Inside the Real Emergency Room with Dr Cedric Dark
Inside the “Canary in the Coal Mine”: Emergency Medicine and the Fight for Policy with Dr. Cedric Dark
In the emergency room, there is no "slow lane." It is a world where doctors are often thrown into the deep end, forced to manage life-threatening injuries under intense pressure. As Dr. Cedric Dark puts it: “The first thing you do when you walk into a code is check your own pulse.”
In this episode of The Adrenaline Zone, hosts Sandy Winnefeld and Sandra Magnus sit down with Dr. Cedric Dark, an Associate Professor at Baylor College of Medicine and a leading voice in health advocacy. They dive into the high-stakes reality of the ER, the operational parallels between medicine and spaceflight, and Dr. Dark’s provocative new book, Under the Gun.
The Operational Mindset: ER vs. Fighter Jets
Coming from backgrounds in fighter piloting and space exploration, Sandy and Sandra recognize a kindred spirit in the emergency physician. Dr. Dark explains that while much of modern medicine can be "Googled" by a trained professional in a quiet moment, the ER is different. It requires physical memory and worst-case scenario training - the kind of preparation where you don't have time for a refresher.
Whether it’s performing an emergency thoracotomy or managing a difficult airway, the goal is the same: stay calm, follow the algorithm, and salvage the life in front of you.
The Canary in the Coal Mine
Dr. Dark describes the emergency room as the "canary in the coal mine" for society. Unlike private practices, the ER cannot turn anyone away based on their insurance status. This puts ER doctors on the front lines of every social issue, from poverty and homelessness to the healthcare cost crisis.
“One of the reasons I love doing my job,” Dr. Dark shares, “is because I get to show up and take care of people regardless of whether they have insurance or not. I don’t have to worry about the money... I just get to do the medicine.”
#ThisIsOurLane: Tackling the Gun Epidemic
A significant portion of the episode focuses on Dr. Dark’s advocacy for gun violence prevention. Following a 2018 tweet from the NRA telling doctors to "stay in their lane," Dr. Dark helped lead the #ThisIsOurLane movement, arguing that because doctors treat the victims of firearm injuries every day, they have a moral obligation to speak up.
His book, Under the Gun: An ER Doctor’s Cure for America’s Gun Epidemic, focuses on evidence-based policies rather than partisan rhetoric. Dr. Dark advocates for a "bridge-building" approach, summarized by his colleague’s powerful mantra: “We are not anti-gun; we are anti-bullet holes.”
He breaks down actionable policies that save lives, including:
Domestic violence restraining orders that allow for firearm removal.
Universal background checks to close private sale loopholes.
Safe storage and child access prevention laws.
The Problem with the Price Tag
When asked about the skyrocketing cost of U.S. healthcare, Dr. Dark doesn’t pull punches. Citing the late economist Uwe Reinhardt, he notes, “It’s the prices, stupid.” He points to a startling statistic: in one year, S&P 500 healthcare companies gave $170 billion to shareholders - roughly 4% of every healthcare dollar spent. Between profiteering, private equity, and a lack of price transparency, Dr. Dark argues that the system is built on a foundation that makes "shopping for care" impossible during a heart attack.
Advice for the Next Generation
Dr. Dark’s advice for aspiring medical students is grounded in practical wisdom:
Do what you enjoy: If you love the work, you’ll never truly "work" a day in your life.
Follow the money: Medical school is expensive. If a school in Iowa offers a full-ride scholarship, take it over the "prestige" of an expensive coastal city.
Pay yourself first: Doctors start their careers a decade behind their peers. Start saving for retirement during residency to ensure you're working because you love it, not because you have bills to pay.
Want to hear the full conversation? Listen to the latest episode of The Adrenaline Zone to hear Dr. Dark’s stories from the front lines and his vision for a safer, more equitable healthcare system.
Dr. Cedric Dark’s book, Under the Gun, is available now from Johns Hopkins Press.
Transcript
Sandy Winnefeld:
One of the most challenging sectors of the medical profession is emergency medicine.
Dr. Sandra Magnus:
Not only does the emergency room team need to be able to deal with a wide variety of immediate life-threatening injuries and other conditions, they have to do so under intense pressure.
Dr. Cedric Dark:
It feels like I was just thrown into the deep end of the pool. The first thing you do when you walk into a code is check your own pulse.
Sandy Winnefeld:
Many people who can't afford health care actually go to the emergency room because they can't be turned away.
Dr. Cedric Dark:
People would say it's like being the canary in the coal mine. You see all of society's problems. One of the reasons I love doing my job is because I get to show up and take care of people regardless of whether they have insurance or not. I don't have to worry about the money. I don't have to worry about the cost. I just get to do the medicine.
Sandy Winnefeld:
That in turn increases the workload challenge for these emergency rooms.
Dr. Sandra Magnus:
And at any moment, a mass casualty can overwhelm the staff, forcing it into triage mode.
Sandy Winnefeld:
Our guest today is Dr. Cedric Dark. He's an associate professor in the Henry J.N. Taub Department of Emergency Medicine at the Baylor College of Medicine in Texas.
Dr. Sandra Magnus:
And he's been labeled the "Obi-Wan Kenobi of health policy and advocacy" by the Emergency Medicine Residents' Association.
Sandy Winnefeld:
And he's the author of Under the Gun: An ER Doctor's Cure for America's Gun Epidemic.
Dr. Cedric Dark:
The NRA decided to tweet out that physicians need to stay in their lane and not talk about gun violence prevention. Most of us fought back with a hashtag called #ThisIsOurLane.
Dr. Sandra Magnus:
So you're about to be treated to a behind-the-scenes look at what life is really like in the emergency room.
Sandy Winnefeld:
But first, many thanks to our sponsor for this episode, Culligan. Culligan's drinking water systems deliver the superior filtration and refreshing hydration you need to fuel your high-performance lifestyle. Culligan: it's water you love.
Dr. Sandra Magnus:
And we caught up with Dr. Dark in Houston.
Sandy Winnefeld:
So, Dr. Cedric Dark, it's really a pleasure to have you on The Adrenaline Zone. Thank you for being with us today.
Dr. Cedric Dark:
Thank you for having me.
Dr. Sandra Magnus:
And we're really excited to get to some of the things that you've been doing in the emergency room as well as some of the books and articles that you've written. But we really like to start at the beginning and ask our guests what motivated them. So what made you decide to pursue a medical career?
Dr. Cedric Dark:
Medical career in and of itself, my mom's a nurse. I have uncles and aunts that are in the medical field as well. My cousin is like a trauma surgeon, and he's maybe about 15, 20 years older than me. So I think the sciences and health care kind of ran in the family a little bit. Eventually, at one point, my mom's sister, my aunt, she passed from colon cancer. And I think that happened late in high school. And I kind of felt like that was one of those turning points, you know, as you're trying to decide what to do within the sciences, maybe do something that's one of the healing arts.
Sandy Winnefeld:
So as you got into medical school and started down that long, torturous journey to getting to where you are, did you start by knowing you wanted to be in the emergency medical field, or was that something you sort of grew into as you navigated through that process?
Dr. Cedric Dark:
Absolutely not. The thing I actually thought I wanted to do was to be a surgical oncologist, sort of taking after my aunt's story. And then I got to spend a week or so before going to medical school with her son, who's the trauma surgeon, and realizing I didn't like waking up at 4:00 a.m. every day. I kind of went to medical school halfway afraid that I was going to like surgery and would be stuck with early mornings for the rest of my life.
And fortunately, every time I went to the OR during third year of medical school, I did not like it. And every time I walked downstairs to the ER to do a consult, no matter what the rotation was, I enjoyed that. So it clicked for me. At some point, I came to my senses and figured out that the better way of doing life is working daytime, afternoon, overnight, weekends, weekdays, holidays, non-holidays, just everything. It's so much better.
Dr. Sandra Magnus:
Yeah, I was going to say, you traded early mornings for a random schedule from emergency medicine. We'll get more into that in a moment. You also got engaged in policy and advocacy. What drove you to add that to your bag of tools?
Dr. Cedric Dark:
That was something that I wound up focusing on between third and fourth year of medical school. I think for most med students, you start seeing patients, and it feels good to finally, after a couple years of book work, to be able to take care of people. That was rewarding. But I think at the same time, it also felt somewhat limiting because you're only taking care of one person at a time.
And I happened to come across a program at Columbia that was being offered for medical students in the city of New York when I was there. And we wound up, I think, taking about 12 students through this thing called the Macy Scholars Program. They paid for our public health degrees. I wound up taking courses in health policy and management, focusing particularly on health policy.
I thought that really dovetailed nicely with what I wanted to do because, you know, being in the emergency department, it's like people would say it's like being the canary in the coal mine. You see all of society's problems in that one place. Whereas lots of other specialties don't necessarily have to witness that because the first question anyone is going to ask you when you call the doctor's office for an appointment is, "Well, what's your insurance?" And so that screens out a lot of the problems that the emergency department doesn't screen out.
So that's something that I've incorporated in. I mean, just probably last week, you know, I explained to a patient that one of the reasons I love doing my job is because I get to show up and take care of people regardless of whether they have insurance or not. I don't have to worry about the money. I don't have to worry about the cost. I just get to do the medicine. So that's one of the things that drove me towards EM and I think something that drove me into policy as well.
Dr. Sandra Magnus:
That's a powerful point.
Sandy Winnefeld:
Let's talk a little bit about the emergency room. You know, Sandra, as an astronaut and myself as a fighter pilot, we lived very operational lives. And to us, what you do is like the cutting edge of being operational in the medical world. So you're never quite sure what you're going to be faced with from moment to moment. What's that like? How do you manage the risk and uncertainty not knowing what's walking in the door in 10 minutes?
Dr. Cedric Dark:
Well, that's part of the fun of it is you don't know what's coming in the door. So you never get, I mean, you do get bored when things aren't happening and you're just sitting there at three in the morning and twiddling your thumbs. But you learn to recognize, let's enjoy this boredom while we have it.
You know, fun fact, and I'm highly jealous of Sandy there because I wanted to be an astronaut growing up. And I even applied for their 2013-ish astronaut call when I was moving to Houston. And I was like, "If I become an astronaut, I'll be in Houston. If not, I'll just work an ER job." And so I did not pass. I completely failed at that.
And I'm just going to name-drop one guy named Jonny Kim. I don't know if you know him or not, we like to call him, amongst my circle of friends, which includes some faculty at Harvard, an emergency medicine residency dropout. But this guy's like a Navy SEAL and now an astronaut. And I just was liking some of his photos on Instagram from ISS. So, yeah, this guy makes all of us feel really inadequate.
Sandy Winnefeld:
Just goes to show, if you can't hack it as a doctor, you know, if you can't hack it as a doctor, you might end up as a Navy SEAL or an astronaut.
Dr. Cedric Dark:
I mean, yeah.
Dr. Sandra Magnus:
Yeah, that's a good fallback.
Dr. Cedric Dark:
Yeah, I mean, I think it's similar to probably what you guys train on as well. Right? If you're a pilot, you've got to be ready for certain emergency situations to take place. And so you simulate a lot of that stuff. Same thing, you know, with spaceflight. Right? You have to be prepared for the worst-case scenario. And I think that's what emergency medicine does really well is we prepare for the worst-case scenario.
So the other day, you know, I had to perform sort of a life-saving procedure on somebody. And it's something that I would say I'm prepared for, but I also feel like I'm halfway prepared for it as well because of the fact that I work at a place where you have so many helping hands. Sometimes you get comfortable realizing that you're going to have help around you. Whereas let's say emergency docs in rural environments have to do so much more because they don't have that backup there.
And for us, I think being prepared for this is really important, that you focus on certain critical procedures that you have to do that are timely that can't be looked up. A lot of medicine, I hate to say it, can be Googled now. Not by ordinary laypeople, it can be Googled by people that know what they're doing and are trained to do it but just need a refresher before getting it done. But there are certain things where you don't have time for that refresher and those are the things that you really need to train on so that it's almost as hands-on, like riding a bike, kind of like memory, that sort of thing, physical memory, as opposed to having to think about it.
Sandy Winnefeld:
Many of our listeners have seen the TV series The Pit. I watched it almost continuously through. It was so interesting to me, the layman. As you mentioned a moment ago, how realistic were the emergency room presentations in that series? I don't know if you had a chance to watch it.
Dr. Cedric Dark:
I've never seen an episode, but I did watch some scenes of it because at our emergency medicine conference this past September, Noah Wyle came in to talk to us with Joe Sachs, who's an emergency physician that works on the show. And they showed some scenes from it that were amazingly realistic-looking, I would say.
Sandy Winnefeld:
Wow. I don't know how they did it. It's incredible.
Dr. Cedric Dark:
Well, they explained to us, and you know, it's the art of filmmaking and sort of having good sort of models and I guess, I don't even know what you call these things, but it's just like the makeup department and everything can do their work so well that when they're showing a person's face and then pivoting down, because they show like a baby being delivered, they essentially had it done in such a way that you think that it's real even though what you're seeing below the belt is fake. So it's very interesting how they can accomplish that.
And I think it went to show the level of detail that they have and that the creators of the show have in terms of getting it right from an accuracy standpoint, which is not easy. There are other movies and film that I've seen where they say they have a throwaway line. And one of my favorite ones to be annoyed about is in one of the X-Men movies where they claim that a person received a medication that made them appear dead. And it's not even the right kind of thing that you would use. I'm like, "This is a blood pressure medicine. It's not going to do anything. This is a diuretic. It's not going to make you appear at least..." Like, could you just call me on the phone and I could give you some options to make it sound better as opposed to just randomly pulling some drug off the pharmacopeia?
Sandy Winnefeld:
Well, I can tell you there are some cringe-worthy moments from the Top Gun movies. But, you know, they're still a good movie.
Dr. Cedric Dark:
I mean, yeah. I'd imagine that those things would look like, from your perspective, extraordinarily difficult. This is why I can't watch The Pit right now. Like, I do this all the time. I just, I don't want to like be put back into that. Thanks. So instead I watch the space movies and stuff like Top Gun. Love it.
Sandy Winnefeld:
When you do watch The Pit, send me an email and tell me what you think.
Dr. Sandra Magnus:
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Sandy Winnefeld:
One of the things I wanted to ask you about in that series is one of the premises, you know, the dramatic themes, is like a brand-new crop of residents shows up on that day in the operating room and what they progress through and, you know, without being a scene-stealer, a mass casualty event where they're actually doing tracheotomies and all this kind of thing. It would seem to me that a resident is pretty much doing baby steps and that there is a decent progression. Or are you just thrown into the mix right away as a resident?
Dr. Cedric Dark:
It's a little bit of both. I mean, I've journaled when I started residency. I remember reading back and I was like, "It feels like I was just thrown into the deep end of the pool." To some degree, yes. You're given a lot of responsibility that you don't necessarily feel ready for.
Then at the same time, I think the way we design medicine is it is graduated responsibility. We're not going to go ahead and give the person that's a one-day, one-day wonder, you know, doctor, the knife to do the crike. You know, so when I was mentioning sort of the life-saving procedure that we were doing, it was like an ED thoracotomy. The other day I'm working with an upper-level resident and our surgeons were not yet downstairs and we needed to get started on that procedure. So I'm there standing there and I'm telling the resident, "Go ahead and cut."
You know, we start doing that and to a degree from my view, it's like she looked like she knew what she was doing and all of that. And then you know, a couple hours later we're sitting in our room furiously typing notes because that's what modern medicine has turned into. And she's talking about how her hand was trembling and doing all this and I was like, "Well, I didn't notice it." I remember being a fresh attending out in practice and every time I would code somebody or do CPR on somebody, my hands are trembling too. Until the point, like nowadays, it doesn't happen anymore.
But that's part of the training I think too is sort of overcoming that nervousness when crazy things are happening and being able to suppress that. There's this book called The House of God, which, if you've never read, one of the famous quotes from it is, "The first thing you do when you walk into a code is check your own pulse." I think it just kind of goes to show: keep yourself calm in those situations.
Dr. Sandra Magnus:
I had to do medical training for one of my training sessions. We kind of did some EMT stuff, and it was harder for me to take somebody else's blood than my own blood because I was sticking it with a needle. Like, "I'm sorry. I'm sorry." To circle back for your training real quick, who decides what procedures you're going to practice? And how do you guys do simulations? I mean, because you don't really have a patient, do you, when you're doing simulations?
Dr. Cedric Dark:
That part is heavily negotiated between emergency medicine and surgery in certain places as to who does what procedures on real patients and everything. Typically, the way we have things set up on our shop is the surgeons get the left half of the body if we need to do a chest tube or thoracotomy, because that's something that realistically needs a surgeon's touch. The right side, if we need a second chest tube, we usually have that available for the emergency team to do.
Airway: back in the day, it might have been an anesthesiologist. In most places now, where emergency medicine exists, EM takes that. The rules we have set up for that is the emergency medicine resident gets the first shot. If they miss, I get the next shot. If I miss, the anesthesiologist is right there over my shoulder in these very serious cases to get it going. And then recently we had someone that was going to be in terrible, terrible airway, and the anesthesiology attending was standing there next to me, and we're talking about it, and we're like, "You know what? You just do this one." Because the plan that we needed to do was something beyond the level of training that I felt perfectly comfortable dealing with. And I think we all worked collaboratively in that situation to get it done.
Sandy Winnefeld:
And you're trying to balance, I would imagine, training with the best interests of the patient as well.
Dr. Cedric Dark:
I mean, exactly. That's what it's really about is you want to be able to train people, because if you can't train people, then the next generation isn't there for you when you need it. But then at the same time, you have to have adequate backup so that if things get difficult, the highest-trained person can handle it.
And to get to the point of how do we train, there's a lot of simulation. The simulation can be done on models or mannequins. Sometimes we have a cadaver lab, people that donate their bodies to science. You can do these kinds of procedures and practice in that situation. So you can at least see what the anatomy looks like and all that. It's very different in a live human being where there's blood and everything that's pouring. So that's the difficulty when you translate from mannequin to cadaver to live person.
Sandy Winnefeld:
I got a healthy respect for all that when I, believe it or not, was invited to assist when I was a squadron commander in a hernia operation that was performed on the ship. And they were just trying to brag, show me what they do. And I thought I was just going to watch. And they actually invited me in and, you know, I was cauterizing things and I actually sewed the patient up on the inside.
And what it gave me was a very healthy respect for not so much the technique and stuff, but you open that stuff up and there's a bunch of goop in there and somebody's got to know what that goop is. I hate to put it that way, but my respect for physicians, particularly emergency room physicians, skyrocketed after that. It was incredible. You know, without violating any protocols or anything like that, in your experience, what has been the most difficult situation you've found yourself in the context of an emergency room case? What really got your heart pumping?
Dr. Cedric Dark:
I mean, I think it's not the heart-pumping parts of it, it's the aftermath of that. I think that's really the more difficult situation. Having to inform a parent that their child is gone. Whether that child is an actual kid or even if it's a 30-year-old, that's the hardest part of the job, quite frankly. And I think it's something that no matter how many times you do it, every single one of these things goes differently because some people are going to react numb, some people are going to react loud and tearfully. There's one guy I remember who started punching at the wall. You don't know who's the person that's going to just take it and who's the person that's going to then be a threat to your own safety. And I think that's the most difficult part of emergency medicine.
Dr. Sandra Magnus:
Wow. Yeah, that would be hard.
Sandy Winnefeld:
And you know, you do that a lot. Your team has to deal with the emotional aspects of having to do this day in and day out, and not only informing people they've lost their loved ones but just dealing with traumatically injured people. I imagine you actually get a little numb to that yourself, or how does that work?
Dr. Cedric Dark:
You do compartmentalize a lot of it too, I think. But I think that some of that trauma gets stuck in your mind over time. So I vividly remember a patient who died by suicide by drinking acid. We thought we had things going, we thought we were in a good position, and then all of a sudden just stuff spiraled and went downhill. And then we lost the patient. And it was one of those things was like, "Did I do something wrong? Did I miss something? Did I do this right?" And I think it leads to a lot of introspection over the next few days. The fact that I remember this story from five years ago tells me how much that has impacted me in terms of sort of my lifelong pathway and journey.
There's a case I remember of a kid who got shot. And by this, when I say "kid," I mean we're talking probably 20 years old. They got shot in the neck area and more or less bled out. But we actually were able to get him going again enough to the point that they could get him to the operating room. And he made it to the ICU for a few days, but then ultimately expired. And that's one of those things. I wasn't sitting there in the ICU watching it, but go back and you read the chart a few days later and you realize all this life-saving effort you put into it, all for naught because someone wanted to shoot somebody else for whatever reason. You know, those are the kinds of things that stick with you.
Dr. Sandra Magnus:
So how do you deal with that? You compartmentalize it, but you still need to have a healthy way to kind of purge over time. So what's typical coping mechanisms that emergency room personnel use? I imagine ICU people have the same issues, but you guys are on the front lines.
Dr. Cedric Dark:
I think for most of us, and I don't know that we all have perfectly good coping mechanisms. I think, again, I think a lot of us probably carry this with us as sort of the burden of being physicians. I think one of the things that we can do is we do talk to one another because it's one of those spaces where we can explore this in a means where we're not violating anybody's patient privacy or anything like that. I think for a lot of emergency medicine, maybe trauma surgeons, dark humor is probably one of our biggest coping mechanisms too.
Sandy Winnefeld:
Is that a pun, by the way?
Dr. Cedric Dark:
That is not a pun, but that was a good ask. But I think a lot of it, for me at least, I think it's the compartmentalization of it. Having people that are in health care that are either your friends or family that you can discuss things with, or talking with your coworkers about it, I think is kind of where I think a lot of that leans. And then, you know, if you need to get a therapist and have a professional you can talk to about it, even if it's only to vent, because at least that's protected under your, in that case, patient-provider sort of relationship.
Dr. Sandra Magnus:
You commented earlier a little bit about the difference between a rural emergency center and perhaps a trauma center in the city. So what's the difference between the two? And what makes a trauma center effective and minimizes the most risk? Is it just the size of the team? Is it the number of cases they deal with? Because it seems like if in your rural area, you're in a little bit of a disadvantage.
Dr. Cedric Dark:
It's a little bit of all of that. You do have more bodies that can help, more hands to help. You have better training with people that are trained specifically to be in those roles. But then also they do it more routinely. And so we get used to the pattern of it.
There's this program called Advanced Trauma Life Support. It's something that occasionally I'll teach, but it's through the American College of Surgeons. And the reason it was founded was because I think an orthopedist was in like a plane accident in the middle of rural nowhere, and no one could really manage how to take care of him and his family at that point in time.
And they came up with this system of how we would train somebody that really doesn't have this as part of their day-to-day but make sure that they are capable of doing what needs to be done just to salvage somebody long enough to get them where they need to be. And that goes from the basic principles of what we call ABCs: making sure that the airway is protected, making sure that people are breathing, making sure they have circulation, blood pressure, and all that kind of stuff, and then worrying about identifying injuries after that, and then transferring them in an expeditious manner to wherever they might need to be.
And whenever you get stuck at a point, you kind of go back to that beginning of that algorithm and keep thinking about it that way until you finally get to where you need to get to with the patient. But the main thing that's always taught in all these classes is: the soonest you can get them out to where they definitively need to be, do so, because otherwise you're just putzing around and you don't want to putz around with somebody's life.
Sandy Winnefeld:
Cedric, we're going to move on to another serious topic that I know you care deeply about. But before we do, I have to ask you, you mentioned earlier about doing a lot of typing and I know the bane of every doctor's existence is typing up reports and stuff. Is AI moving into that field at all where you can maybe accelerate that, which would make much better use of your time, of course? Are you seeing any glimpses of that yet?
Dr. Cedric Dark:
There are what they call ambient AI scribes. So maybe like your doctor might wear a microphone on them and then AI listens in on the conversations and types up what you would type up in advance for you. So all you have to do is kind of go back and revise it, hopefully.
How I feel about that, I don't know. I don't know if I want the computer listening in on all these conversations. Theoretically they're HIPAA-protected, but who knows if they're just going to wind up somewhere in Grok or whatever and just get leaked out to the world? Who knows? I don't know. But that's my internal paranoia about this. Just too many sci-fi movies.
Sandy Winnefeld:
It's a real thing. I mean, I think you're wise to think about that.
Dr. Cedric Dark:
Yeah.
Sandy Winnefeld:
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Dr. Sandra Magnus:
We're going to shift a little bit to your book. You wrote Under the Gun: An ER Doctor's Cure for America's Gun Epidemic. And you share stories of dealing with gun violence in emergency rooms. And I think you had some particular motivation for writing that book. Would you care to share that with our audience?
Dr. Cedric Dark:
Yeah. The main reason that this book got written was because the NRA decided to tweet out in 2018 that physicians need to stay in their lane and not talk about gun violence prevention, which most of us that actually deal with this on a day-to-day basis, especially those of us that have advanced training in the policy side of it, we were highly offended by that remark and fought back with a hashtag called #ThisIsOurLane.
And maybe 30,000 or so of those hashtags went out in like two weeks after this had taken place. I was part of that group of people that were writing op-eds and maybe doing some media interviews here and there talking about why physicians do have a right to talk about firearm injury prevention. And then maybe a year or so later, a colleague of mine reached out and was like, "You should write a book about this." And I really didn't want to, and she kind of tricked me into doing it.
So if you look at the book, you'll see Seema Yasmin's name in the really small print. She told me she was going to be my coauthor, but then when it came down to it, she was like, "Okay, I got you going, you know, pushed you on your way." So she's like, "My name doesn't really need to be on there." I was like, "Well, it needs to be on there because you did write some of it. We'll have mine big and yours small." And that's sort of what happened. It's all Seema's fault that I wrote this book, quite frankly, because otherwise I probably would have just stayed on Twitter harassing people on Twitter. That's kind of what I was doing back then. Then I spent the next five years writing a book.
Sandy Winnefeld:
Wow, five years. You found out how hard that really is.
Dr. Cedric Dark:
Yeah, it was. We signed the contract with Johns Hopkins Press in the end of 2019, and I thought, you know, I could get this done in the next couple of years, have it published in time for like the 2022 midterms. And then COVID hits. I'm like, "Okay, maybe I should do other things like take care of patients and trying not to die," you know, that kind of thing.
But I've never written a book like this before. The process is a long-ish process. During that timeframe, I happened to read President Obama's book A Promised Land. And like, in the beginning of his, he talks about how it took him five years to write it. So now I don't feel bad because I don't have the resources that the president of the United States has. I got it done in the same amount of time.
Sandy Winnefeld:
Well, at least you didn't have to go through the Department of Defense vetting process to make sure you didn't have anything classified in there. I'm really interested in hearing what you express in the book because I've got two confessions: I have not read the book, but on your website, there's a very interesting statement that I think a gun owner like me actually would very much appreciate. It says, "We are not anti-gun, we are anti-bullet holes," which I think is a remarkably prescient and mature approach to this whole problem. Tell us a little bit about what specific policies that you have in mind that could save lives by helping prevent gun violence in the first place.
Dr. Cedric Dark:
Yeah. So first of all, let me give all credit to Dr. Esther Choo for that statement. She tweeted it out one day and the rest of our group kind of rallied around that, and she allowed me to steal that for all eternity to use.
There's many things that are evidence-based and proven based on the RAND Science of Health Policy textbook that you can find on their website. And just a few of the ones that are out there: there's these things called domestic violence restraining orders. If someone has this restraining order placed on them, not only does it say, "You need to stay away from the person that you are abusing," but we also allow police to go in and remove guns from that situation. And that's extremely helpful to prevent intimate partner homicide.
Things like background checks help reduce homicides. And the problem that we have in today's society is that about 22 percent of all firearm transactions are done privately without intervention with a federally licensed dealer. If you're the one out of five persons that wants to get a gun and probably doesn't want to go through official channels, you go buy it privately. I imagine there's more people that want to do that that happen to be criminals than people that are trying to go to the store to buy it. So that's one thing.
One of the most effective ones we can focus on is safe storage or child access prevention. It helps reduce unintentional deaths from firearms. And then it gets into some more controversial items too. You know, one of the things when you read it, I never argue for anything like an assault weapons ban because the science of gun policy doesn't say that that's necessarily effective. And we could probably get into sort of things like power calculations and mathematics and stats if you wanted to, but I imagine your readers would be bored of that because it's an adrenaline-zone podcast, not like a statistical podcast. And that would bore me to tears having to hear about math.
But in one of these editions, it went from the third edition to the fourth edition of this book by RAND, it actually talked about banning large-capacity magazines. And I think that kind of makes intuitive sense that if someone has to reload a little bit more often than not, maybe you can reduce the number of people killed in a mass shooting. And so that's one of those things in there.
And one of the last ones that I do want to mention is Stand Your Ground laws, which, you know, I'm also a gun owner too. I don't carry, but for those that do carry, they have a right to protect themselves in their home. Some states, you can protect yourself in your car. Other states make it any place where you're allowed to be. And I think what that opens up is a situation, especially like in Houston where driving is terrible. You get into a road-rage incident, you get out of your car and you start talking to the next person, the person makes you feel threatened. Now you're authorized to shoot them. And I think that's where we could see that some of the things that we do in our society might be a little bit too far. And I would argue maybe we should pull some of that stuff back.
Sandy Winnefeld:
And that's the problem is, of course, that there's this slippery-slope thing where some people will say, "Well, you put one restriction on, you're opening the door to like total banning of guns." And I don't think that's what any of this is about. And I think there are some pretty reasonable things you can do that you probably have in your book that would dramatically reduce gun violence and so you don't have to see it so much in the emergency room. That's the whole point.
Dr. Cedric Dark:
No, absolutely. I list out the things that are evidence-based and kind of leave out everything else that might be considered common sense or whatever people want to call it. I'll give a little bit of a preview. There's a group at Tufts that's been working on something with folks like you, either gun owners, or folks like me that are more on the gun-violence prevention or the injury-prevention side of things, and actually getting us all together in one room. And it's maybe about 22 of us, I think, and we voted on all these different policies. We came up with a list of policies, like eight different policies that may be helpful, also evidence-based, that could save people's lives. It's not yet ready for release, but I just wanted to kind of tease that and put it out there.
Sandy Winnefeld:
Well, that's a really interesting concept. In the drug-overdose prevention world, and I have a drug-overdose prevention nonprofit, getting those two sides together, we call it "getting the meat eaters and the leaf eaters together." Surprisingly, it works. You know, you can get law enforcement and you can get people who are advocates for needle exchanges and that sort of thing in the same room and they actually can start agreeing on things. So I think you've got a really good project going there. That'll be good.
Dr. Sandra Magnus:
What are the major barriers that you think are in addressing some of these issues and some of these, you know, the implementation of these policies that you think would be most effective? Is it ignorance? Is it lack of willpower?
Dr. Cedric Dark:
Politics. It's politics. I don't think it's necessarily ignorance. I think that people can recognize what will work, what won't work. And I think just having conversations. I remember having a conversation with one of the panelists over ERPOs, or Emergency Risk Protection Orders. Some people call them red-flag orders.
You know, that person brought up their concern over due-process issues and we had a conversation about how that really goes into play there. And I think it was interesting because on one side they saw, and I can't remember whether it was the homicide aspect of it or the suicide aspect of it, but on one side that person saw that it was possibly useful and they could get behind. On the other side they couldn't get behind. And it just took having that conversation to be able to get to a point where we could finally get something to happen.
We are terrible at doing that in today's public forum because our politicians are so polarized and they will not have conversations with each other on anything of substance for certain polarizing issues like this. We live in this age of social media where any quote or soundbite gets taken out of context and circulates around the world within an hour, as opposed to quote unquote back in the day when our politicians could sit in the cloakroom in the Senate and smoke cigars and probably drink themselves into a stupor and have a conversation that no one knew about and then could come up with a compromise.
And I think that's one of the things why this process has been helpful, because I think it can get the politics out of it and get people that just want to fix a problem to discuss it in ways where they don't have to cater to their constituency.
Sandy Winnefeld:
Cedric, you've written a lot about something I'm not sure I understand called freestanding emergency departments. Can you explain that to our listeners? What they are and the pros and cons of those compared to, say, a hospital-based emergency room? Is one riskier than the other or more efficient? Tell us about that.
Dr. Cedric Dark:
The way I think of a freestanding, and we have a ton of these in Texas, it's one of the places where they originated, I would say, or at least started the more modern proliferation of freestandings. It's everything that an ER needs to have, except there's no hospital upstairs. That's essentially all it is. And it's a way of thinking of me as an emergency physician having my own office per se as a primary care doctor.
If they need an office, they go buy an office and they get a nurse and some exam rooms, and they do whatever they would want to do there. For me to do that, I need to have a CAT scan, a small lab, an X-ray machine, an X-ray tech, and maybe access to an ultrasound. So I have more equipment that needs to be there, which is why a freestanding ER tends to be more expensive than something like a doctor's office or an urgent care. But it allows me to do everything that I could do in the hospital.
The only thing I can't do is send the person upstairs. So it'd be bad to go there for a trauma, like a major trauma where you need like immediate surgery. But for those things that you don't need immediate treatment for, even if you're having like pneumonia and you need to be admitted to the hospital, it's still not a bad place to be because once you're seen, once you get put on oxygen, you get your X-ray, your antibiotics get started, then someone can look to transfer you to a hospital for the rest of your hospitalization.
You know, a lot of the hospitals and corporations out here have started to do this as more of like a hub-and-spoke type of model, where you have the mothership in the center, and then you have little freestanding spokes way out in different communities to try to bring people into your mothership.
Dr. Sandra Magnus:
Wow. There's different ways we can go with this. A first question is, you know, this is a problem for the patient if they don't know which one to go to and they need to be followed on. And then Sandy will lead in, I think, with the next question, talking about the fact that people use emergency rooms in a way that they weren't really originally intended because of the insurance thing.
So let's go with the first question first, and then Sandy can hop in. You mentioned before that a good trauma center has the ability to move the patient on, but the freestanding ones can't.
Dr. Cedric Dark:
So I like to look at it from, and I wrote a letter to the editor about whether or not we should have freestandings in rural environments. When you think about how a lot of rural hospitals are closing, is it important to have access to emergency care that's close by, even if you don't have a full-fledged hospital?
And I would argue yes, it is. Because if you think about it, most likely five out of every six patients that goes to an emergency room goes home. They don't get admitted to the hospital. And so for those five out of six patients, having that facility close to where they live is helpful. For the one out of six that needs to be hospitalized, again, we're still able to do what we need to do for the vast majority of those people.
Even if you're having a heart attack or a stroke, if you could get that initial treatment started closer to home at a freestanding and then get transferred in to the major stroke center or cardiac cath area, you're going to do better most likely than if you had to drive an extra two hours to get there. And I think that's the thing that people may not think about. In my opinion, having access to emergency care is the most important thing, and having access to emergency care closer to home is important. Now, do you need five of them on the same corner? No, probably not.
There's literally an area, a suburb of Houston, where probably, I think it's within like a two- to four-square-mile range, you have six different freestanding emergency departments, or five freestandings and one full-size hospital. But that's because the way Houston is set up, we have all these different competing entities. And so once one gets a foothold, the rest have to put their tentacle there too.
Sandy Winnefeld:
I would think that having the satellite freestandings would loosen the load on the high-end, if you will, the ones that really should be getting all the trauma cases without having a crowded emergency room with a lot of people in there, maybe freeing up space and time and capacity for those.
You mentioned the number of people going to emergency rooms because they can't afford health care and how that's kind of satisfying for you because you don't have to ask them questions about money. But there has been a lot in the news about health care costs and the U.S. spending far more per person and a higher share of GDP on health care than say Japan, Australia, Germany, but doesn't really achieve better overall health outcomes. What would be your "policy prescription," if you'll forgive the pun, for maybe what we could do to get this under control?
Dr. Cedric Dark:
That's one of probably the most difficult questions of our era. I have no problem with you asking me for policy prescriptions because I actually trademarked that phrase several years ago and blogged under the title "Policy Prescriptions" for a long, long time.
Sandy Winnefeld:
Duly noted.
Dr. Cedric Dark:
I welcome that one. I would say the main thing, and we're dealing with prices mostly, so the cost of health care largely is due to prices. And the great, late health care economist Uwe Reinhardt out of Princeton has this saying of: "It's the prices, stupid." Because no matter what it is, we're paying more per unit cost than any other country.
Now, how do you get those prices down is the complex problem that we have to deal with because is it because doctors make too much money? I would argue not really. Is it because pharma makes too much money? Is it because the health insurance companies make too much money or the hospitals make too much money? I think if you ask any of those industries, they'll probably say, "No, not really."
I do think we do have a problem with profiteering in health care. And especially as we've seen things like private equity entering the health care space, we've seen that. But I ran across like a startling statistic. There's a JAMA Internal Medicine article that came out back in February that talked about, from these companies in the health care sector that are S&P 500 companies, they've given $170 billion to shareholders. And when you factor that in to the size of our health care economy, that's about 4 percent of every health care dollar is going to a shareholder just on those S&P 500 companies. So how much more, percentage-wise, is being siphoned off for profit elsewhere? So I think that's one thing we have to deal with.
I think another thing too is we probably do have some overuse, you know, low-quality care, low-value care as people would like to call it. People getting antibiotics when they have a virus, people getting whole-body MRIs like Kim Kardashian, you know, stuff like that. Do we really need to be spending our money there or should we be spending it on other things?
But how do we get those costs down? That's a really complex answer. And it may not be as simple as some people would like to argue of, you know, "Let patients have more skin in the game," quote unquote. Because even though you can make a reasonable decision about whether or not you want to buy one car versus another car, you can't do that when you're having a heart attack and say, "Well, I want this stent versus that stent." Because first of all, do you even know if you need a stent? The doctor probably doesn't know that you need the stent until you're actually in the middle of the procedure looking at the blood vessels.
And then if the stent costs X dollars or Y dollars, like, who knows about that? It's certainly not you, the person on the table, to be able to say, "Please give me the discount stent instead of the gold-plated one," that kind of thing. And so there's some areas where, you know, having sort of price transparency will be helpful. We've seen this with like LASIK eye surgery and elective procedures. Right? That stuff you can shop for, but you can't do that when it's your money or your life.
Sandy Winnefeld:
Cedric, you are in the middle of a remarkable career, both as somebody who's an emergency care physician, but also somebody who cares about the profession enough to write about it. So you probably have some views on advice you would give young people in medical school in terms of preparing them for their generic medical career, but also specifically for emergency care. Any thoughts on what you would tell your young self as you were getting in?
Dr. Cedric Dark:
Do what you enjoy doing. I think it's one of those cliché things, right? If you love what you're doing, you'll never work a day in your life. But I think it's true. Like, as long as you enjoy doing what you're doing, then getting up and going to work will be rewarding for you and it'll hopefully stave off things like burnout.
One thing I would definitely encourage every single person that's going into medical school is to go to wherever the money is. If you want to go to San Francisco because you think it's the coolest place on earth and you know you have family there and all that kind of stuff, but then Iowa is giving you a full-ride scholarship, go. Go to Iowa. Take the money. Because medical school is expensive. You're going to be deferring income for a long time. And with the way student loans have gone lately, it's been one of those things that you just don't want that hanging over your head.
I literally just paid off my student loans like last year. And you say, "Wow," but it's not that bad because when I happened to finish, the interest rate on my student loans was like 1.6 percent. It was so low that I gladly would have taken more money at this point if I knew then what I know now, because I will never get access to money that cheap ever again. But student loans these days are nowhere near there. And so it doesn't make sense for people to do that.
And I think the third thing is when you get out of residency, you know, pay yourself first. Start saving for retirement now because, again, we've already in the medical field been deferring life for an extra four or five years. By the time you finish residency, it's going to be like almost a decade behind your peers and now you're starting to play catch-up. So at least start trying to save some money for retirement in residency, because the last thing you want to do is keep practicing until you're 70, 80 years old because you have to. If you love doing it, great. And I took care of a 90-year-old doctor the other day in the ER. I want to be like that guy one day where you're still well enough to be up and around, moving around and have your wits about you and all that kind of stuff. But I don't want to do it because I have to pay off some bills. I want to do it because I enjoy it.
Sandy Winnefeld:
Sandra told me she wanted to be a 90-year-old astronaut, but I don't think that's possible. I mean, we're getting close. We've had some pretty old people go into space, right?
Dr. Cedric Dark:
Well, we might have to move everybody to Mars one day. Who knows?
Dr. Sandra Magnus:
It would be nice to see some people heading there during my lifetime, but we'll see. We really appreciate your time. I feel like I could talk to you for hours more on some of the things that you've done and some of the thoughts about health care because that is a tangled thing. But I think we'll probably just shut it down here. And thank you very much for being a guest. It's been really wonderful listening to your stories and getting some insight into the issues that you're working with.
Sandy Winnefeld:
And I think I speak for both of us in saying thanks for what you're doing. You've sacrificed a lot to get to this point and you're doing difficult things every day in a tough environment. We really do appreciate it. So thank you.
Dr. Sandra Magnus:
Absolutely.
Dr. Cedric Dark:
Well, thank you very much.
Dr. Sandra Magnus:
That was emergency room physician Dr. Cedric Dark. I'm Sandra Magnus.
Sandy Winnefeld:
And I'm Sandy Winnefeld. Thanks again to Culligan for sponsoring this episode. Get exceptional water for exceptional performance. Learn more at culligan.com and join us next time for another episode of The Adrenaline Zone.