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This safety-net hospital doctor treats mostly uninsured and undocumented patients

Many of Ricardo Nuila's patients at Houston's Ben Taub Hospital are dealing with serious illnesses as a result of not being able to access basic preventive care. His new book is The People's Hospital: Hope and Peril in American Medicine.




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This is FRESH AIR. I'm Terry Gross. There are private hospitals and nonprofit hospitals, and then there's safety net hospitals with the mission of treating all patients whether they have insurance or not. My guest, Dr. Ricardo Nuila, is a doctor at Ben Taub Hospital, the largest safety net hospital in Houston, one of America's most diverse cities, located in the state that has the nation's largest uninsured population. Nuila says he's felt the injustice of a patient dying after he was dropped by his insurance. And he's also seen patients hit with unexpected medical bills showing arbitrary prices after visiting the ER of a private hospital.

His experiences at Ben Taub and how the doctors and nurses manage to give quality health care at low cost is the subject of his new book, "The People's Hospital: Hope And Peril In American Medicine." The peril relates to his critique of the American health care system, especially expensive health insurance and the risks facing the uninsured. Working at Ben Taub Hospital, he writes, connecting with patients has meant he's not only had to perform all his duties as a doctor, but has had to uncover and understand the policies that both limit and enhance his patients' care.

Dr. Nuila is the son of immigrants from El Salvador. His father is an OB-GYN. His grandfather was a doctor in El Salvador. In addition to his work as a hospitalist, Dr. Nuila is an associate professor of medicine, medical ethics and health policy at Baylor College of Medicine, where he teaches the practice of hospital medicine and directs the Humanities Expression and Arts Lab, which integrates the arts and humanities into medical education. He has another career as a writer of fiction and nonfiction.

Dr. Nuila, welcome to FRESH AIR. What do you like about working at a safety net hospital?

RICARDO NUILA: I like that I can focus on medicine. I like that I have the time to be able to hear my patients' stories, that I don't have to think about billing all the time, that I can sit with them and hear about why they came to the hospital and learn about their lives, and that no matter what, we are going to be thinking about how best to help them, regardless of whether they have insurance or not.

GROSS: Well, you said you like to - you like having the time to listen to your patients' stories and having more time to spend with them. Why do you have more time for that than doctors at for-profit and nonprofit hospitals?

NUILA: Well, first of all, at the safety net hospital where I practice, we have a cap of patients that we can see, each of us, every day. For instance, my cap is 15 patients in one day. If I'm at 14 patients, I can only take one more admission. That's compared to some of my colleagues in the private world, who I've heard admit up to 24 patients in one night or don't carry a cap. And so that restriction of patients per doctor is something that allows me to organize my day and also allows me to think about, you know, where I can utilize my time.

GROSS: Why is it that you can spend more time with patients when you're trying to operate at a lower budget than private and nonprofit hospitals?

NUILA: Well, I think that the safety net model is to utilize the resources that you have. And what I've learned is that we have quite a bit of resources at our safety net hospital. So there's not a pressure to utilize more medical services. There is a pressure more to utilize what we have. And a lot of times, we found that that's enough. For instance, on my daily practice, I'll often find that an MRI or extra imaging - when it's available at the push of a button, it just generates more and more expenditure and more and more time for a patient, more and more data that needs to be interpreted. But if you're able to arrive at that answer without the extra testing, well, that gives more time and more focus on the patient.

GROSS: You know, you've gotten to see a lot of diseases and conditions that most doctors don't get to see. Is that because people who are poor and lack adequate health care are subjected to diseases because they have no preventive care and no follow-up care?

NUILA: I would say so. I think that one of the common things that we see in the safety net hospital where I work is that patients present for the first time to a health care facility, and we already find that their cancer is widespread, or we find that they have an infection that has not been treated or discovered. And so what we see is that patients' lack of health care has meant that the disease has been able to grow within their bodies.

GROSS: So give us an example of something you've seen that is pretty rare and was a result of somebody lacking adequate health care.

NUILA: There was one patient that comes to mind who - she was in her early 40s, and that's what the chart said. But when I went and saw her, she looked a little bit older than that. She was sitting with her partner, who I found out was in his late 30s. And what she had was that she was not able to control her urine. She was not able to - she would be urinating over herself. And she manifested signs of dementia - early dementia.

Now, when I saw her, in my mind, I was thinking, well, this could be a very rare form of early Alzheimer's or something called Lewy body dementia. But what I found was - is that this was the result of multiple, multiple strokes occurring in her brain because of untreated diabetes. When diabetes is allowed to run rampant, it can manifest in, you know, little strokes that can affect the heart or that can affect the brain. And in her case, she had the effects of - what we would find in somebody who is a 90-year-old with with Alzheimer, she had those in her early 40s.

GROSS: So, you know, in terms of conditions that you don't typically see at a hospital, but you do see at a safety net hospital like yours, because patients problems have gone untreated because they don't have insurance - you saw a patient who had something called dry gangrene. Can you tell us about that case?

NUILA: Sure. Well, Roxana is a patient that I met in the Ben Taub ER. She had ended up at the Ben Taub after she was diagnosed with a heart tumor that had wrapped around her heart and around her liver. It had sprung from her - one of the major veins in her body, and she had to go as an emergency to a private hospital, where a surgeon was able to take that tumor out. Literally, that surgeon was one of the best surgeons in the world. And that's one of the things that's remarkable about the health care system, is that we do have surgeons like this in this country.

But she suffered a very, very profound complication from her surgery. That's rare, but it does occur - that when the tumor was incised, it released a lot of cytokines or molecules that signal to the body's circulation to clamp down and guard the vital organs. And it clamped down on her limbs. And what resulted is that her arms and legs started to die or wither. They looked like charred wood by the time I saw her because all of those cells were dead. And...

GROSS: That sounds that sounds really, really severe and quite awful. But she wasn't able to get the follow-up care that she needed because her condition was now described as chronic...

NUILA: Correct.

GROSS: ...As opposed to, like, an emergency. So she couldn't get treatment at an emergency room. What were the implications of it being described as chronic?

NUILA: Well, the implications were that the hospital and the doctor couldn't receive - couldn't tap into a fund to reimburse the care that they provided. She was - she qualified for something called emergency Medicaid. That's a fund tapped for people who don't have health insurance in emergency situations. But once she became chronically ill, once that tumor was removed and she was now having dry gangrene, which was, quote, "stable," now she no longer qualified for emergency Medicaid, and now she became a chronically ill patient.

GROSS: But you were able to treat her at the safety net hospital?

NUILA: Yes, we were able to treat her at the safety net hospital because the bar is much different. When she came to the emergency room, you know, the question is, can we help her? And underlying that question is, is this person going to need health care in the future? Is this a problem that requires care right now? And so she was admitted to the hospital, and we found a way to get her to have elective surgeries with orthopedic surgeons to remove those limbs, which is what she wanted.

GROSS: And she was able to get prosthetic legs but declined to have prosthetic arms. But she was able to function after that and wasn't walking around with, like, dead limbs.

NUILA: Correct. She had those limbs removed. And by the time - I met her once at her graduation from occupational therapy, where she had phone-called herself to a bus to pick her up. It brought her to the therapist. And she was able to be very self-sufficient because of the help of the public health care system.

GROSS: Since this safety net hospital, where you work, mostly treats patients who are uninsured - they don't have private insurance. They don't have Obamacare. And they don't have Medicare or Medicaid. So how does the hospital pay for all of this? How is it funded?

NUILA: It's funded through property taxes. And so every - people like me who own land in Houston, Texas, and Harris County, a small percentage of our taxes goes toward a hospital district. And that takes in taxes the way that a school district would in - to be self-sufficient and in order to fund this public health care system in Houston, Texas.

GROSS: Let me reintroduce you. If you're just joining us, my guest is Dr. Ricardo Nuila. He's the author of the new book "The People's Hospital: Hope And Peril In American Medicine." We'll be right back. This is FRESH AIR.


GROSS: This is FRESH AIR. Let's get back to my interview with Dr. Ricardo Narula, author of the new book "The People's Hospital: Hope And Peril In American Medicine." It's about his experiences working at Ben Taub, a safety net hospital in Houston that treats the poor and uninsured as well as patients who have insurance. It's part of Houston's largest medical complex.

Abortion is now outlawed in Texas. It's a very harsh law. There is a carve-out for the exception if a mother's life is endangered. How has this affected people coming to Ben Taub?

NUILA: That's a...

GROSS: And I'm interested in how it's affected the patients who come there and also what doctors have to think about because they can be sued - I think they can face criminal charges if they provide an abortion or anything that Texas would consider an abortion. And my understanding is that the definition of putting a pregnant woman's life at risk is kind of fuzzy.

NUILA: I can speak from the doctor's side because honestly, I - you know, in my work at the - as a hospital medicine doctor, I don't interact with patients about this. And it's - the law is so new that it's been hard for me to get a grasp from patients coming in about this. But from the doctor's side, it is very confusing, and it's difficult for my colleagues to know if they're going to be breaking the law by trying to help out an individual, a person. And so - and it also confuses research goals. At the end of the day, it confuses that patient-and-doctor relationship. And that's what's very concerning.

GROSS: A lot of undocumented people live in Texas, which is just across the border from Mexico. They're not eligible for Medicaid. Are you allowed to treat undocumented people at your hospital? Is that considered illegal in Texas?

NUILA: It's not considered illegal. In fact, there's been politicians who have raised problems with the idea that we would care for people on a ongoing basis. Now, the law EMTALA, the Emergency Medical Treatment and Labor Act (ph) that was passed in the 1980s, that states that anybody in the United States, whether you're a resident or not, whether you have health insurance or not, can go to a hospital and receive a exam and stabilizing treatment. So that's a right that everybody in the United States has regardless of citizenship.

What's different about the safety net hospital is that we have clinics and we have chronic care also. And that was under question by certain politicians who ultimately found that it didn't make any sense to question that because when you get in the way of preventive care, when you get in the way of primary care, those patients end up coming to the emergency room, and they become much more expensive. So those two opposing ideas created in the politicians, you know - they had to yield to something. And so they decided that the financial gains were more important.

GROSS: Isn't it a public health risk, too, of people walking around untreated for diseases that might be communicable?

NUILA: Definitely. And that's one of the things that we at the hospital care for. I see a lot of patients who have tuberculosis, for instance, or other illnesses that affect all of us in a city. And so we need a public health care institution in order to assure that all of us are safe.

GROSS: What's it like when you have to explain the really complicated American health care system to undocumented people from other countries who don't understand what they qualify for and what they don't, and why they're going to be rejected from certain health care?

NUILA: You know, it's very different for every person. You know, some people understand because they've felt illness in their own family. I mean, the patients are also so different because some have had, you know, multiple family members in the United States before. So they understand the landscape a little bit better. But yeah, it can feel very, very contradictory when I tell patients that, well, you need health insurance for that. And they will say sometimes, well, in Mexico or in Guatemala or whatever, I don't necessarily. And it's hard to explain that, that in the richest country in the world, there's little available for people without health care insurance.

Now, I'm happy that in Harris County, where I work at Harris Health, we can provide a robust set of services. But that's - you know, somebody who lives outside of the county doesn't have availability for those services. And that's one of the things that I've argued, is that the line between Mexico and the United States is not as important as the line between Harris County and Fort Bend County, for instance, in some of the treatments that we give to patients.

GROSS: Your parents are immigrants from El Salvador. You grew up with Spanish. Although, you say you speak it now like a gringo because...

NUILA: (Laughter).

GROSS: ...You learned English so quickly. And that became your language. But you still do speak Spanish. Is it helpful to you to be from a Salvadoran family when you're dealing with people who are from Latin American, Spanish-speaking countries?

NUILA: Oh, no doubt. And, I mean, that's one of the reasons that I love my job and I love the hospital where I work at, is that I can speak Spanish. And even the - maybe I'm a little bit rough on myself to call gringo. But I do hear the accent that I have. I wish that I had a perfect accent in Spanish. But the people are so happy to hear somebody attempt to speak their language and not just, you know, on a translation basis, but the flavor of the language. And also thinking about the locations from where they're - you know, for instance, when I ask somebody where they're from and they say Mexico or El Salvador, it's never enough for me to hear just a country. I need to ask a region just so I can situate it in my mind, the map - where, what is it, city? - and to draw a relationship that I have with that region. And so I think it helps a lot for building trust with patients.

GROSS: One of the ways you keep costs down at the safety net hospital where you work is expensive antibiotics have to be approved by infectious disease doctors before you can prescribe them to a patient. You have to make sure that non-standard drugs aren't prescribed unnecessarily. There's a long waiting time between getting into the ER and getting a hospital room. I think the average is, like, 11 hours. Do any of the limitations that you face feel like serious problems when you're treating patients?

NUILA: Well, I've gotten used to those limitations. And I've gotten used to working within those limitations so that they feel like a freedom to me. But there are certain situations, certainly, where you feel like things can move faster for a patient. And that's where I feel the system is flexible enough to allow for argument. For instance, there's a limited amount of MRI machines. It's not available at the click of a button, an MRI, not like in other hospitals where if a doctor orders an MRI, it's going to be performed immediately. But because of that limitation, the scarcity means that I have - when I feel there's an emergency, I talk to the radiologist directly. And I say, I think this person needs to go to MRI stat because of X, Y, z.

I feel that that's a - that's not a bad thing because sometimes the radiologist will say to me, well, actually, I think that, you know, maybe you can get - if you're looking for this, maybe you need to do this type of exam. And we can do that faster. Or maybe the radiologist will listen to my point of view and say, yes, we should - we need to put this person on the list pronto, a priority. So there's benefits to further discussion between medical professionals about emergencies and how to deal with these emergencies.

GROSS: Well, let's take another break here. If you're just joining us, my guest is Dr. Ricardo Nuila, author of the new book "The People's Hospital: Hope And Peril In American Medicine." It's about his work at Ben Taub, a safety net hospital in Houston that treats the poor and uninsured, as well as patients who have insurance. We'll be right back after a break. I'm Terry Gross, and this is FRESH AIR.


GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with Dr. Ricardo Nuila. His new book, "The People's Hospital: Hope And Peril In American Medicine," is about his experiences working at Ben Taub, a safety-net hospital in Houston that treats the poor and uninsured, as well as patients who have insurance. It's part of Houston's largest medical complex.

In addition to his work as a hospitalist, Dr. Nuila is an associate professor of medicine, medical ethics and health policy at Baylor College of Medicine, where he teaches the practice of hospital medicine and directs the Humanities Expression and Arts Lab, which integrates the arts and humanities into medical education. He's also a writer of fiction and nonfiction.

You treat a lot of patients who are not only in great distress, but they are likely to die soon or relatively soon. And...

NUILA: Yeah.

GROSS: ...You describe your work with a patient who felt he was a real burden to his family. He was cared for by his daughter, who slept by his side when he was in the hospital, then went to work cleaning, I think, cleaning offices.

NUILA: Yeah.

GROSS: She also had children in school. And, you know, he was probably not going to survive for long. And you told him it's OK if you die. Why did you tell him that? How did you decide to tell him that?

NUILA: I don't think it was a conscious thought. I think that somehow that day it just escaped my lips. And it was - when I put myself back into that moment, it was truly the most compassionate thing that I could tell him because I saw his suffering. I saw in his history, in what he told me, how much he feared going back to the intensive care unit, how much he feared all of this to continue. And, you know, it might have been that at that moment I was just also just a little bit fresh and a little bit green. And I didn't have that filter that some of the doctors develop that - to not say the wrong thing.

But it escaped my lips that I thought, it's OK if you die because, you know, you're the one that matters the most. And in your - you know, I - it's hard. It's hard. I understand that, you know, when people suffer, they need to have - they need to be listened to. And I think in this case, the way that we view health care just keeps people on a track, and it keeps them in a tunnel where sometimes they don't even see what's the best thing for themselves. And maybe that's one of the reasons why I said what I did was because I wasn't yet in that tunnel of health care. And I try to resist that tunnel all the time.

GROSS: What was his reaction?

NUILA: Well, his reaction was to nod and to - you know, his face was just - yes, he understood what I was saying. We continued our conversation, and I wrote his wishes, which was that he did not want to be resuscitated, in the charts. I had my attending at the time sign it. And I proceeded about my day. And 10 minutes later I get a phone call that he passed away.

I still - that's one of the mysteries. I embrace that mystery. I - you know, I don't - we can't - we don't know everything that happens. And I don't know if my words, our conversation, if what I said had any impact on that. That's a mystery. But that was what happened is, is that he died 10 minutes later. And it's still something that I think about.

GROSS: Did his daughter know that you had told him it's OK if you die? And if so, what was her reaction?

NUILA: I had talked with her before entering the room, and she had said that he's tired. And I said that I know that he's tired. And we had spoken about how tired he is. I don't know if she heard me say those words, but her reaction was also one - my interpretation was that once this had all happened, that she was a bit relieved by it also. I think she had been living with the suffering.

GROSS: You were in a kind of similar position with your grandmother who lived in El Salvador...


GROSS: ...And she was eventually diagnosed with esophageal cancer. You wanted her to come for tests to Texas where you worked. Her family in El Salvador declined. They wanted her to stay in El Salvador. And she got a test. She had esophageal cancer. Her esophagus was removed in a surgery that ended up being really botched. And, you know, her - she paid the consequences of that with enormous suffering. You have real regrets about how you handled that. What were your regrets?

NUILA: My regrets were that I - at different moments throughout that process, I was less involved or that I abided by what I call algorithmania (ph), which is that I followed the algorithm above the patient care. And let me explain that. My grandmother - the initial test to diagnose her, I had recommended one test to her. And I was - you know, I was very early in my medical career, but I knew the guidelines. I knew the algorithm. When that test was negative for a diagnosis of esophageal cancer, I just let it be. I just let her - I didn't follow up. I didn't call her and say, well, what else - you know, what else could this be? I just basically ruled out the biggest possibility.

But then she did get another test in El Salvador that demonstrated clearly the esophageal cancer. And that was that was an indication to me that I had just let it slip. I didn't pursue the satisfaction of her symptoms. I didn't say, you know, well, what else could this be? Why - how else can we help her?

And then when she was diagnosed with cancer, I think that I didn't make - I didn't argue strongly enough afterwards to say she needs to have this staged correctly to make the appropriate decision, because at that time, where she was...

GROSS: In other words, is it stage one, stage two stage...

NUILA: Correct, correct.

GROSS: ...Three or four cancer?

NUILA: Yeah. We - because different recommendations are available for different stages. I think it would have been very appropriate for her to have a surgery if she wanted it and if she knew the potential risks for stage 1 cancer. But that staging wasn't fully complete, and then there had to be another test to be performed.

But the push from the surgeon in El Salvador was, let's just go to surgery right now. And even though I expressed to her that I didn't think that this was the right thing - I think I could have expressed things differently, and I had already lost a bit of standing because I had not been that person to follow up on the diagnosis before. And I wish that she would have had that test because that would have - because ultimately, we're trying to make the best decisions for people. This is a very, very hard field because you have to prognosticate. And in this case, I feel that we couldn't really prognosticate well because of the way that I had not followed up with her symptoms as well as I should have.

GROSS: So are you saying that her cancer was so far advanced it wasn't worth having the surgery to remove her esophagus...

NUILA: Correct. Correct.

GROSS: ...Because it wasn't going to save her? It was just going to make her suffer more.

NUILA: Correct. You know, the report that we got was - or when they started to operate on her, it was that that they found metastases, but they proceeded with the surgery. I think in the United States, that would have been something that a lot of people would have questioned. I don't think that that's practice in the United States. But in El Salvador, they found, at the time of surgery, metastasis. And I - and my argument was - is that they should have, you know, stopped the surgery at that moment. But that wasn't the case. They continued. And I think that she suffered greatly in recovering.

And that's one of the things that I think people have a hard time envisioning. There is this bias that we have that when a therapy is offered, that we perceive that the best outcome is going to come from that. And that's not always the case. I think one of the most - one of the wisest surgeons that I've ever met - 'cause I've always been enamored by surgery. But one of the wisest surgeons told me that it's not technical prowess that makes a surgeon great. It's the decisions on who to take to surgery. And I think that that was evident in the case of my grandmother, that knowing all that, I think a poor decision was made, and she suffered for that.

GROSS: If you're just joining us, my guest is Dr. Ricardo Nuila, author of the new book "The People's Hospital: Hope And Peril In American Medicine." We'll be right back. This is FRESH AIR.


GROSS: This is FRESH AIR. Let's get back to my interview with Dr. Ricardo Nuila, author of the new book "The People's Hospital: Hope And Peril In American Medicine." It's about his experiences working at Ben Taub, a safety net hospital in Houston that treats the poor and uninsured as well as patients who have insurance. It's part of Houston's largest medical complex.

Your grandmother said at one point about the medical care that she was getting and the decisions that were made - with the love of God, it will go well. A patient you were treating at the hospital in Texas said - and this was the mother of a patient. She said, God will protect him. What is your reaction as a doctor who decides what medical interventions are appropriate or inappropriate? What's your reaction when a patient puts their faith in God?

NUILA: Well, it's multifold, but I don't dismiss it because I feel that science and medicine, we haven't - we don't know everything. There is a lot of mystery in this world. And I think faith is of importance. I'm not saying that faith in one particular religion is important, but the - but faithfulness is important. I think that in my experience, when people demonstrate faith, whether it's in their God or whether it's in the treatment, they do better. And so I don't - it's not my job to take away that person's faith.

I - what I tell people is, is that I'm just doing my job, which is I'm a human being, and I need to tell you what is the recommendation from doctor human beings for this illness and for the treatment, but that I'm just a person and that I don't know. And that's the truth, though. I mean, that is - we don't know everything about - you know, we have very good ideas, you know, that when somebody is close to death, we can prognosticate quite accurately, you know, if that person's going to die or not. But I cannot tell exactly when that is going to happen. And I don't want to rob somebody of their faithfulness if that's exactly the identity that that person's built themselves around.

GROSS: You went to a Jesuit school and a Jesuit university. Do you consider yourself to still be faithful? And if so, how does that figure into your work as a doctor?

NUILA: Well, I'm faithful in that meaning exists. And, you know, I see that meaning in different faiths, in different - you know, I see that Christians, Hindu, Muslims, they all have a very - you know, people of faith have - are oriented toward meaning. We have different language to explain exactly, and there are differences. I'm not going to, you know, state that there's no differences. But I feel like we're close enough where it's - and there's clearly no, you know, demonstrated answer that - it's within the realm of mystery. And so I think it impacts my work because I embrace that mystery, and I feel like I'm just a person who's trying to help somebody figure out a big problem, aware that that mystery exists. And I'm not there to state that science knows everything, but science can give a bit of - you know, science can give some information - a lot of information in many cases - to help that person make decisions.

GROSS: So during COVID, you had a lot of COVID patients. And a lot of people lost their insurance during COVID because there were no longer employed. So that probably brought even more patients to the hospital. Of course, COVID itself brought more patients to the hospital. You know, around the country, doctors and nurses were just, like, burning out and living in fear of infecting the people that they loved.

One of the main medical people at your hospital, the director of general internal medicine - during COVID, he died by suicide, which really shocked you. And he was somebody who was really important in your life. When you - after volunteering at Ben Taub, the safety net hospital where you work - after volunteering there, you applied for a job. This guy turned you down. But after you'd written an article or a story that was published, he liked that a lot. And then he reversed and hired you. So he was a key figure in your life. You were shocked by his suicide. But after that, you found yourself thinking about suicide. You write you didn't have a plan; it was more of an urge. Why do you think you started thinking about it yourself?

NUILA: I think it was just very overwhelming to know what - where I would end up in health care, in my career. I think everything was a struggle. And I think that seeing somebody like Dave, who I admired so much, who was a friend, my best friend in the hospital, who I could speak with and who was so knowledgeable and intelligent - just to know that that is a risk for me as I grow older to - I mean, Dave was also a very good father, and it's something that I've struggled with, is parenting.

I mean, I think everybody struggles with parenting. But it felt so much like a pressure, that trying to be a good father while trying to be a good doctor, while trying to be a good writer - all of those - they can work together. But there's moments where they feel like they can just implode on themselves. And I think that knowing that that had happened to my friend weighed on me and made me think, is this going to be me? Is this the fate that so many of us who care a lot will - you know, that we face?

GROSS: How did you get through that period?

NUILA: Therapy helped. I found a therapist who was very attuned to people who were creative types, he called it. And that listening really helped. I feel like, also, my relationships improved. There was - when I was at my lowest, you know, I could look at my relationships with the people who were around me, who I valued the most, and I can see that at that moment, they weren't great relationships. And somehow over time, those relationships started to improve, and that helped immensely.

I think that writing also helped me, too, at the end of the day. I'm - I could probably pinpoint a time where - writing this book - this was - I was writing this book for years before COVID happened. And, you know, I think that, you know, it's probably the case that I was struggling with this book when I hit my lowest. And, you know, just the day in, day out of writing - and you start to see, like, a light at the end of the tunnel, or you see or you figure something out - that probably helped also.

GROSS: I should probably mention at this point that if any of our listeners find themselves having suicidal thinking or know somebody who is having that, there is a suicide hotline that you can contact. And probably the easiest way of doing that is texting 988. That's 9-8-8. That's also the number to call if you want to call instead of texting. If you're just joining us, my guest is Dr. Ricardo Nuila, author of the new book "The People's Hospital: Hope And Peril In American Medicine." We'll be right back. This is FRESH AIR.


GROSS: This is FRESH AIR. Let's get back to my interview with Dr. Ricardo Nuila, author of the new book "The People's Hospital: Hope And Peril In American Medicine." It's about his experiences working at Ben Taub, a safety net hospital in Houston that treats the poor and uninsured, as well as patients who have insurance. It's part of Houston's largest medical complex.

What's your impression of the burnout level of nurses and doctors now? I mean, there's so much pressure at a hospital like yours, at a safety net hospital. You're dealing with patients who are very sick and have had little health care because they don't have insurance. And, you know, because of COVID, doctors have been very stressed out because of the extra patients, because of exposure to infection, because of seeing so many people earlier in the epidemic die. People are still dying. Doctors were sick. Nurses were sick. So people were - hospitals were understaffed for long periods of time. Many doctors and nurses have decided to leave the profession because it's just too much. So what are your thoughts about how that's changing medicine and changing life for doctors, like you, who are staying?

NUILA: Well, I think it's very sad because I think that it's such a beautiful field. It's so beautiful to be able to sit with somebody and to try to think through their problems and use different philosophies, really, or, you know, areas of inquiry, including science, to try to help that person. And yes, without a doubt, that the pressures have gotten so much. Our health care system does not help. It worsens things, I think, and we would feel pressure - if you look at health care systems around the country, doctors suffer from burnout at similar levels. Ours happens to be due to bureaucracy more than anything else. Other doctors surveyed say other things impact them.

What really bothers me about it is when I hear some colleagues who tell me that they lost the sense of meaning in their job 'cause, for me, that just demonstrates a real, fundamental problem with how health care is administered in this country. If something like medicine, where you are helping people on a daily basis - if you can't see the meaning behind that, that's very - you know, that's a bad omen. I find - one of the things - you know, whenever a patient tells me, you know, I'm thirsty and I go get them ice water, I feel really good that day - something as simple as that. When I - with my Spanish-speaking patients, they can say one phrase to me, and I will feel satisfied for that day when they say (speaking Spanish), which means that, you know, you were very kind in the way you said that. And I feel that that's - that gives me a lot of meaning for the day.

But I feel that the pressures and the mechanism by which health care operates right now obfuscates that for so many people. And that's sad to me. Now, I take a little bit of heart in that the medical field is really taking this seriously and is trying to do something about this. There is an added emphasis now on bringing in the arts and humanities into medicine.

GROSS: You direct a program at Baylor College of Medicine, where you teach medicine, but you also direct a program about integrating arts and humanities into medical education. Can you give us an example of a couple of books that you recommend to your students or require them to read?

NUILA: Sure. One of them that comes to mind is "Blindness" by Jose Saramago. Others are certain short stories. There's "Tenth Of December" by George Saunders and stories from Edwidge Danticat. And all of these are meant to demonstrate moments of empathy, to get into the mindset of other people's consciousness so that we can promote empathy. We can also learn to tolerate ambiguity, which has been a problem in medical education so that people can understand that it's not a black-and-white world; it's a gray world. And hopefully, that can lead to better decision-making. But also, the patients recognize that and help with patient satisfaction scores.

GROSS: Dr. Nuila, thank you so much for talking with us.

NUILA: Oh, thank you very much, Terry, for having me.

GROSS: Dr. Ricardo Nuila is the author of the new book "The People's Hospital" and is an associate professor of medicine, medical ethics and health policy at Baylor College of Medicine.

Tomorrow on FRESH AIR, we'll talk about the new Tennessee anti-drag law with drag queen Bella DuBalle, the show director and host at the largest drag club in Memphis. The club has nighttime performances for adults and brunches for families including their children. The new law would make it difficult for drag clubs to stay in business, and drag queens, like Bella, could be sent to jail. I hope you'll join us.


GROSS: FRESH AIR's executive producer is Danny Miller. Our technical director and engineer is Audrey Bentham with additional engineering today from Al Banks. Our interviews and reviews are produced and edited by Amy Salit, Phyllis Myers, Roberta Shorrock, Sam Briger, Lauren Krenzel, Heidi Saman, Therese Madden, Ann Marie Baldonado, Seth Kelley and Susan Nyakundi. Our digital media producer is Molly Seavy-Nesper. Thea Chaloner directed today's show. I am Terry Gross.


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