Scene 1: Preface to the Book "Other Possibilities"
2025: What I Learned from a Patient in Room 9 and a Forgotten Physician from the 1890s
I could hear Ms. Wilson’s moans of agony before I entered her room. She was one of many patients I was caring for that day in the emergency department. A nineteen-year-old had overdosed on Tylenol. Would she need a life-saving antidote? A middle-aged woman who was intoxicated had fallen onto her chest. Did she need a tube urgently inserted into her thorax to correct a collapsed lung? A desperate mother of four, living with chronic headaches, now said this was her worst ever. Could it be different this time—a ruptured blood vessel, bleeding inside her brain?
But those patients would have to wait. My attention was on Ms. Wilson in Room 9. The chart read “severe back pain.”
Grimacing, Ms. Wilson shared her story. The pain had started three days earlier, suddenly, and had worsened to the point she could barely get out of bed. She was scared. Scared she wouldn’t be able to use the bathroom or feed her dog. The pain felt like a knife, stabbing her in the midline of her back and radiating to her right side. No injury. No fever. No prior episodes. Movement made it worse. Her bowels were normal.
My questions were designed to identify the cause of her pain—or more importantly, to rule out life-threatening conditions. “Any new weakness or numbness? Have you lost control of your bladder or bowels?” She shook her head. That made a surgical emergency much less likely.
I listened to the rhythmic beat of her heart. No murmurs, no irregularities. I pressed gently on her abdomen. No tenderness. No swelling. That made an abdominal aortic aneurysm, an enlargement of the body’s main artery that could rupture and cause fatal bleeding, much less likely. Her muscle strength was strong and equal on both sides. I pressed along her spine, flexed and extended her legs, but couldn’t reproduce the pain.
I left the room confident there was no life-threatening cause for her symptoms. Maybe it was a kidney stone. Or a bulging spinal disc compressing nearby nerves. I sat down at my computer and ordered medications: ketorolac for inflammation and morphine to make her more comfortable. Then I reviewed her medical records.
What I found shocked me.
Ms. Wilson had visited six different emergency departments a total of nine times over the past four months—each time for incapacitating back pain. Each time, the doctor on duty had ordered strong opioid pain medications, sometimes imaging tests, and then sent her home.
I was humbled, and a little horrified, to realize I had been one of those physicians.
I canceled the morphine order and walked back into Room 9. When I asked Ms. Wilson about her prior visits, she broke down and wept.
Her husband had died five months ago. She was devastated. Isolated. She had no one to turn to.
Yes, she had back pain. But that wasn’t the main reason she came to the emergency department.
She came because she was lonely.
The opiates dulled her physical pain, and the emotional anguish of her loss. So did the human connection, brief as it was, in the ER. Ms. Wilson didn’t need an IV full of pain medicine. She needed someone to listen. She needed people. She needed connection.
This Book
Ms. Wilson’s experience is emblematic of the enormous challenges facing our country’s health system. In communities, clinics, and universities across the nation, professionals work hard to improve health, but the system isn’t built to deliver the outcomes we truly want. No matter our politics or profession, we all want our families and neighbors to be as healthy as possible, at the lowest possible cost. We want them to be well, in body and mind. Yet that’s not what we get.
We all rely on, and pay for, a system that no one would design.
Today the need to reimagine and recreate our health system is greater than ever. It seems that most are at least superficially aware of the statistics. Our life expectancy lags behind similar countries, though we spend almost twice as much for healthcare. The number of people experiencing depression among adolescents and adults rose 60 % from 2013 to 2023. Medical debt is a leading cause of bankruptcies. The percentage of people reporting at least one chronic disease—such as high blood pressure or diabetes—increased from 52.5% in 2013 to about 60% in 2023, with the sharpest rise among young adults. Black pregnant women are up to 3 times more likely to die in childbirth than white women.
These statistics barely scratch the surface of what’s wrong—and what’s possible—in our health system.
A few years ago, I set out to understand how we ended up here. I quickly realized we’ve inherited a tangled web of incentives, assumptions, values, institutions, and communication norms that stretch back over a century. Most of the forces shaping our system were set in motion more than 100 years ago, in a very different world. And today, many people feel stuck.
This book tells the true story of two physicians—Lawson Scruggs and Hubert Royster—who began their careers in the late 19th century, a moment when the roles, institutions, and ways of thinking that shape health today were only beginning to be established. But their struggles and aspirations remain strikingly familiar. Like us, they were trying to improve health by changing minds and organizations. Like us, they were imperfect, flawed and biased.
This is their story. Every scene, every action, every quote comes from a historical source. They showed us that change is possible, though it comes at a cost. This is also the story of our health system. The late 19th century was a moment not only possibility, but transformational change—technological breakthroughs, social upheaval, and institutional birth pangs opened the door to sweeping transformation in both health and medicine.
Today is also a moment of possibility. Will it be a moment of transformational change? I see the need everyday in the emergency department.
This book is my attempt to understand how decisions made over a century ago still shape the health we experience today. Things didn’t have to turn out this way. Many of the changes were beneficial. But things could have turned out far better.
I hope that you’ll subscribe and read and comment and share. I hope that together we can finally catalyze the transformational change in our system that we all need. It feels daunting.
But it was daunting over 100 years ago as well, and they did it. There is much that we can learn from their experience.
NEXT SCENE
Sources and Notes
https://ourworldindata.org/grapher/life-expectancy-vs-health-expenditure
https://www.cdc.gov/nchs/products/databriefs/db527.htm#Summary
https://www.cdc.gov/pcd/issues/2025/24_0539a.htm?utm
https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm
“Things didn’t have to turn out this way.” Possibly the worst pain point to be experienced interpersonally that manifests within our systems, especially healthcare.
I’ve sat in more than one meeting with clinical staff talking about who could/should be doing what, why something took longer than it should and how frustrating it is to care about patients and see them not getting what they could be. And this was all in small, private medical office settings!
Operational efficiency is hard enough with a small group, but not impossible. But hacking that for an entire health system? Extraordinary. I’m very interested to keep reading ! Love the anecdote and easy-to-follow organization thus far. Can also feel your passion propelling the words.
I read and enjoyed the Preface. It brought to my memory the book My Grandfather's Blessing written by cancer physician, Rachel Remen, and her experiences in healing and serving her patients to restore wholeness.