Three minutes per patient
A doctor's confession from deep inside the American healthcare system
Welcome to my 8,000-word essay on What the Will Smith Incident Means. Just joking.
Later this week, I have a big reveal for you all — something I’ve been excited and nervous to share with you for some time: the cover of my new book, forthcoming this October. So stay tuned for another email.
But today I have something special for you: a raw, bracing dispatch from inside a Chicago ER, by a doctor unafraid to call out a healthcare system that forces him, as a guardian of human lives, to function like a “short-order cook flipping burgers.” He has three minutes per burger — I mean, person.
Read Thomas Fisher’s moving, infuriating chronicle below, and stay tuned for my book news later in the week…
“Three minutes is all I have”
By Thomas Fisher
The rapid assessment unit (RAU) of the department is always a frenzy of activity. My objective is to meet patients right after they’re triaged by the nurse, start their care by ordering tests, and then direct them to the place in the ED where they’ll have their problem treated. In a busy shift I’ll see ten patients in an hour. While the math suggests each patient gets six minutes, each patient receives only a fraction of that time— I talk with them for three of those six minutes and then sit in diagnostics and document the interaction. Three minutes is all I have to see the person in front of me.
Along the way the electronic medical record tracks the time it takes for a person to be seen by a doctor. While I am the “doctor” captured in the report, the few minutes I give each patient barely qualifies as doctoring. In this setting I can deliver only a fraction of the skills and insights that I have accrued in my decades of experience. Still, sometimes, even in that small window, I can find a threatening disorder and influence its outcome. For those with straightforward complaints like a cold, rash, or sprain, I know with a little more time and a couple of extra resources I could solve their problem and send them on their way. When I can’t or don’t, it leaves us both frustrated.
Once past the waiting room, I land at my computer in the RAU and survey the landing screen of the electronic medical record, which is a track board of every registered patient in the entire ER. There are thirty-eight people waiting to be seen. A couple of them have been waiting six and a half hours.
There is a sixty-eight-year-old woman in the waiting room who has been waiting for five hours and whose son wants to take her home.
The triage nurse owns a semi-private cove in the waiting room where they check in patients and assess their vital signs. Before I meet the family, I nestle in behind the nurse and quickly review the woman’s labs ordered by the prior rapid assessment doctor. It turns out she has kidney failure. A tech, Craig, brings over the older woman’s son.
“Aye, Doc, nice to meet you, nice to meet you.”
“Good to meet you too, fam.” With that we bump fists. “I understand you want to take your mom home.”
“Yeah, Doc. We been here five hours, we’re tired. Why don’t we just come back tomorrow?”
I look over his shoulder but can’t identify his mom among the many people hunched in the rows of wheelchairs, but I advise him not to go. “I just took a look at her labs, and she’s got some kidney trouble. It looks new. I know you’ve been here a long time, and it’s not right, but can you stay just a little longer? It’s important. We should really find out why her kidneys are damaged and try to reverse it. I can’t promise how much longer she’ll wait, but I’ll make her a priority.” With his hands on his hips, he sighs deeply, looks to the ceiling, and nods okay.
I feel like I am abandoning him to a purgatory of more waiting. Five hours is too long, but I know all our beds are full, and after reviewing the other patients who are waiting, even her life-threatening condition might not make her the sickest person waiting for a room. My neck grows warm with the spark of irritation, the exact emotion I struggle to manage when I’m hungry or tired. It’s too early for this—I just got here. I take a deep breath and try to quench that flicker of exasperation by reminding myself that suffering is part of the human condition, we’re here doing our best. Every day I push the boulder; every day it rolls back.
“Today matters!” I repeat to myself every so often to ground myself. Evan and I dive into the first three bays to meet patients needing care. The first is a thirty-three-year-old woman in a pink and black hijab who says she’s two months pregnant and has been bleeding for two days. This is her second pregnancy after an uneventful first one. Now her left side hurts, and she’s concerned. I am, too: this could be an ectopic, a life-threatening pregnancy where the embryo implants in the fallopian tubes instead of the uterus. When I press her stomach through her black shirt, she has no pain. I let her know we’ll get a urine sample, blood tests, and an ultrasound as soon as we find her a room with a door. Three minutes.
Next is a forty-year-old healthy-looking man in a gray sweater, jeans, and polished brown boots. He says calmly that he’s been bleeding when he has stools, four times already today. Out of his pocket he produces an iPhone photo of what looks like Thanksgiving cranberry sauce in a toilet. His vitals are normal, his countenance is calm, and he appears younger than his age. I let him know we’ll draw blood and set him up in the specialty area of the department for a full exam. Three minutes.
The third is a twenty-seven-year-old man, dressed in Timberland boots and a puffy black winter coat, complaining of back pain. This is one of our ER’s most common complaints. While nagging back pain is usually benign, I still have to sort through the garden-variety aches to find the ones that signal a kidney stone, spine infection, or aortic aneurysm. It hurts him when he moves, and he has no concerning signs. I order a pain-numbing patch and let him know we’ll continue treating him in the low-acuity area, where we sew lacerations and wrap ankle sprains. Three minutes.
Each of these three interactions started the same way. “Hi, I’m Dr. Fisher, this is Evan, our scribe. We work as a team. He writes notes while we talk. So, tell me, what’s going on? What brought you in?”
Evan is a white dude in his twenties. He wears beige scrubs to distinguish him from the caregivers; we wear blue. Evan is always relaxed and ready, but we’re not exactly friends—no banter, no chatter, just business. This combination makes us very productive together. We get through patients quickly, but I rarely have time to probe the more detailed questions that might unlock why now, why today, why they are really here. I almost always learn the obvious portions: where it hurts, what they’ve tried for it, what makes it worse. But I want to know the twists in the path that led them here, sitting in front of me in an ER bay for three minutes. Without these details, by the end of a four-hour block, patients start to blend together in my mind, and it becomes difficult to pick out a specific memory of more than a few of the thirty or forty people I’ve seen.
After an hour the nurses switch shifts. I review labs of people who are waiting and scan the track board to see if that older woman with kidney failure is still in the waiting room. With every bed in the ER occupied, we’re now closed to ambulances. The thirty-six waiting to be seen when I arrived have grown to forty-three.
I’m interrupted when three family members of an older woman in the waiting room come to the locked door that leads to the treatment area. I see the tallest of them, a gray-bearded man wearing a black puffy coat, through the window of the locked door. He summons me with a wave of his hand, and I open the automatic door. I stand on one side of the threshold; they’re on the other side. He appears to be in his fifties and is flanked by younger women, who could be his sisters.
“Hey bruh, we’ve been waiting six hours, my mom is in pain.”
“Damn, I’m sorry. Who is your mom? What’s her name?”
“You right, the wait is way too long. I really apologize for that. Let me see if she can have some Tylenol.” One of the younger women sucks her teeth and rolls her eyes. I shake their hands and head back in.
I really don’t have much else to offer. Eight years of training, nearing twenty years of experience, and all I have is Tylenol, apologies, and a handshake. And depending on what I find in the chart, maybe not even the Tylenol. A helpless feeling washes over me, and my neck grows hot again.
Now ninety minutes into my shift, I’ve got more patients ready to be seen. In one bay is a tall, gangly, eighteen-year-old woman in light blue jeans and a white sweatshirt. Her name is Nicole and she’s complaining of a sore jaw after being jumped by a group of young women at school. She’s calm, but her emotions are as bruised as her face. Her anxious mom is with her and at full attention. I ask about neck pain and loss of consciousness. She doesn’t have either and speaks clearly and cogently, allaying my worry about a concussion or broken jaw. Medically this is easy, but the circumstances around it are more complicated. I ask if she’d like to talk to the social worker about school safety. Mom says yes, daughter says no. I let them know they can decide when they’re seen in the low-acuity area.
I’m moving through patients so fast that I’m missing things. While I’m searching the track board to see if the older woman with kidney failure is now being cared for, Frankie, the social worker, finds me. She met Nicole, the young woman who was jumped at school, and asks if I’m worried about her mental state. Honestly, I don’t know. I didn’t explore the circumstances. I have no idea whether she’s being bullied or if she’s depressed. I didn’t go further. My shoulders slump, and I sigh deeply: I should have queried more. I only gave her three minutes. That wasn’t enough.
I am here in my community, in this particular ED, taking care of these specific patients, because at some point I decided this was my mission: to care for my people. But I can’t. I can’t get my grandma with kidney failure to a bed, and I can’t take my time to investigate the warning signs my little sister shows after being attacked. I know some patients only get one chance to get help, and if we don’t seize that opportunity, they miss their shot at relief, safety, freedom, or peace. Here there’s more suffering than time or resources. I feel my ears burn red and a flutter in my belly. I can’t tell if it’s fury, humiliation, or resignation. Now is not the time to dwell; I’ll sort it out later. There are more patients to see. I look back to the chart as Frankie walks away, but I know Nicole will visit my thoughts later tonight. But first I meet this fifty-year-old man. He’s smoothly dressed in white huaraches, a white polo shirt, and artfully ripped skinny white jeans. His hair is salt and pepper, his legs are crossed, and he’s high as a kite. Aside from having no teeth, he looks much younger than his age.
“I’m here to get checked out so I can go to rehab.” “Rehab? What do you use?”
“Since getting out the pen I get high on embalming fluid.” Every day I hear people talk about their coke or heroin habit, occasionally meth, but embalming fluid?! I have to ask more questions.
“Do you drink it?” “Nah, smoke.”
“How do you smoke a liquid?” Laughing, he tells me how they soak tea bags in the fluid and then smoke the leaves. Incredulous, he asks me, “You never heard of this?” But I’m brand-new on smoking embalming fluid. He lets me know he got out of the penitentiary in 2016 and has been on it ever since. “It puts your mind somewhere pleasant,” he says. He’s happy and charismatic, flirting with the nurse, cracking jokes, asking for a sandwich. His nurse, laughing at the jokes and at my ignorance, clues me in that “embalming fluid” is slang for PCP. But he’s not aggressive, like most people on PCP. I direct him to the area where we sober up intoxicated people. Frankie can connect him to rehab there. For just a moment his charm and joy has enchanted the ER. I feel lighter for having met him. The woman next to him has a grease burn on her right hand. She’s a large, brown-skinned woman with a gray hoodie pulled over her head. She’s got a plastic bag covering her hand. Her body language is tense, and her words quiver. I ask her about her hand.
“I burned it last month at work.”
She went to a different hospital at that time, where they cleaned and dressed it. But she doesn’t have insurance and never went to the burn clinic where they referred her for follow-up. Now crying, she tells me, “It hurts, and it smells. I think it’s infected.” Opening the plastic bag releases a stench that churns my stomach. It’s clearly infected, her tendons and bones are visible, and the tissue that hasn’t been burned away is swollen. She’s unable to move the hand. I take her good hand in both of my hands. “I’m glad you came in. I know this hurts, and I know you’re afraid. We have a lot of work to do to fix this.” She begins to sob—the flow of tears prompts the nurse to find tissue.
She continues sobbing and avoids eye contact. I wish I had more time to sit with her, but there are still forty people in the waiting room. Three minutes.
A lump grows in my throat. I know that this woman is in in- tense physical pain, but more than that, I know that she’s been suffering for a long time. It’s her hand. Not some nagging injury in a remote part of her body. Her right hand. And the smell coming from it is the smell of rot, of death. Coming from the hand she probably uses to write, to work and dress. She has been feeling it, looking at it, thinking about it. She has likely been on a carousel of poisonous emotions, panic and shame and grief. I know it is not just a burn. But the burn is all I have time for. The lump makes me want to stay, but it also tells me I have to move on. So I do. Ever onward.
The next three are up. I’m acting without thinking, one after the next, whistling to fill the silence. I’m a short-order cook flipping burgers at lunch hour.
By now my shift has become an exercise in endurance. Many ER doctors develop bad coping habits to relieve feelings that are hard to quell. Alcoholism, overeating, reckless sex, cocaine—all responses to pressure and stress—are common. The pace of misery never relents. For us the challenge is to avoid becoming inured to suffering or crippled by it. We struggle to maintain our humanity in the face of suffering and our own fatigue. As we persist, our patients teach us about themselves and the world. But only if we listen.
With almost four hours done and four to go, I stroll to the break room. One of the security guards is in there sipping coffee, still wearing his winter hat and coat. We silently give each other the nod Black men give to each other. He’s got the TV tuned to BET. I finish my Rice Krispies treat and wash an apple while I keep an eye on Martin Payne talking smack to his best friend, Tommy. With a satisfying crunch and juicy tartness, the apple numbs the pins and needles in my stomach. I hope the older woman with kidney failure has gotten a room, but I gain nothing by trying to find out. I give the guard the nod as I head back to the fray.
Thomas Fisher is an emergency medical physician at the University of Chicago. This essay was adapted with permission from his new book “The Emergency.” Reprinted by arrangement with One World, an imprint of Random House, a division of Penguin Random House LLC. All rights reserved.