The emergency room is where the United States’ social problems come home to roost

From “Legacy” by Uché Blackstock, M.D., published by Viking, an imprint of Penguin Publishing Group, a division of Penguin Random House, LLC. Copyright © 2024 by Uché Blackstock, M.D.

In the U.S., access to health care has long depended on insurance and a person’s ability to pay, with patients of color making up a disproportionate number of the under- or uninsured, as I have seen firsthand.

This trend dates back to the mid-20th century, a period when medical technology improved substantially, and visits to hospitals increased. Although insurance policies at the time covered hospital visits, they didn’t tend to cover outpatient office visits, and so people without insurance found that they could access no-cost care through hospital emergency rooms instead.

As a result, the history of emergency medicine is bound up in the experiences of Black and Latinx communities’ exclusion from the health care setting. Prior to the 1960s, the vast majority of hospitals in the United States were segregated by race, or they had separate wings or staff for patients strictly stratified according to skin color. Many Black communities in the South simply had no access to hospitals at all. After the passage of the Civil Rights Act in 1964, Title VI of the act mandated that any hospital that practiced racial discrimination would have federal funding withheld from it.

Concurrently, a new medical specialty was emerging: emergency medicine. Until the mid-1960s, emergency rooms tended to be staffed by a motley crew of interns and residents, supervised by whatever physician happened to be on call, with specialists moonlighting. There was no such thing as physicians who were trained specifically in providing emergency care. The first ever EM training program in the country started at Cincinnati General in the late 1960s, after Black residents in the area marched on the hospital in protest against the long waiting times and subpar treatment they were receiving there. At that time, the emergency department at Cincinnati General was staffed only by trainees, patients had to wait many hours to be seen, and the quality of care was shoddy. Inevitably, medical errors were made. In response to the protests, the University of Cincinnati began its landmark emergency medicine residency training in 1970, which led to other academic medical centers across the country following suit.

The field of paramedicine also grew out of this era of civil protest. While most cities in the 1960s had private ambulance services, at the time, ambulance staff weren’t trained in emergency care, and they tended to service predominantly white communities. That changed in 1967, when a group of Black leaders in the Hill District of Pittsburgh approached a physician at their local Presbyterian University Hospital with an idea to provide better transportation to hospitals for their community. Up to that point, Black residents were expected to call the police when they needed transportation to a hospital. Wait times for transport could be long, with many patients understandably reluctant to call the police due to the history of police brutality and abuse against Black communities. Meanwhile, many people — Black and white — were dying on their way to hospital, deaths that could have been avoided if ambulance personnel were trained in emergency care. The physician at Presbyterian University Hospital, Peter Safar, agreed to begin training Hill District residents — many of whom had been unemployed for long periods of time — in providing emergency medical care to patients while in transit. And so, the first mobile emergency medicine program in the country was born.

Emergency medicine physicians have long taken great pride in the fact that we provide care to our patients regardless of their insurance status. In 1986, this became law with the passage of the Emergency Medical Treatment and Active Labor Act, which created a federal right to emergency care for everyone. Today, nearly half of all medical treatment in the U.S. occurs in emergency medicine departments.

When it came time to select my fourth-year clinical rotations, I chose to do my elective rotation in emergency medicine. It felt natural for me to take on the role of comforter and caretaker, as I noticed myself drawn to patients who seemed fearful. Due to my mom’s experience being sick — a physician herself, she died of cancer at 47 — I knew how unsettling and downright scary being a patient in the hospital could be. It was instinctive for me to sit with an elderly woman who was suspected of having a stroke, who was terrified to go into an MRI machine, talking her through her concerns and allaying her worries enough to help get her through the procedure.

As I prepared to graduate from Harvard Medical School, the time came to choose where I wanted to go for my residency. While my peers were vying for competitive residencies at prestigious, well-known institutions, my heart was set on returning to Brooklyn. I knew I wanted to make a difference within my community, just as my mother had. At Harvard, I had found myself mostly supervised by white residents and attending physicians, alongside my white peers — I often was the only Black person in the room. In such situations, I felt as if I were under a microscope, always hyperaware of how I spoke, the words I used, the way I dressed. I found my body would stiffen up as I walked into a patient’s room. I’d stand up straight, trying to project confidence, to prove myself. I didn’t know the term for what I was doing, but now I can see that it was what is known as “stereotype threat” — a psychological phenomenon in which an individual feels at risk of confirming a negative stereotype about a group they identify with. If I did see another Black person working within the HMS hospitals, it was usually a member of the housekeeping or janitorial staff. We would always make eye contact, gently nod, and smile at each other.

And so I chose to do my residency at Kings County Hospital/SUNY Downstate, the same hospital my mother had spent the bulk of her career, where I knew I would be right at home, literally and figuratively. At Kings County, on some shifts, both my senior resident and attending physician would be Black.

The patients we saw at the Kings County ER were predominantly Black and faced myriad and often complex needs. In 2006, when I came to work at Kings County, the New York City Health and Hospitals Corporation, which runs Kings County and the other 10 public hospitals in the city, was facing a projected deficit of $579.2 million.

As a result of the immense need and this dire funding gap, the Kings County ER was a crowded, noisy, and often chaotic place. We never had enough nursing and ancillary staff. During my shifts, I wasn’t just administering to my patients’ acute health care needs. I found myself taking care of their many other needs, too: checking on prescriptions, calling family members, contacting the social worker to make sure a patient could sign up for emergency health insurance and wasn’t left with a huge bill. If I left a shift at 11 p.m. and came back at 3 the next afternoon I might see the same patients still waiting from the night before.

On every shift, I encountered people facing challenges that often went far beyond health issues, such as the Creole-speaking elderly man who’d lost his housing, had no family, and was living in a shelter; he didn’t have any diabetes medication left, as someone had stolen his last few pills at the shelter.

I had gone into the field seeing the ER as a place where I could have the opportunity to serve those most in need. As time went on, however, I came to view it as the place where the United States’ social problems come home to roost — just as they did in the 1960s.

Uché Blackstock is a physician and thought leader on bias and racism in health care. She is the founder and CEO of Advancing Health Equity, appears regularly on MSNBC and NBC News, and is a former associate professor in the Department of Emergency Medicine and the former faculty director for recruitment, retention, and inclusion in the Office of Diversity Affairs at NYU School of Medicine.