And they also worked really hard to embed in me and not just my parents, but the whole community that I grew and that I'm a part of something bigger. Right. There are a lot of different ways to be black in America and in across the global diaspora. And I had a very specific experience on the South Side of Chicago. Like, look, between 1960 and 1970, Chicago netted a half million black folks who were largely fleeing white terrorism in the South and took trains to Chicago to work, work as pullman porters and in the homes of white folks and in the slaughterhouses.

Thomas Fisher: [00:15:41] And that created an incredible amount of social and cultural capital on the south side of Chicago that it guided Mahalia Jackson, that tuned her voice and guided the pen of Lorraine Hansberry and prepared Michelle Obama to get Barack Obama into the White House. And that community is one that was really bolstering and one that helped me to both understand that there are a lot of really specific challenges that are being created by policies and systems, because I saw so much genius around me that. Was both constrained in some elevated but also helped me realize that there's something here to build, to build upon and to be a part of. And so very early on I was interested in health equity, although we called it health disparities at those times when I was training and social determinants of health were just beginning in its infancy when I was in medical school and was largely clarified where you live, learn, work in play, shape your bodies and health. But in my head at that time, I kind of thought that these were big misunderstandings. And as soon as I had the opportunity to create the sort of research that would clarify this, we would sweep it all away.

Thomas Fisher: [00:16:53] And what I mean by that, being halfway through my career, we would be in a very different world. And it wasn't until I actually was confronting these challenges as a clinician that I realized, Oh, no, these are recalcitrant, these are systems that are working exactly as designed to do. These are not mistakes. And so it's not going to go away simply with better information. In fact, we have plenty of information that we do nothing with. That has both steeled me throughout my career, the understanding that this is a part of something big. But it also clarified for me in this moment what's important. I took care of an older person who died in my care. They were much older. They were in their eighties and they had an arrest at home. Ems did CPR, and when they got to us, they had a very faint heart beat. We did the things that we do in the emergency department and after a course where we got them back and lost them, got them back and lost them, we ultimately lost them. And part of what I do after that is I go talk to the family. Something that I've done a lot over the years. I do less now because I work less now, but I have a process that I do that I know what I'm going to say.

Thomas Fisher: [00:18:09] I use myself, I sit down, I make eye contact. It's a thing I try to get an understanding of what happened in the moment. Prepare them for what I'm going to say. Say it. The whole thing. When I introduced myself and began my process, the gentleman I was speaking to stopped me and said, Sir, don't you remember me? And I was embarrassed because I did not. This happens to me sometimes because you meet a lot of people in a shift. I thought they may be a patient. They could be a family member. Maybe. Maybe I'd worked with them in another set of life. And so I asked them, No, I don't remember. Can you refresh my memory? And he said, You sat with me in this same room and gave me this same talk when my other parent died three years ago. I have no recollection of it at all. And what it brought home was that the practice of medicine generally, but specifically the practice of emergency medicine, touches people on these days that are that are fulcrum in their life before and after events, days they'll never forget. Like this gentleman never forgot it, even though it was just a day for me. The Why are you here? Question goes back to respecting those moments and recognizing the core humanity of people that we touch in the emergency department and recognizes that that is a part of these bigger societal forces at play.

Thomas Fisher: [00:19:43] And here we have the opportunity to intervene sometimes not all the time, but sometimes we can sometimes we can make that conversation one that's memorable. Sometimes you can change the direction of somebody's care and health. Sometimes you can liberate them from these forces that pin them in. And when you cannot, you can still bear witness in so much of this book is simply bearing witness to things that we cannot change and talk about it in honest ways that allow for there to be light. And allow for subsequent generations to build on this know hopefully not just my patients can better understand what's happening, but medical students right now will be able to start in a different place than I started and are building from here to something that's more just and equitable.

Tyler Johnson: [00:20:35] So let me ask a question here. You know, every once in a while, I've had someone reach out to me and say that they think that because I'm a doctor, I'm a, quote, hero, unquote. And I always I try to graciously accept the compliment, but then I try to explain that, no, there's nothing particularly heroic about what I do. Write go talk to firefighters or something. If you if you want someone who's who's heroic. But I have to say that during the pandemic, for certain kinds of doctors. I think that the label really applies. And the reason this gets back to what you were just talking about is because you have explained so nicely how you came into medicine with this almost bringing this sense of kind of a heritage with you. Right, that you were you were bringing this this sense of these generations that had gone before you and trying to sort of continue their legacy and continue the improvements that they had made, especially as you've talked about in other venues as well for people specifically on the south side of Chicago. Right, that you wanted to continue to make things, these things better and you wanted to continue to decrease inequities and increase health care and increase respect and all the rest of it. So then as we talked about earlier in February and March of 2020, we're getting these really, really scary reports out of Italy and then especially out of New York. Right. In New York, they have the morgue trucks can't pick up the bodies fast enough. Right. And they're running out of ventilators and they have people asphyxiating in the hallways and whatever. So I'm curious if you can walk us through for you personally, what was it like when this sense of legacy and heritage and commitment to the bettering of society came up against what I have to imagine must have been some fear and trepidation at meeting what could have even resulted in your own death? Right? Were there moments when you thought about stepping away because it was just too much, or was that just a did you just naturally say, well, no, this is the mantle I've taken, so I'm just going forward with it or what? Because for me, that feels like a moment of heroism. Sorry, you'll probably try to dismiss that, but that's what it feels like to me. But I'm curious what it was like on the inside.

Thomas Fisher: [00:22:52] Well, I guess what makes it heroism actually putting yourself at risk. Is that the part that makes it heroic?

Tyler Johnson: [00:22:57] Yeah. I mean, knowingly, right. Like you're stepping in to work every day that you work to shift, not knowing if the next patient is going to be the one that gives you a disease that could kill you.

Thomas Fisher: [00:23:08] I remember very clearly when society shut down and when that happened, we'd already started seeing a few cases. It wasn't a deluge, but we'd seen a few. And I remember there was an email that went out that described some of the things that we had access to in order to keep ourselves and our families safe. And those things included things like there was rooms in the hospital you could spend nights in. There were hotels and other venues that were giving healthcare workers access to their rooms in order to give them a place to stay so they wouldn't go home.

Thomas Fisher: [00:23:50] And that was probably the one time where I was like, You know what? Maybe I just don't need to go back. Like, it turned out I had like maybe a ten day period before my next shift, so I could, like, sit there and just stare at it and say, Oh, my God, this is terrible. What would happen if I just said I'm going to take a hiatus because I know that morally and ethically it's not like they would fire me or anything. They would just accept my decision and let me know when to come back. And I toyed with it and then I thought about it. Okay, let's think this through. Let's say you don't go back. What are you going to do? Are you going to sit here in this place and just sit here scared? For the next six months year. How long are you going to sit here? Scared. And then what are you going to find? Another line of work because there's going to be another pandemic one day. I mean, you knew that was part of the equation. What are you going to tell yourself when you're an old man? When this COVID pandemic came, what were the decisions you made in that time frame? And I think that going through the exercise of acknowledging my fear and acknowledging the risk. Helped make clear that there was really no other decision to make except to face it and go and do the work that I'd been trained to do to serve the community.

Thomas Fisher: [00:25:26] That was the entire reason I went into medicine. And so, you know, it didn't really feel heroic. It felt scary and it felt meaningful. And I think that it wasn't a blind choice. I definitely toyed with what would an alternative look like? And many of my colleagues took alternatives, and there were ways in which we tried to mitigate the risks, like focusing the most sick COVID patients in one area and giving people the option of not working in that area if they didn't want to. And thankfully, many of my much older colleagues took that option and didn't expose themselves to the highest risks. But not going in in those moments. I mean, it certainly felt like a personal crossroads. Who are you? I mean, it was really a question. Who are you? And if you are who you say you are, if the decisions that have motivated your professional in many ways personal life up to this point are actually true. Well, then you show up. And so I did. And I look back to what we were doing in those moments, and I cannot believe how little information we had to make such big decisions.

Tyler Johnson: [00:26:42] Well, and to that point, I just want to remind listeners that now we have two and a half years worth of experience. At the beginning of the pandemic some of the initial reports that were coming out of Italy, obviously we knew the numbers were flawed because no one had any idea how many people were actually infected. Right. So the denominator was always totally obscure. But nonetheless, some of the initial reports that were coming out of Italy indicated that the virus might have a mortality as high as 15 or 20%, meaning that one out of every five or six people who got it would die. Now, again, we knew that was probably inflated. We knew it probably wasn't right. We could tell pretty quickly that older people were at higher risk. But nonetheless, I'm just saying that going to work every day, not knowing which patient might cough on you and give you the virus, and knowing that if you or thinking you had an idea that if you got the virus, you could have as high as a one in five risk of dying. That's not nothing, is all I'm saying.

Thomas Fisher: [00:27:37] Oh, and also, we saw what it looked like to be an extremist. It's not just the number when you're in the emergency department. It's not just, oh, more people are dead. Like we saw them turning blue and gasping for breath. We saw their pulse oximeters at 73-74%. It wasn't an abstract notion. And to risk trading places with those patients was so terrifying that it almost wasn't real. So I was a White House fellow and then part of the fellowship there are a number of people who are in the military and some of the folks who are in the military with who are in my class who had military experience, were actual operators, people who saw combat. And I called them, I was like, Man, this is very different now. All of a sudden my health is a part of the equation. So that reminds me a little bit about your experience where you're being trained to do something but you're getting shot at. How do you deal with the fear? How do you deal with that part of it? And one of my friends told me, when you are in those moments, your training is really taking over. And it doesn't really feel scary. It's scary before and after. And he was right. When you're actually taking care of a sick person like you take the moment to do the right things to protect yourself and remind your team like you don't have eye protection. But then you're focused on like, what do we do for this sick person? These are heavy, weighty decisions, because if I intubate this person, is that going to make them better or worse? If I intubate them and put them on a ventilator, we only have one more ventilator.

Thomas Fisher: [00:29:15] Is this the one you want to use that ventilator on? These are huge questions, right? And I'm not the resident. The buck stops with me. You're not really thinking about your own safety anymore. You're really trying to navigate these this this really challenging question. Then when you get home, you go through this similar process like I wanted to change in the hospital and not change in a way that would flick whatever virus was on my scrubs into the air that I might inhale. Then get home and make sure that I leave whatever I brought home with me outside. I was changing in the hallway before I would enter my apartment. I was taking a shower as soon as I entered, and only then could I relax and realize, well, I was definitely exposed today. I hope I don't have it. It was tough that I would say right up until it got warm outside when you could actually go outside and walk around. That first march until May was tough. Really tough.

Henry Bair: [00:30:15] Well, that is incredible. I mean, I was around the time of COVID, I was working on my surgery rotation. I was in trauma surgery. So we did go to the E.R. So I saw a lot of what you were describing. But I was not living that day and day out like we would you know, we had our own work rooms on on the floors, the, you know, the second floor, third floor. And then whenever trauma came in, we would come down. And that was my exposure to the very early days of COVID was being working side by side with the ED, the emergency room doctors, who were actually having to answer the call for all the COVID patients. So thank you for sharing that.

Henry Bair: [00:30:50] I want to shift our focus a little bit now in your book, one of the purposes you mentioned many times is in your own way to change a conversation around health equity or disparities in health care. That was what you hope to address a part of it. And you do this with a really interesting portions of your book in which you wrote letters to your patients. In these letters, you address them to the patients you saw in the emergency room and you delve a little bit into your own history. But you also write about the history of South Side, Chicago. You address historical inequities, food disparities, health disparities, redlining. All these things make it into these letters. And that struck me because I don't think I had ever seen something like that before. I was hoping you could tell us a little bit about the genesis of those letters and what those letters meant for you and what you hope to convey to your readers.

Thomas Fisher: [00:31:50] In writing a book, you have to choose an audience. Who did I want this book to be intended for and why? And in the end I realized that you can't please all people. And so my focus was, how do I get? My patience to understand what is going on. How is it that their bodies are shaped by the society that they live in? And then when they come and seek care, how is the care system also shaped by this same societal influences and. Its first an early version was kind of wonky using like well, let me tell you about how the payment system is structured and you know, the Balanced Budget Act of 1997 and blah, blah, blah, it's incomprehensible to real people. Right. And I don't mean real people because they're not smart. They are smart. They just don't know about health care in some of these technical and tangling ways. And so in a couple of revisions, my editor was just like like pretend like you're sitting in a room with them. What would you tell them? Or writing them a letter. What would you tell them? Because then you're not saying everything that could be said. You're focused and you're communicating in a way that you communicate to somebody who you actually know. Right. So it becomes more casual, it becomes more clear, and it becomes more. Here are the most important things I need you to understand. And so while it was a rhetorical device for my editor, who's a genius, to kind of help me understand how to approach it, I took it literally like, let me just literally write a letter. And he was like, Yeah, absolutely. Please do write a letter. And if that lands, we'll keep it. If it doesn't, we'll find another way. But like this wonky stuff is not actually going to convince a wonk. And it also won't convince somebody who is not a wonk like you've landed in this weird middle. So make it a letter. And in the process, it was very crystallizing to me about what are the most important parts of this, not the technical parts, like the the large constructs that are active in society, that lead to the distributions of goods, services and resources that ultimately shape our bodies. What are those? Where do they come from? Not every single decision, but in general. Where did they come from? And it helped me to think more clearly when I was writing in that way.

Thomas Fisher: [00:34:44] And so, not all of the letters were ultimately to patients. Some of them were to colleagues and trainees in order to help them understand what they're facing or what I saw from mentors. But in the end, knowing that my audience was a bunch of folks who may not know much about health care, but I hope that they learn much more. Using that device made it much more intimate and more engaged to explain these large, weighty challenges. And look, I went to public health school. I went to medical school. I've worked. And so often it's been fragmented. The public health world thinks that this 50,000 foot level and the medical world thinks that this granular, even molecular level. And my goal in the book was to connect the two, create this crosswalk between how these broad societal forces shape a body. Yes. In medicine, we then use medicines that work inside a cell to try to repair them and. But there's an interplay between the two that needed to be bridged. And that was ultimately what I was trying to do here.

Tyler Johnson: [00:35:57] So let me ask you this. As you may be aware, one of the main purposes of this podcast is that there's an epidemic of burnout among health care workers. And Henry and I share, I think, a hypothesis that part of it is big picture, systemic problems. And there is also another part of it that is about, I think, a personal loss of meaning. We have doctors who are very busy doing things but often lose their connection to the reason that they're there. Right. And it's fascinating to me that you have mentioned now multiple times that as you're sort of heading into battle with the pandemic, you actually felt this distilled or crystallized sense of purpose, right. Like that. This was sort of the moment that you had been preparing for. But nonetheless, one thing I know that I've heard many physicians in a lot of different capacities over the years express deep frustration about is that you're working in an emergency room. Here comes a person who comes into the emergency room, often because the emergency room is in effect where they go to get their diabetes care and you know that they are going to need to have their foot amputated because of 27 different complicated, interrelated factors. Right where they're living, which may have partly to do with the color of their skin versus where the good clinics are versus what their insurance looks like or is is what they can get covered versus how much the insulin costs. And you could go on and I'm sure you could make a much more comprehensive list than I can. And yet here they are in the emergency room. Their blood sugar is really, really high and they need you to fix that right then and there. How as an emergency room doctor, do you keep a sense of meaning and do you keep a sense of purpose in the face of these overwhelming what often seem to be overwhelming systemic factors against which many people might feel pretty impotent? How do you think about that, and how have you kept your career meaningful in spite of those difficult challenges?

Thomas Fisher: [00:38:00] That is both a very interesting philosophical, also tactical question. Philosophically, I have understood myself to be a part of something bigger. Part of what I've described already was this linkage to the community. But also there's this linkage to the fact that taking care of each other is deeply meaningful. If we see one another is human, fully human, and we recognize that we all have this shared core humanity that in medicine allows us to honor that by taking care of each other. Then it's easy for me to step back and realize that this is important, even beyond like the tactical. Like, what am I doing with this person's insulin? Are the right drips done? We did this algorithm around trauma wrong or right, but like being there with people in these moments is meaningful. Being a part of these these before and after events is meaningful and caring for the biological platform that allows for us to do everything. It's just it's just deeply meaningful. And so that's part of it. Another part of it is the recognition that much of what we need to solve won't get solved in my lifetime.

Thomas Fisher: [00:39:21] That took me some time to grapple with. People in medicine achieve stuff. We've been trained to be achievers. You need an A, right? You've got to do stuff in order to get here. But actually, what I'm talking about is capital justice. And that's something that is long road. That's something where I'm only carrying the ball. I am not the one who ultimately will deliver it. And that brings a level of perspective that allows for day to day frustrations to still be grating and painful, but a recognition that it's a part of the process. Tactically, that means I needed people. A community of folks who are like minded. Who also recognized themselves to be part of something bigger and struggling toward some part of a long arc. Black folks have been trying to make America honor its expressed goals for as long as we've been here. We've demanded that democracy be inclusive, demanded equal rights for all, demanded. And most generations never saw that. I mean, there were hundreds of years where black folks were held as property. Another 100 years where there was state sanctioned segregation. And even now we I mean, black men are still being executed by the police and put on tape and broadcast around the nation. I mean, we're still making these demands, but these demands are things that if any one generation gave up. We would not be here. So there is this sort of cultural heritage that I feel I'm a part of that allows for this long arc.

Thomas Fisher: [00:41:08] And I have surrounded myself with people who believe similarly. And so when I get tired. Because I do get tired and I get sick and tired. I have a community of folks who I can talk to and say, you know, here's the bullshit that I'm facing right now. And it becomes a part of a conversation and not just a one off conversation, but like, you know, a community of conversation that spans decades and years. So this is not something I could do alone, and I don't think anybody can. No matter what it is that motivated you to go into medicine, if you don't have a community, it's going to be hard. It also means you've got to pick something that matters to you. Like life is difficult enough if it doesn't matter. Like how are you going to maintain the stamina to do anything? Like nothing comes easy if you're actually trying to do anything of meaning. You've got to pick something you care about so that you have this endurance because it's long. Otherwise, I think it is very easy to say, Well, look, I don't get paid enough. I'm not getting enough of the social capital that should come from my professional endeavors. And they're not coming fast enough. I should be. And then it's very easy to look at what the Joneses are doing and how shiny somebody who made different decisions life looks and have envy and want to quit.

Henry Bair: [00:42:28] That's that's really inspiring, Dr. Fisher. Over the course of this conversation and in your book, it's readily apparent that you approach each patient with a degree of care and introspection about what each of these encounters mean to you. That is quite remarkable. And I have to say, I think that contrasts slightly with a lot of the sentiments I heard when I was on my emergency medicine rotation. I think multiple times I heard my attendings or my residents in the emergency room saying something like, We get to enjoy the most exciting, the best first 5 minutes of every other doctor's job. I have heard that before. I don't know if you've heard that before. I don't know how common it is, but that seemed to be something that was refrained during my time there. You know, I understand that might be enough for a lot of people, for other people in health care, that might not be enough. They might feel like, as you've written in your book, I have so many patients to go through in a day. Each of them needs a lot of my help. There's so much I can potentially do for them, but I have 3 minutes per patient and that just seems like what do I do in that circumstance? So my question for you is what advice do you have for medical trainees, for clinicians who are facing these issues, these dilemmas in practical, everyday life terms? What advice do you have for them?

Thomas Fisher: [00:43:55] You know, writing the book actually slowed me down and helped me to see the patients across from me. In ways that I don't always do. So first of all, there's a component of this which allows for the grace that all humans should give to one another, to physicians have to give that to themselves. You're not going to be perfect. You're going to screw it up. You're not going to be present when somebody needed you to be. Sometimes you will misdiagnoses. It's not going to be perfect. And so I think there has to be the capacity for that level of personal acknowledgment and grace. Then I think it's required that you remember what is happening on the other side of that bed. Right. This is somebody who came for help and they came today. And while this is every day for you and you're going to go back to your computer and finish searching Zappos for whatever Air Force ones you wanted, like that individual is like. There's a reason that they're there that may extend beyond whatever that clinical reason is. There were circumstances that led to that clinical problem, or maybe maybe they just need shelter. Maybe they're being pursued. Who knows? And I think a lot of that is solidified outside of the clinical setting. Those are things that are happening in your training process and your professional selection of what sort of specialty you'd want to go into in the moral, ethical foundation of who you conceive yourself to be and and what's in the life of your mind.

Thomas Fisher: [00:45:31] And then your job is to try to find presence in those moments, to bring that into the clinical setting, which requires like practice. I mean, look, early in my career, I was just holding on. I didn't want to hurt anybody. Right? And so when I'm in the clinical setting, I'm processing through all these clinical algorithms, like, is this okay? This is chest pain. Is it above or below the diaphragm? Is this pulmonary, cardiac, musculoskeletal? How do I make this diagnosis? What's the first test? How do I look smart to my attending when I'm attending? How do I look smart to the residents like, you know, just tactical stuff. But now I'm an O.G., right? I've been in the game 20. It's slowing down to me. I've seen a lot of things and so it allows for me to have a different perspective that I was able to put into the book. I couldn't have written this book ten years ago because I wasn't the person that I am now then. And so I think it's also incumbent on finding and using mentors, professional mentors, to help you navigate that arc.

Thomas Fisher: [00:46:32] Emergency medicine is new. It was founded in the seventies. Like the people who trained me were some of the first people in the profession at all who are board certified. So now I'm sort of that next generation of folks, and I think there's a lot more opportunity for us to communicate with one another how to slow down and see people when it's easy for them to become a blur and for you to forget that each of these is a person no different than your own mother, no different than your own brother, no different than your best friend. And the sort of grace that you would extend to them or should extend to yourself needs to be present in the room when you're having that conversation and when it is, things like laughter with people, even in the most extreme situation, become more common. I mean, I'm always joking and laughing with my patients, even if I'm laughing at myself. They want you to pray. You sit down. You hold your hands like you take those moments because you won't be able to do it with every single patient. But if you can do it with some regularity, it makes it more meaningful to you and will create a much more fulfilling career over time.

Henry Bair: [00:47:42] Dr. Fisher, with those poignant and inspiring thoughts. We want to thank you again for taking the time to join us in conversation. It's been a delight and a privilege.

Thomas Fisher: [00:47:54] Awesome. And it's been a pleasure. Thank you for inviting me. Thank you for reading the book and I hope we have further conversation.

Henry Bair: [00:48:02] 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 the Doctors Art. 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: [00:48:21] 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: [00:48:35] I'm Henry Bair.

Tyler Johnson: [00:48:36] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.