Emily Maloney was misdiagnosed for years before a suicide attempt buried her in medical debt. She labored to pay off a staggering five-figure sum while working various medically-related jobs. These experiences offered her a unique perspective on the costs at play within medicine, both to the system and the patients it seeks to help. Her memoir-in-essays, Cost of Living, comes at a crucial turning point when many healthcare workers are changing employers or leaving the field altogether and patients are struggling to access care.
Maloney writes repeatedly of her inability to fit in — in a schoolroom, in a job, in a grocery store — due to a condition that is never defined but sounds similar to autism. Her “outsider” status positions her well to be an astute observer. As an ER technician, Maloney notices the lack of coverage for an MRI that might have better diagnosed the source of a woman’s neck pain, pain managed instead with prescription narcotics that led to heroin addiction. Elsewhere, she chronicles the misuse of an EKG machine that led to unnecessary hospitalizations and the firing of the employee who made a mistake.
As an aspiring student in the field of healthcare — taking an EMT course she doesn’t complete, considering enrolling in nursing or medical school but being daunted by the MCAT — Maloney details the time, tuition, and mental bandwidth that are difficult to come by while juggling her own health, family obligations, and financial constraints. Years later, she holds a series of jobs within the pharmaceutical industry, including medical writer and project manager, which allow her to scrutinize the disconnect between the industry’s exorbitant expenditures and its ineffectiveness at tackling greater societal issues like addiction to pain medicines. Reminding us that she is ever the patient, Maloney includes the exact cost of medications prescribed to her and how her life circumstances dictated her ability to pay for them and receive care.
Blending personal experience with reportage, each essay has a distinct structure and flavor, though one through-line stands out: Maloney’s search to understand why she stayed with her psychiatrist through ineffective treatment. Maloney explores questions like, “What kind of relationship should we have with our doctors?” and “What is the right level of medical intervention?” But at the end of the day, she, like all of us, simply wants to know: “Will I be okay?”
Maloney writes with a humble, explorative tone that doesn’t purport to have simple answers for the complex issues facing healthcare but manages to convey the urgency of what is at stake. Like gapers at a car wreck, we can’t tear our eyes away from her descriptions of the financial awareness baked into each decision in the emergency room. We are there with Maloney in the hospital breakroom as she reads the note on the bulletin board:
“PLEASE CONSERVE YOUR RESOURCES, ONLY USE WHAT IS NECESSARY.”
For me, this moment was eye opening. During my years as a medical student and resident, my access to bandages, plastic tubing, and highly coveted suture materials was restricted. There were locks on supply closet doors, with codes known only to nurses or staff in roles like Maloney’s. I understood the materials were expensive but also felt judged for using them. The staff was well aware of how materials might be wasted given the steep learning curve medical students faced, regardless of our good intentions. Still, it wasn’t until I read Maloney’s essays that I began to understand the pressure she and other staff members felt from hospital administrators to ration those items.
However, the stresses go beyond the cost of Dermabond or a suture removal kit Maloney used in the ER. Hospital employees internalize financial constraints, in addition to logistical, legal, and moral expectations, and, in turn, are always on edge. During my first year as a doctor, I got into a spat with the nursing supervisor who didn’t want to break protocol and use a medication that was necessary for the patient but restricted to certain areas of the hospital.
I was the intern who, as Maloney reports, spent “13 percent (or less) of [my] time with patients and 40 (or maybe 60) percent of the time sitting in front of a computer.” No matter that it made it appear I didn’t care about the patients themselves. I cared every time a patient requested a speedy discharge and every time I needed to ensure a smooth handoff to the next medical team, and would have even without the foreboding omnipresence of “Quality Improvement.” During rounds, Maloney herself internalized the ensuing pressure as a representative of the ever-present institution was “following us and taking notes [while] looking at her phone, her portable stopwatch.”
I recalled the janitor who, at three in the morning, glared at me, a deflated intern, when I snuck beyond his barrier of caution tape, too tired to take a different route to my workroom. I left offensive sneaker prints on his polished floor, my guilt that he would have to redo his work layered onto my fatigue.
I feared any situation that would give staff or patients reason to doubt me, so I worked diligently, with a smile plastered on my face in order to make it through a curriculum where every day felt like a job interview. The pace of medical training is relentless. No time for reflection. Or sleep. Or to use the bathroom. How do surgeons not need a break to pee? You just don’t need to, is the standard reply. And once you have the experience, you realize what they mean. You are hyper-focused on the task at hand. The tunnel vision is intoxicating. You lose all sense of time or bodily need.
Similarly, you stop thinking about your emotional needs. I let mine go unattended for long enough and found myself crying nonstop at work, even as I did something as utterly satisfying as throwing perfect stitches across a belly to close a wound after a successful operation.
Maloney’s psychiatrist tried to help her by prescribing twenty-six different medications, hoping that the next one would work. While reading this, I was suddenly transported to the basement office where I saw a psychiatric nurse practitioner for depression during my internship in medicine and surgery, a professional who told me, “With the options we have today, there is definitely a pill out there for you. We just have to find the right one.”
Rather than explore twenty-six options for my depression, I left medicine in the middle of my residency program, but with her prose, Maloney brought me right back. As she second-guessed her billing decisions — “Did I make a mistake in the last chart? Could I go back and revise? There was the guilt of billing a patient for too much” — I relived the doubt I harbored towards my medical decisions, such as my choice not to order a CT scan for a man with chest pain. One that could have potentially identified the pulmonary embolus that killed him the following day. As I read Maloney’s work, I had to remind myself to breathe.
In particular, her observations as a bioethics student led me to reflect on the formation of my perfectionism in medical practice and its detrimental effects on my health. While on rounds with a team of doctors, Maloney observed the medical student, resident, and nurse jockeying to intercede on behalf of a patient — a dispute that results in a flustered nurse who takes Maloney aside to confide, “[I] hate — absolutely hate — medical students. They’re useless!” Maloney herself concludes, “med students… don’t know anything… [t]he ethical implications of the relationship between med students and nurses seem potentially problematic at best; at worst, we are harming patients, one medical student at a time.”
I was the medical student misjudged by nurses every single day, but if I was awkward or in the way, it was because the way was not explained to me, or my role was not clear. As a student, you have no privileges, but you absolutely need the practice if you are ever going to become a doctor. You have no place. You must politely fight for your right to exist in these restricted areas.
I fought with my smile, or the crinkling around my eyes when my smile was hidden by face mask. I wonder how my path might have been different if more of my experience had been like one particular day in the operating room during my third year of medical school. The charge nurse had just sighed and stomped off to retrieve gloves for me, gloves I understood would add to the expense of the operation. I surveyed the scrub nurses and did a double take when the tallest one spoke. She had been one of my patients on the medical floor and had told me to look for her when I rotated through surgery later in the year. She caught me staring and stopped her conversation. I held my breath as all six feet of her took a step closer.
“I remember you.” Her suspicious squint morphed into a smile behind her mask. With a whisk of her hand she brushed away all of the meanness from the room. “No, this one’s good. She took care of me,” she told the rest of the staff. For one afternoon, I was handed instruments. It was not assumed I would break the sterile field. For those few hours, I enjoyed the work. There was even the hint that in welcoming me, the environment was improved for all. Because the thing is, in a world sterilized of any kindness — with no room for questions or doubt — nothing can grow, not even us.
Maloney is right to consider the explicits costs of healthcare including finances, misdiagnosis, and medical mistakes. But there are also hidden costs: the fear of mistakes, burnout, and the demoralization that comes from a lack of kindness. If, as Maloney concludes, medical students are doing harm, we need to shepherd them better while providing space for them to ask questions so they can learn.
I can still conjure the brisk chill of the operating room, the way the suture felt in my gloved hands — the satisfying tension of purpose and order, and the knowledge that my perfect stitches would save the patient from a scar. I made my choice to quit, but I can also see what a mistake it was that I never thought I could be a surgeon.
In the end, Maloney’s tone is hopeful as she writes about the interconnectedness of healthcare workers and patients: seeing herself in their shoes, wanting to believe that even the psychiatrist who never treated her accurately or adequately had good intentions, wanting to humanize the unreasonable, drug-seeking patient who could have been someone she knew. I too was buoyed by the acceptance and kindness I encountered, like the time I grabbed a cleaning wipe from a hospital aide’s cart, intending to help him with a mess in a patient’s room, only for him to look at me in alarm. He didn’t have the English skills to explain; instead, he pointed to the canister: “Warning. Carcinogenic. Do not use without gloves.”
Even after all she has been through, Maloney believes that healthcare workers truly want to help.
I wish more people could see us that way too.