Conversations: Emily Maloney
SYNOPSIS
The American healthcare system is a tapestry of providers, insurers and chargemasters, and often leaves patients with unexpected and crippling bills. That is, if they show up to the hospital at all.
In this episode, Emily speaks with Emily Maloney who has been on both sides of the healthcare cost equation. After being hospitalized for a suicide attempt, she began working as an emergency room technician to pay off her medical debt. Emily Maloney tells her story in a new collection of essays, Cost of Living.
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GUEST
Emily Maloney is the author of Cost of Living. Her essays have appeared in Glamour, Virginia Quarterly Review, The Atlantic, Best American Essays, and the American Journal of Nursing, among others. She has worked as an ER tech and EMT, dog groomer, pastry chef, general contractor, tile setter, and catalog model and has sold her ceramics at art fairs. Maloney has twice been awarded a MacDowell Fellowship. She lives in Evanston, Illinois.
CREDITS
Hosted by Emily Silverman.
Produced by Emily Silverman and Jon Oliver.
Edited and mixed by Jon Oliver.
Original theme music by Yosef Munro. Additional music by Blue Dot Sessions.
The Nocturnists is made possible by the California Medical Association and people like you who have donated through our website and Patreon page.
This episode of The Nocturnists is sponsored by M3 Global Research.
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TRANSCRIPT
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The Nocturnists: Conversations
Emily in Conversation with Emily Maloney
Episode Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Emily Silverman
You're listening to The Nocturnists: Conversations. I'm Emily Silverman. American healthcare is a messy business. The system is a tapestry of providers, insurers and charge masters and often leaves patients with unexpected and crippling bills. That is, if they show up to the hospital at all. Today's guest, Emily Maloney, has been on both sides of the health care cost equation. After being hospitalized for a suicide attempt, she began working as an Emergency Room technician to pay off her medical debt. Emily tells her story in a new collection of essays called Cost of Living. Previously, her work has appeared in Glamour, Virginia Quarterly Review, The Atlantic, Best American Essays, and the American Journal of Nursing, among others. In addition to working as an ER tech and EMT, she's worked as a dog groomer, general contractor, tile setter, and catalog model, and sold her ceramics at art fairs. She's twice been awarded a MacDowell fellowship, and lives in Evanston, Illinois. Before I spoke with Emily, I asked her to read an excerpt from her book. Here's Emily:
Emily Maloney
In 2008, the hospital where I worked—a Level II trauma center just outside Chicago—was $54 million in debt. Everyone seemed to be aware of this fact; the figure floated beneath the surface of all our conversations, an unspoken rigidity we seemed to bump up against everywhere we turned. We were to be careful when we distributed small stuffed animals to unhappy children in the ER, were told to dispense fewer scrub tops to adolescents with dislocated shoulders and bloodied shirts, to pay attention to the way that canes seem to walk off as if under their own power. Everything cost money, Helene our nursing manager, reminded us, even if the kid was screaming and had to get staples in his scalp. I was an ER tech then, someone who drew blood, performed EKGs, and set up suture trays. Most of my knowledge of the world of the ER came through direct patient care. If a nurse or a doctor needed something for a patient, I'd get it for them. I'd run into the stockroom, sort through yards of plastic tubing, through dozens of disposable plastic pieces, acres of gauze. We—the techs—were expected to guard against the depletion of resources. Helene seemed to remind us at every available opportunity, by tacking notes up on the bulletin board in the staff break room. PLEASE CONSERVE YOUR RESOURCES. ONLY USE WHAT IS NECESSARY. These notes were pinned next to our Press Ganey survey results, a form sent to patients upon discharge. Helene blacked out staff names if the feedback wasn't positive. But the question of resources seemed like the kind of problem that couldn't be solved through gauze or surveys or suture trays.
When it was quiet—a forbidden word in the emergency department—I'd help with the billing. We'd break down charts as fast as possible: scan them, assign codes and decide what to charge. Names I vaguely recognized flew by on the PDF reader. I studied my handwriting on their medication lists, a form techs weren't supposed to fill out, but did anyway. (Nurses were supposed to keep up with the medication lists, but there was never enough time for them to actually do it.) Because there were only twenty slots on these forms, I sometimes had to use two pages.
I was twenty-three at the time, still paying off the cost of the mental-health-care debt I took on at nineteen, a cost I believed I would shoulder well into my thirties, a figure that felt more like a student loan than an appropriate cost for medical care. I didn't understand the nature of my mistake at the time, that I should have gone somewhere else for treatment—maybe the university hospital, where the state might pick up your bill if you were declared indigent, or nowhere at all. Sitting on a cot in the emergency room, I filled out paperwork certifying myself as the responsible party for my own medical care—signed it without looking, anchoring myself to this debt, a stone dropped in the middle of the stream. This debt was the cost of living, and I accumulated it in the telemetry unit, fifth floor, at a community hospital in Iowa City, hundreds of miles from home.
Emily Silverman
Thank you for reading that excerpt. I am sitting here with Emily Maloney, the author of Cost of Living. Emily, thanks so much for being here with me.
Emily Maloney
Thanks so much for having me.
Emily Silverman
So Emily, we know each other. We actually met.
Emily Maloney
We do.
Emily Silverman
We met at MacDowell, a writer's retreat. And I have to say, I was immediately drawn to you, at that retreat, because I felt like we were healthcare brethren. And I'm very honored to have lived in the woods with you, for a short while, as you worked on this book.
Emily Maloney
MacDowell is such a magical place and such an incredible opportunity. It was really kind of a miracle that we were able to be there at the same time and meet each other and get to know each other. So, I'm really appreciative of them for that.
Emily Silverman
Let's talk a little bit about your medical debt. Tell us the story of how that accumulated. When did you find out the number that you owed? And talk about that journey.
Emily Maloney
Sure. I received a bill. I don't even remember the original bill. I received a bill that said "balance forwarded" from the original hospital bill. It went immediately to collections. It was tens of thousands of dollars in debt. Which, I realize for someone who receives organ transplant or open heart-surgery, that's nothing. But, it was an enormous amount of money to me. As a student, as someone who intermittently worked a lot of different jobs, I did not have anywhere near the resources necessary to cover those costs. I was not made aware of those costs either. I don't remember much about the experience of signing my life away, as people do as they are admitted to hospitals. And so I did not find out about the nature of my debt, or the amount of my debt, until much later. As a result, it was something that I had a lot of shame about. And I carried that shame for years and years and years and years. I both avoided trying to pay it, and then intermittently would pay whatever the minimum was, but the debt itself never actually seemed to go away.
Emily Silverman
Until you get this phone call... So tell us what happened there.
Emily Maloney
So I actually received a phone call from my bank saying that they were being sold to another larger bank, and maybe the routing numbers would have changed in the acquisition. And so, I actually called my collections agency to tell them that this information had changed, and maybe I would need to send them a canceled check or something along these lines. I ended up speaking with a woman from the collections agency who told me that it had exceeded the statute of limitations. And so it was no longer an enforceable debt. And, she took me off the books, and told me to have a great weekend. It was.... it was a... it was a wild experience, because I was under the impression that I was going to continue to labor underneath this debt for years, if not decades, to come.
Emily Silverman
So, the debt goes away in one phone call. She says, "Have a nice weekend." I mean, that... that moment in that essay is so striking. I also don't understand what that means, if she says it's beyond the statute of limitations. What does that mean?
Emily Maloney
Apparently, debt cannot be enforced to be collected. They've gone to collections after seven years. There are some debts that are not dischargeable, no matter what, like student loan debt. But apparently with medical debt, you can either negotiate to reach this end sooner, which I was not made aware of, or you can stop paying it and eventually it drops off your credit report and is no longer enforceable as a collection.
Emily Silverman
What a crazy world we live in!
Emily Maloney
Late capitalism is the darkest timeline.
Emily Silverman
So, one of my favorite essays in this collection is the essay called, "I stalked my psychiatrist". And, this essay is a portrait of your relationship with your psychiatrist, Julie, who you say prescribed twenty-six different medications to you, under her care. Tell us a little bit about your relationship with Julie, and that essay, and your experience writing that essay.
Emily Maloney
I actually wrote this essay in 2014. And, I wrote it really quickly, I remember, and sent it off, and then immediately got this response from The Atlantic which was really surprising at the time. Basically, my relationship with Julie was that I was a student at the University of Iowa in Iowa City. And, I was not well. I was depressed. I was a college student. I was also trying to escape from beneath the thumb of my own upbringing, which was complicated. And, I was trying to figure out who I was as a person, and I was also very impressionable. As it turns out, I later found out I have nonverbal learning disability, a developmental disability similar to autism, and some other issues around that. But, basically, I was told I had bipolar disorder by Julie.
And Julie, (not her real name; everyone's name has been changed)... Julie prescribed a lot of different drugs to me. She was sort of made in the biological revolution in psychiatry, that sort of came about in the late 1970s, in Iowa City, at the University of Iowa hospitals and clinics. And, it sort of brought about this idea that we could fix psychiatric problems in some of the similar ways that we fixed diabetics with insulin; that there was this relationship between medications you could take and how you could feel. So, she was educated in that school, and was very much of the belief that had I received the appropriate dose of whatever it was that I needed to have, I wouldn't be facing the kinds of problems I faced. Instead, I just really wanted to do whatever it was that she wanted of me. I was really lonely, and I began to sort of monitor her movements outside the office. And she was someone who... I wanted to meet her under other circumstances. Like I say in the essay, that had we met in some other format, probably, maybe, possibly, we could have been friends, or something along those lines. And, instead, she had this immense power over me, and I wanted to do anything I was supposed to do, to behave. I wanted to be a good patient. I would just take anything she prescribed to me. And I did.
Emily Silverman
And in the book, you talk about how the medications didn't really help.
Emily Maloney
Oh, no, absolutely not. Like, I needed to go to therapy. I needed to figure out what kind of person I was going to be. There were a lot of other issues that really didn't have a lot to do with a chemical imbalance. I don't know to what extent I could have benefited from other kinds of medications, or other kinds of interventions. I think this kind of behavior is really prevalent: where we sort of prescribe, particularly women, medications that may not actually result in a resolution of symptoms. But also that, you know, with this increased tendency towards reimbursement of physicians, of psychiatrists, for medication management appointments, but not reimbursement of therapy, or that reimbursement of therapy takes place at such a, much lower, rate of return, that it's just not uncommon for a lot of people like me to end up in that same situation.
Emily Silverman
You talk about how Julie came out of a school of psychiatry that was very focused on biology and medications, and how there was a lot of work that you needed to do at the time, around yourself and your identity. Was there any talk therapy component to it? Or was it really just more of, "Hey, I just got in these new samples of this new anti-psychotic. Why don't you try it out and let me know what you think?"
Emily Maloney
Oh, the latter. It was very much focused on "how are you immediately feeling, so I can have a enough words for the note." And, then "what can I do to make sure that you're taking whatever it is you need to take?" The idea, I think, with... with Julie, was that she was very focused on medication management and medication compliance. I did not receive any therapy at that time.
Emily Silverman
I want to spend a minute on your mis-diagnosis. You carried this diagnosis of bipolar disorder for a time, and you were taking lithium, and ultimately that diagnosis was proved incorrect. And, you were diagnosed instead with depression, you say, maybe from vitamin D deficiency, and untreated hypothyroidism, also with this nonverbal learning disability, which had been undiagnosed for a long time. Tell us about that realization. Like, "Oh, I actually don't have bipolar disorder; I have this other set of conditions." What was that shift like for you?
Emily Maloney
It was a little terrifying, to be honest. Because, when you have been assigned a label for a particular period of time, it's a really easy shorthand to explain yourself to other people. And, often the reality is much more complicated. I was diagnosed when I went to community college, to try and get my bachelor's degree and take some science classes. And my chemistry professor actually said, "Have you ever been evaluated for a learning disability? Because it's very clear that you're not ever doing the homework when I put it on the board, without telling people about it. If I just write it up on the board and don't tell you, you don't do the homework. And you don't seem aware that there's homework assigned." And I said, "Okay." So, I went in got evaluated by a neuropsychologist, and was subjected to hours and hours and hours of testing. And, as it turns out, I have this really big gap between my verbal IQ and my performance IQ, which mostly just means that there are a lot of things that are really challenging for me. That I have some issues with the way I look at the world; the way that I manage space and time is difficult. Some of the other things that often impact autistic people often also impact people who are NLD'ers (nonverbal learning disability) folks as well. So, basically, until I reached the point where I realized that my life was maybe not as easily distilled to bipolar disorder, I was able to get some of the resources that I needed.
Emily Silverman
You talk about what it's like to move through the world as somebody with an NLD, a nonverbal learning disability. And, you get into this a little bit in the book; you talk about navigating social situations, taking a class called "Reflective Listening Skills". And there's one scene where you're grabbing drinks with some of the other ER techs after work. And you say, "I am trying out my newly acquired social skills with them, trying to remember what to say, and how to act, to behave." Can you give us an example of what that feels like?
Emily Maloney
Sure. I have very limited verbal or auditory processing skills; I have, like, a delay in how I process information. People with nonverbal learning disabilities struggle with how far apart to stand from somebody else, to remember the give and take of conversation, to understand that your face needs to match what you're relaying to someone else. We can come across as having a flat affect. I actually went and saw a speech pathologist, who helped me develop scripts for difficult situations, and also just how to learn the ins and outs of small talk with people. That was something I never really quite understood or had interest in prior to my diagnosis.
Emily Silverman
What might we find in one of these scripts?
Emily Maloney
That's a good question... which is another thing I learned to say. A lot of the scripted moments for me were things like: remembering to turn the conversation around to the other person, remembering to not spend too long on the things that interest me. This is something that is more common, I think, with autistic people than NLD'ers, is the idea of the special interest. I have deep and stupid knowledge in a variety of subjects. And it took me a long time to realize that most people don't care... and I'm fine with it.
Emily Silverman
One of my favorite essays in your collection is "Soft Restraints", in which you tell the story of a patient named Elizabeth, who comes to the emergency room and she's in a psychiatric crisis. And you see a bit of yourself in her, or maybe you see a bit of her in yourself. Tell us about that essay.
Emily Maloney
Thank you. It's my favorite essay in the book. I think that my exposure to Elizabeth, or patients like Elizabeth, was something that provided a turning point for me, even though I didn't acknowledge it at the time. And it was that, I have to make a choice. I have to make a choice every day to wear clothes and put myself together and participate in the world. And, I don't think I realized I was making a choice, or that I could make that choice until I started seeing patients like Elizabeth, people who felt like maybe they couldn't make that choice. And, I think it's really challenging because a lot of these patients weren't taken seriously. And, I think that a lot of these patients were just hoping to be seen, and for their pain to be acknowledged, and for some hope, of some kind of solution. And we were unable to provide that because the ER is not really actually set up to deal with people's psychiatric crises.
Emily Silverman
One of my favorite moments in that essay is when you're standing at the screen examining a head CT with Mark, one of the ER docs, and this is a patient who you discover has a large brain tumor. And Mark turns to you and says, "Wow, I thought she had just gone off her lithium." And then you say, "I am on lithium." And then he blurts out, "Did you eat lunch?" and launches into a lecture about the importance of staying fed and hydrated to prevent side effects from lithium. Just sort of an awkward moment, but also like a really powerful moment of confession, and I was wondering if you could bring us into that interaction a bit?
Emily Maloney
Sure. I think many emergency department physicians feel frustrated by problems that cannot be immediately resolved in the ER, or by ER methods. So, if you have a broken arm, great. If you've been hit by a bus, even better. But, the idea that, that, some people come into the ER, I don't know, you know, how exciting it is to deal with psychiatric patients, because there's nothing that can be done with them in the immediate term in the ER, aside from keeping them from harming themselves or others. There's obviously pharmacologic interventions, but beyond that... So I think that Mark was one of those kinds of doctors who was maybe less interested in psychiatric patients. And, so me confessing to him, I think, made him think differently about me, and about our relationship and how we work together. Because, I think the relationship between myself as a patient and myself as someone who provided care, that relationship seemed separate. And by confessing my personal medical history to him in the ER, I'm sure that threw him for a loop.
Emily Silverman
So tell me about your decision to share that information with him. Was that intentional? Or did it just slip out?
Emily Maloney
I have poor impulse control.
Emily Silverman
So after you said it, were you like, "Oh, I didn't mean to say that." Or was there regret? Or did you just kind of move on?
Emily Maloney
Probably, in the moment, I was horrified or embarrassed. But looking back on it, I'm glad I did that. Because, if nothing else, it made the line between patient and provider a little shorter, and a little bit more visible.
Emily Silverman
One of the essays in the collection is called "Failures in Communication". And this is an essay where you're shadowing a medicine team on the wards, as a bioethics student, and you're observing all the little power dynamics between doctor and nurse, between resident and med student, between nurse and med student. And you're standing there in the back of the room, not talking much, and people aren't quite sure how to introduce you to the patients. Tell us what that was like, being almost like an anthropological observer of this medical hierarchy and medical culture.
Emily Maloney
I received my MFA in nonfiction writing at the University of Pittsburgh. And, while I was there, I started taking classes in the Bioethics program. I was actually an enrolled MA student in Bioethics. I'm pretty sure my professor, who I still keep in touch with and am friends with, would welcome me completing my thesis someday. But that experience of taking Clinical Bioethics spawned this essay, and helped me understand the ways in which things work on a floor in a teaching hospital... just that there are all these different team members, and all of them have very specific roles. And, at the same time, because I was someone of no consequence, and I was merely there in an observational capacity as a bioethics student, I had the opportunity to be confessed to by a variety of staff members. The nurses, of course, hated the med students, and the med students feared the residents, and the residents... there was this very complex medical hierarchy at play. And, the fact that I was just a fly on the wall enabled me to get a view that other people wouldn't otherwise have the opportunity to see.
Emily Silverman
In that essay you write, "These people have been doctors forever, since before any of us were born. They've been programmed to be doctors, the way they talk about patients, instead of to patients like the nurses do, has been inside them for years. I want to be a doctor, but I can't be a doctor. I'm a tech, an EMT; maybe a nurse if I can get some prerequisites and get into the program at the community college, though these programs have gotten more and more competitive as time has gone on. This is all clear somehow." That paragraph really stuck with me. And I'm wondering, how do you think about your identity as a healthcare worker? I know you're not working in healthcare at the moment. But, how do you see yourself in the healthcare web?
Emily Maloney
I think I'm sort of a worker bee. I really have always gravitated to jobs where I can work my body, and in some ways, turned parts of my brain off or keep parts of my brain to myself. And, I think being a tech can be like that, in that there's a certain physicality, that you're the one doing the CPR, or running labs to Specimen Processing, or that you're the one who needs to interact with the patient; who needs to turn patients; who needs to make sure everybody's got their leads stuck down. That kind of work has always been really appealing to me. I was also a dog groomer, and had a lot of other kinds of jobs like this. I was once hired in college to work on the line at the Procter and Gamble plant, which was basically, like, watching bottles of shampoo and making sure the line didn't get tangled. But that sort of work has always been really appealing to me, because it's very clear what my role is; how I exist in that role.
When I meet medical doctors, I think, a lot of them have known forever that they wanted to be a physician. And I think that that idea is something that gets encouraged when they're very young. And, as someone who was not going to go to college, and essentially dropped out of high school to attend an early college program, I was someone for whom the idea of becoming a doctor was completely antithetical to my being. I mean, granted, I did take the AP exams that a lot of my classmates were taking, but I think the expectations around what it was I was going to do with my life were very low. And I think that also contributed to this idea that being a doctor was something that certain people did, but it was definitely not something for me.
Emily Silverman
You mentioned some of the other jobs that you've worked in, and in the book, you break down how much money you made doing each of those jobs. And your relationship to money has varied a lot over the years. You talk about being a pastry chef's assistant, making $5.15 an hour; being a dog groomer at PetSmart making $9 an hour; being an ER tech making $1,400 to $1,800 a month; being a medical publications manager in Gastroenterology, in which you were offered a yearly salary of over $150,000. There's such a range of experience here. How did this experience shape your perspective on class, opportunity, happiness, life in general?
Emily Maloney
I don't think that people who make money have any more value than people who don't make money. Some of the worst people I've ever met make a lot of money. I'm more interested in whether or not you can be a good person. I think that it's important to do good work and to help other people when you can, and to participate in a community. I think that living in a world where you can get anything mailed to you at any time is really problematic. I think that the American healthcare system has cost a lot of money to a lot of people, and has maybe not delivered any of the results we were hoping for. I think health care should be free. I think that there are ways in which we can compensate physicians and healthcare providers for doing life-saving work without passing that cost to the patients themselves.
Emily Silverman
So, my last question is, what do you love about healthcare? We've talked a lot about the flaws and the deficiencies and the corruption. But you could have picked a million different jobs to pay back your debt. And I know you did work many different jobs. But healthcare is something that you kept coming back to: the ER tech, the EMT. You've talked a little bit about liking the physicality of the job. But, is there anything else about healthcare, specifically, that draws you to it?
Emily Maloney
Ah, so much. Everything. The science... the human body is just this ultimate puzzle. I may end up back working in that kind of capacity or a different kind of capacity in the future. But the reason I would go back would be because of the puzzle of it, the science of it. And, also just the opportunity to interact with people, and to actually help people. A lot of the ER is about people having the worst days of their lives. And, to be able to provide comfort and care to people in those places, is huge. It's an incredible experience. And I really loved every minute of it.
Emily Silverman
This has been fantastic. I am speaking with Emily Maloney about her new essay collection, Cost of Living. The book is out on February 8, 2022. Please pick up a copy. It's a really wonderful read. It's very literary, and just offers a fresh perspective. And I'm so glad that you wrote it, and that you came onto the show to chat with me about it today.
Emily Maloney
Thank you so much for having me. I had a great time.