If you are a field instructor in a hospital setting, here’s my recommendation: assign The Emergency to your student. If you’re a social work student or a new social worker in the hospital environment, seek this book out.
Dr. Thomas Fisher is an emergency medicine physician, and his book recounts a year of working in a Chicago emergency department. The chapters in The Emergency alternate between a monthly recount of the year 2020 and direct messages to various people in Dr. Fisher’s life as he moves through the year. 2020 means, of course, that the chronology is a narration of the first year of the COVID-19 pandemic. Images are still fresh in the mind. Hospitals faced unprecedented struggles, and the mortality rate was so high that special storage units for cadavers needed to be set up.
The direct message chapters are uniquely compelling. Dr. Fisher’s voice is unwavering in his knowledge and compassion as he speaks to patients he has treated and colleagues with whom he has worked. He speaks with deep empathy to a patient who has been shot, a man struggling with poor health who has been led to believe his Blackness is to blame, and a new colleague for whom Dr. Fisher is a mentor. The last chapter, addressed to his mother, is devastating.
The cases Dr. Fisher provides here are real, filled with detail, and come with the still-fresh sting of the COVID pandemic. The Emergency, especially at the policy level, is an essential text for learning the “big picture” forces, mezzo and macro, and how they impact each patient. As a social worker, I reflect on how so much of the daily minutiae of emergency center social work is spent navigating the cases. The environment is immediate, of course. Reading Dr. Fisher’s book, I am reminded of the need to keep focus on the bigger questions. Fisher is clear and direct on the history of emergency rooms and the policies that got us here, including federal reimbursement programs, private insurance, the lack thereof, and hospital administrative decisions that seek to maximize income revenue wherever possible.
I’ve often heard various health care and allied professionals describe the notion of treating “the whole person” rather than the pathology. “What I do is exceptionally comprehensive,” in other words. I appreciate this sentiment. I’m sure I’ve invoked this same phrase in practice. As a social worker, I want to see myself as uniquely skilled to work with individuals and families. Yet, during my time as a hospital social worker, treating the whole person usually means nothing more than vague attempts to ask about a person’s psychosocial condition. Perhaps a patient-helper relationship can be built on these attempts to connect with someone in need. Maybe a community resource can be identified. Good things, but is it truly comprehensive care?
Throughout his book, Dr. Fisher provides case narratives that truly exemplify what real whole person treatment looks like. In one example, an early section of the book captures with intimate detail the nature of “door-to-door” time, the metric hospitals use to measure contact with patients. Fisher describes a host of patients with a variety of issues and various levels of frustration. Throughout this passage, Fisher’s approach to interviewing a frustrated patient is an excellent example of why clinical skill requires empathy, as well as knowledge of the local political geography, and how a patient is failed by it. In one case, a patient works in health care, knows well how referrals and specialty evaluations diminish on weekends, and basically feels neglected by a system that refuses to see her. Fisher describes his approach here in those personal terms: he acknowledges her and her pain, while also considering how admitting her will likely be detrimental, as it would expose her to higher risk of COVID-19.
In other words, case examples like this speak to what true whole person care looks like. It doesn’t center the physician or allied health care professional as the hero. Nor is it lip service. Fisher is acutely aware of the societal inequities that impact so many of his patients in the Chicago emergency department.
That level of perception isn’t limited to individual emergency department encounters. Fisher is acutely aware how inequalities in the health care system create concurrent levels of care in emergency departments. For social work students considering hospital social work, I especially recommend Chapter 9, “Dear Dania.” Fisher gives a clear and honest understanding of how the U.S. health care system has come to be what it is today. His short-hand approach for the programs of Medicare and Medicaid is something I wish I had learned decades ago: Medicare provides “care” for “the elderly,” while Medicaid provides “aid” to “the poor.” It’s a differentiation that speaks to how we, as a country, choose to frame how these programs are intended to work.
This history is important especially as Fisher describes how his hospital seeks to implement a new, business-focused “Patient of Distinction” plan, which will separate patients by ability to pay, placing priority on privately insured patients and subjugating patients on public assistance. Fisher knows how this will go—an ER segregated by race, as more white people have the preferred method of payment in Chicago. It’s a truly infuriating passage, but it’s a system failure that is playing out in health care systems already. Fisher describes how hospital administration rejects data from physicians and academics as unnecessarily wonky, and that “you gotta break some eggs to make an omelet,” failing to understand how those broken eggs are people’s lives.
The Emergency is an important book that contains deep insight into social justice, and the forces working against that justice, in the hospital setting.
Reviewed by Stephen Cummings, MSW, ACSW, LISW, Clinical Associate Professor and MSW Program Director, University of Iowa School of Social Work. He was a hospital social worker for 10 years.
