Doctor, author describes quest for more equitable health care

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient," with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Dr. Ricardo Nuila sees patients at Ben Taub Hospital in Houston, and he's an associate professor of medicine, medical ethics and health policy at Baylor College of Medicine. He's also a writer, and his book is "The People's Hospital, Hope and Peril in American Medicine." Dr. Nuila is in Syracuse as a visiting lecturer at Upstate's Center for Bioethics and Humanities, and he agreed to talk with "The Informed Patient." Welcome to "The Informed Patient," Dr. Nuila.

[00:00:43] Ricardo Nuila, MD: Thanks so much for having me this morning, Amber.

[00:00:46] Host Amber Smith: You're in Syracuse as the 2024 Reise Family Visiting Lecturer in Ethics and Equality, so I'd like to ask you about the concept of equality in healthcare. Does it exist in America?

[00:00:58] Ricardo Nuila, MD: It's a great question, and what I would say is that equality exists in some forms. It doesn't, in practice, it doesn't pan out like that, that people have equal access to healthcare. We do have a law -- EMTALA, the Emergency Medical Treatment and Labor Act -- that guarantees that anybody in America, even if you are undocumented, even if you don't have insurance, you can step into an emergency room and have your emergency condition evaluated, make sure that you're not dying, or make sure that if you're in labor, that it's taken care of. So that is a level of equality. But I think that part of that comes out, that law was passed in the 80s, and part of that came about because there's a deeper inequality in the United States that's almost like patchwork, really, I would say, that law. Because what was seen at that time were that people were being dumped if they didn't have insurance, onto the public hospitals. The private hospitals were taking advantage of patients who could not pay and shuttling them to, or telling people to go to, hospitals where they didn't have to worry about them not paying.

So I think that it's a really tough question to answer because some people might point to EMTALA as a way of equality, but that equality of everybody being able to walk into an emergency room doesn't mean that people have equal access because some of those conditions are chronic, and you can get seen by an emergency doctor, and you can be sent out of the emergency room without any way of finding a solution to your chronic condition if you don't have the wealth to pay for it. So we have deeper inequalities. We have certain patches, like laws, that give the guise of equality, but I would say overall that people do not really have equal access to the healthcare system.

[00:03:13] Host Amber Smith: Well, listeners may not know much about Ben Taub Hospital where you work. It's the "safety net hospital" in Houston. What can you tell us about it?

[00:03:22] Ricardo Nuila, MD: Yes. It's the public hospital in Houston. And to be honest with you, I didn't know that for a long time. It's weird how, I mean, in Houston, Texas, the word "public" just doesn't come up to the fore very much. And so I started off there in the early 2000s as a student. It's the teaching hospital for Baylor College of Medicine. And what I saw there were that patients actually got healthcare. We would talk about how this person is poor, can't afford it, but you know what? We're still able to provide them with healthcare. They're able to go to specialty clinics.

I had a continuity clinic, which meant that I saw patients months after they left the hospital, and those same patients were able to come, they didn't have to pay for healthcare, or if they did pay, it was a nominal fee. And it really just didn't strike me. I was like, this isn't this... people are actually getting healthcare here. I had to really kind of sit down and think about it. Wait, this is a public system funded by public money. The money comes from property taxes in the city. So I pay toward the hospital and the public healthcare system. And it is mission driven, meaning that it is designed to provide care for those who can't afford healthcare and who are the most vulnerable in the city.

What I've found over the last 20 years, and what America has found, really, is that who is the most vulnerable changes. In fact, there's many people who might look at themselves in the mirror and not think that they're able vulnerable, but actually, we are all vulnerable. We all have, we're all, in our healthcare because of the way that it's organized, on a sheet of ice. We're standing on a sheet of ice. Some of us are very lucky to have a more thick layer of ice underneath our feet when it comes to our healthcare. But really on the whims of insurance companies making deals, our primary care doctors deciding what plans they take, all of that. Like, that thickness can shift, and we can fall through the cracks. So I've seen a lot of people who don't consider themselves to be vulnerable end up at Ben Taub Hospital.

[00:05:41] Host Amber Smith: But in Houston, they look at the hospital being funded by property taxes, like they do the roads and the police and things of that nature. It's a public good for everyone?

[00:05:54] Ricardo Nuila, MD: They're starting to. I think that that's one of the things that I find inspiring, and I find optimism in that, is that people in Houston, are starting to see that as a real public good that they want to invest in. I think that when I was going into medicine in the early 2000s, people might have looked at the public hospital as like, that's where other people go.

You know, there is like a very Texas phrase that people would use: "that's where I'd go if I got shot." That phrase always stuck with me because there was like a double ended sense to that, right? On one side, it really was a tip of the hat to how good the trauma care was and how good the surgeons were. The surgeons are really worldwide recognized as some of the best surgeons. But it was also kind of the flip side of that was just like, "Hey, I'm not the person that's getting shot. That's for other people. Those are for the type of people who do get shot."

Now, America has changed a lot, obviously. It keeps on changing, but the people who do get shot, there's more and more people who have that as a real danger. But also the public system has grown and started to do more than just provide trauma care. As an example of that, in 2015, Ben Taub provided the fastest heart attack care in the country. This is a public hospital where the identification of a heart attack and getting somebody to the room, to the catheterization lab where you can open the artery, reperfuse, get blood flow back established to that area that was lacking in blood flow, the heart muscle, that was the fastest in the country. And to me, that's incredible that right down the road there is the Texas Heart Institute that didn't post as fast times. So it's something about the public health system, their focus, it's doing well, and it's being recognized by the people as a good.

As an example of that, last November, the first time since the inception of the public healthcare system in the 1960s, voters in Houston got to vote to add $2.7 billion in a bond to the healthcare system. They voted overwhelmingly for it beyond party lines. If you look at every other election on that ballot, everything was kind of steeped in politics. Healthcare went above that. People voted overwhelmingly to rebuild one of the hospitals, to add to Ben Taub Hospital, to add more outlying clinics. Public money for this.

So I take heart in that. And I think that that's great that people are starting to see the value of public healthcare just as they would see the value of roads, airports, infrastructure. It's very necessary, and it also offers a great counterbalance to what we all feel, which is how private interests have taken over health care in America.

[00:08:59] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Ricardo Nuila from Ben Taub Hospital, the safety net hospital in Houston. He's in Syracuse for a lecture in ethics and equality.

Well, let me ask you, what drew you to medicine as a career? And then, not only that, but you chose to work at a safety hospital. You did your training there, but you've stayed and you're a faculty there. Why did you choose that?

[00:09:28] Ricardo Nuila, MD: Yeah. I like to joke that I'm totally inbred there because I've stayed. I was a medical student, and I stayed as a resident and stayed as faculty now. And sometimes I don't know if I could move on 'cause I just love it. The reason I love it is because it strikes the perfect balance for me. I can earn a living. It's not excessive living. I don't feel guilty that I'm doing excessive things to add to people's healthcare costs. But I have enough tools to be able to really impact people's lives.

The focus isn't on transactions and insurance. I can count on my hand how many times I've talked with insurance companies. It's really the system provides me the tools that I need. I can focus on medicine. And I can focus on what I like about medicine, which is connecting with people and trying to solve their problems at the bedside, talking with them, guiding them, things like that. And I just love that because it's not what I conceived of medicine, when I first went in.

I was born into a family of doctors. I'm a third generation doctor. My grandfather learned medicine in El Salvador, his home country, but then went to University of Chicago and Harvard to do extra training and then returned to El Salvador to be an academic pediatrician.

My father immigrated from his home country of El Salvador to the United States and was an OBGyn (obstetrician gynedocologist) who had a private practice in Houston. And I was naturally drawn to the field. You know, when you are young and you see... My father used to take me to the hospital on his rounds on Saturday, and I'd sit in the doctor's lounge watching TV, and I loved it. It was glorious for me, just being around that environment, even though the lounge wasn't as nice as it could have been. There was, like, coffee smells and everything. But it was so ... It felt like a dream to me.

But something changed by the time that I started to apply for medical school, even though I had those really early memories. My dad started his practice when I was young. He had two employees. One was a nurse. Another was a receptionist. But by the time that I was applying for medical school, he had multiple employees, but he had three people dedicated full-time to insurance claims. He used to, as a courtesy, take his patients into his office before examining them, talk with them. Any new patient would come into the office, and they'd have a conversation. But by the time that I was applying to medical school, his office where he talked with the patient, his desk, that wooden desk, it was full of just files from insurance claims. It was stacks and stacks of manila envelopes.

And so that influenced me. That really made me think when I was going into medical school, I don't know if I want to be a doctor in America. I literally resisted it to the point where even though I got an admission to go to medical school, I I deferred a year. And then I came back to medical school, was there for two weeks, took a leave of absence. I did not want to be a part of this machine that created paperwork instead of having these real great human experiences with patients that I thought was medicine, you know?

What happened is that I found that there's other options available, like Ben Taub Hospital. I was a medical student there. I was able to speak Spanish with some of my patients, and just seeing how they felt heard and listened to was really moving for me. I could take responsibility over patients. The way that I talked with them made a difference. And I wasn't overburdened by all of that. I wasn't overburdened by all the transactional nature.

It was a public system, not profit oriented. It was like, if you've dealt with the patient well, you've done a good job, period. And I fell in love with medicine at that time. It was also really a time where I learned how to be a writer at the same time that I learned how to be a doctor. One of the struggles that I had, I think that kind of like -- like I said, that I was naturally coming into medicine, but then I saw the transactional nature, and that kind of left, like, an opening in me -- and that opening was filled by literature. I became an English major. I really loved books. I read and read to the point where I couldn't even imagine not trying to contribute to that canon, you know?

And so that was a struggle for me, to the point where when I got into medical school, I went to one of my English professors who taught script writing, and I said, "I got into medical school, but I don't think I want to go. I want to be a writer." I was expecting him to say, "oh yes, go forth, go forth, go write." And he said, "you'd be crazy to leave medicine." Naturally, my inclination was like, "oh, he just thinks I'm a bad writer." But he said, "no, you can learn technique on writing in graduate school, but where are you going to get your stories from? You can get your stories from medicine." And I really, that has stuck with me, and I feel like it's this deal that I have with patients. They give me their stories, and I give them the best care possible. It's this deal. And I feel very fortunate to be at a place where there is a trove of stories there that I can access and bring a voice to.

[00:15:17] Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast, where Dr. Ricardo Nuila is talking about equality in healthcare and his book, "The People's Hospital: Hope and Peril in American Medicine."

In Houston, you direct a program at Baylor that integrates arts and humanities into medical education. Why do you think this is important?

[00:15:39] Ricardo Nuila, MD: Because I think that medicine is actually a deeply, deeply human process. I think that what we really want in illness is another human being trying to solve that problem with us and to guide us through and to care for us.And I think that there is the allure of technology that drags the human element out of medicine. The way I think about it is, is that medicine, there's a pendulum that swings in medicine between science and art. And that pendulum has swung toward science over the last 100 years, for good reasons. There have been incredible technological advances, discoveries, I mean, what vaccines have done, what antibiotics have done. The science is an important aspect of it. But the science is not the care. The care is a human being caring for somebody else. Science is a part of it, and the other part is this personal, the compassion element, the listening element, the trying to help solve the problem element. And I feel like that the arts and humanities are the best way to reinfuse that into medicine.

It's given me that gift. I think that reading literature has helped me look at different lives in different ways. I think it, it just enhances our empathy. When you read a great book, you get a different view of the world. You get that view through different eyes, and that helps you, at the bedside, conceive of what somebody's life might be like, or at least have the courage to ask them more about what their life might look like, so that you can tailor that, what you're doing medically, to that person, so that can be singular for that person.

I think also that these subjects, which are classical. They go back centuries, they've been part of medicine for centuries.They give us an architecture of meaning in our lives. One of the things that really pains me is when some colleagues reach out to me -- and they do the same job as I do; they're hospitalists -- they see patients, and they have, like, lists of patients, and they will reach out and say, "I've lost meaning in my work. I don't see the meaning in my work." And it pains me because I think it's just so, it just shows us that the daily grind obfuscates that meaning from us.

The meaning is there. The meaning is there in every patient in front of you. I take meaning from, even, getting ice water for patients, you know? My mind has been built with the study of humanities to help me recognize that meaning, to build that scaffolding, that architecture, to situate those moments into, like, an overall building of meaning. And I think that that's what's lacking in medicine, for a lot of people. I mean, I know what the training is like. I know how granular it can be. I know how it's like you get like ... I was talking with medical students yesterday, and it's like multiple choice tests and right or wrong answers, and over the course of a lifetime you can start to look at the world as ones and zeros like that. But that is not life. You have to build that architecture of meaning. And I think we do that through the subjects, the arts and humanities.

[00:19:16] Host Amber Smith: In your book, "The People's Hospital," you tell the story of the safety net hospital through the lives of five uninsured, or underinsured, patients. How did you pick who to showcase, and can you tell us a little about each of them?

[00:19:29] Ricardo Nuila, MD: Sure. It was really a deep kind of intuition, I think, with each patient. For a couple of the patients, their stories were just so strong it was just so evident to me. One of the patients, Geronimo, it felt like a rollercoaster being on the medical team, caring for him, being responsible for him. It was literally like your pulse was high in the hospital because this was a matter of life or death. He was my age, so I identified with him. I saw the love that his mother gave to him. And it was also, it felt like I was a little bit of a PI (private investigator) a little bit because I was like, oh, well how do I call a congressman? You know, all these things. So, some of those stories seemed like they were, they had to be placed in there.

There were others that, like, had to do with the real connection that I had. One of the patients, Steven, he is very conservative, and we had these really long talks in the hospital where we were still cordial. And we really liked each other. But we knew that each of us had different opinions. And I thought that that was very emblematic of how we need to fix healthcare, is that we have to have these conversations.. Each side really has to understand the principles on which the other side is standing, you know? And I think that that's the only way that we're going to be able to fix healthcare is through democratic means. So we have to come to a consensus.

I think one of the features of this book is that it started with the patients. The idea was, I want to artistically render the lives of patients. I want people to know what it is like to be ping-ponged between hospitals, and then find a place that's willing to take care of you and to go through the hospitalization, and to test what is that public hospital like? Is it good? Is it bad? So it wasn't like I came up with a thesis and then looked for, patients. It was the opposite. The real difficult part about this book, writing this book, was I had the patient stories, and I had to figure out what bound them together. What were the ideas that came out of them?

And I think that working at that hospital, you often think to yourself, oh, there's a book in every day that I have. These patients, there's like every single list of patients I could sit down and just write a book. And it's because people have these incredible lives. Everybody's so unique. And because there's so many impediments to people getting healthcare that are not known. But I think that what was unique about all of these different people is that they reached a different part of me, you know?

Christian's problem was that he had knee pains that were a mystery. And so part of me was like, that's so interesting. This is the diagnostic quest, but it's also he -- in America, the way we've organized healthcare is, is that if you have a mysterious illness and you don't have the right coverage, you can really suffer. He had an odyssey. He had to go to Mexico. He got stem cells. All of these things that are really emblematic of people not really trusting the healthcare system in the United States. So, that resonated with me.

Geronimo, like I had mentioned, he was desperately ill and needed a liver transplant. And, there's nothing. If anybody who has worked with patients, there's nothing like a failing liver to get your pulse up on the wards because that, you know that people are very, very ill.

Roxanna was one of the people that I bonded with the most on the wards. She was from the same country as my parents, a country that I visited every summer, El Salvador. And she had this major complication from a surgery where she had gangrene on all four limbs. All four limbs were dead. And all she wanted was to have those amputated so she could get a slice of dignity. But she could not get that in our health care system. Only through the public hospital could she really get that. And, I was inspired by her resilience, her attitude, her humor in the face of things. I still am inspired by that.

So all of the different patient stories come from a real sense of me working and just being like, kind of falling in love with an aspect of my patients.

[00:24:26] Host Amber Smith: Thanks for listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. My guest is Dr. Ricardo Nuila. He's visiting Syracuse to lecture on ethics and equality at Upstate's Center for Bioethics and Humanities.

You make the case that Ben Taub could be a model for change in the American health care system, and I think many healthcare providers and patients would really like a system where it's not based on money, but it's based on what the patient needs and what care they need. So why is it so hard for us to get there?

[00:25:00] Ricardo Nuila, MD: Well, I think that there are ... The health care system, it is the biggest industry in America. We spend more money on health care than anything else. Eighteen cents of every dollar spent in America goes toward health care. That's money going into pockets, and those pockets do not want to stop getting that money. So there are real pressures at the lobbying level, at the legal level, where policy is drafted, that will prevent any shortfall of that. So the system is really serving some people. It's serving shareholders of these major corporations. It's serving, like, the people who are employed by the corporations who are Fortune 500 corporations. Anytime that you call about an insurance claim, you have to go through the rigamarole of hit one, do this. Just know that they are trying to prevent you from getting their money. And that is a manifestation of how hard it is to change health care. And this is what my book goes into, is how did we arrive here? These stories that I've written are interwoven with the history of how hospitals became for-profit versus nonprofit versus public, and how some of the nonprofits are really operating like for-profits.

It goes into the history of why we have something called "fee for service," which is an incentive for doctors to do more and to order more. And that's one of the things that's really made health care more expensive is the do more, do more, do more. It goes into the history of how insurance became this behemoth and how it becamesomething that we recognize with our work and something, it's made us think that people have to earn their healthcare in America. And so those challenges, those roadblocks are monumental. But I take heart, in stories like one of the ones that I found in Houston, Texas, which is that we, the voters, have voted for a public health care system.

In 1960s Houston, the only place that you could get healthcare if you couldn't afford it, was at a hospital named Jefferson Davis Hospital. So the poor African American population, the poor immigrants, they could only go to Jefferson Davis Hospital. And since it was a charity hospital, it relied on funding from, really, two sources, the county government and the city government. And each of them were at loggerheads and threatened to end their support so that the other could take it over.

And so, that's kind of the story of America, and the spiral effect of that was that it was completely underfunded and to the point where the whisperings in Houston, if you came into the city of Houston, you went to a party, people would talk about how bad the charity hospital was, how the children would cry at night for a lack of milk, how there would been staph infections that had roiled through the maternity wards and killed dozens of babies.

Well, what happens is that an incredible, remarkable man comes to Houston. His name is Jan de Hartog. This guy is one of the most incredible people thatI've read about -- Nazi resistance fighter, ship captain from the Netherlands who saved a lot of people navigating ships to flooded areas, also a playwright, also an author of many novels, nobel Prize nominated for literature, comes to Houston as a creative writing instructor. And he's also a Quaker, so he really believes in service to the community as part of his identity. He hears these stories at these parties and he says, I want to go there to verify this. He trains himself as an orderly, which is now a patient care assistant, and he is on the wards at Jefferson Davis Hospital, and he sees exactly that except it's worse. He sees people lying in their own filth for days on end. He sees neglect. And he sees that the employees are just, they have a glaze over their eyes, the people who work at Jefferson Davis Hospital, because the work is so overwhelming. So what he does is he writes a series of op-eds about this, about how it's the shame of the city that we've allowed our charity hospital to fall into these conditions. And these op-eds get prominence in the international press. Houston's a big city at this time. It has the attention of the world because of the Cold War. NASA is housed in Houston, and at the time we were building the first dome stadium in the world, the Astrodome. And what the press says is that Houston can't provide for its poor, but it can air condition people in the stadium. And so this becomes a civic issue, and eventually it comes to the point where Houstonians votes in favor of a public system. They vote to give their property taxes to build a system that cares, that provides care for people who can't afford it. And what comes out of that are that place where I work, Ben Taub Hospital, part of that system, which in 2015 provided the best health heart attack care in the country.

So I take heart in that. I take heart in that. I think that that's the way we can help healthcare is democratically. We have to take this as an issue. Those forces, those corporations are enormous forces. But if we can make this a democratic issue, vote for public money to go into health care, we will find major changes. And you know, I think a lot of the people who are in health care know this, that if that happens, that could be a major, major, major change. And it would really make a lot of the corporations that own the insurance companies and hospitals and doctor groups have to adjust their product to better suit the American people.

[00:31:23] Host Amber Smith: So do you think there are aspects of the American health care system that are working right for people these days?

[00:31:32] Ricardo Nuila, MD: I think that the, the innovation is good. You know, there's clearly a incentive toward innovation.There's clearly a focus on research. It's hard to answer that question because the sense that people seem to think that it's like there's an open market. I think I would want there to be. What I advocate for is a two tier system, which is that there's a basic public system for everybody. And then if somebody wants to pay more, they can really go to a cash market or get private insurance on top of that. But that's not really what exists right now. It's really hard to have a cash market right now because of all of these complex contracts between providers and insurance companies and hospitals.

The thought is for some people that they're, that they can access healthcare quicker, and I do believe that people in America can access certain parts of health care quicker than people in other countries. We hear about the waiting in Canada. We hear about the waiting in the UK for certain medical conditions like knee replacements, hip replacements. I believe that's true, that one of the good features in the United States is that we can probably get that for people faster, but I also know of people who, even though they are insured, can't get those as fast as what is broadcast here.

So it's a complex question about whether or not we actually do provide things quicker. I think we should aim to provide things quicker and have that two tier system, where if people really do want to pay more, they can pay more to have something quicker. That's something that I can see being a real principle in American medicine. And that's something that Medicare for All really has not been able to kind of address. The basis of Medicare for All is basically that everybody has the same insurance and that there's no private insurances.

And I think that would make that quickness of getting these procedures for chronic and real ailments that affect people's lives difficult. I happen to think the Medicare for All would be better than what we have right now, but that's why I advocate for the system that I come from, that I've experienced, this public healthcare system where there is local involvement, decisions are made locally, and there is the opportunity for that second tier, if you have like a basic tier that's very good.

[00:34:14] Host Amber Smith: Dr. Nuila, thank you so much for making time for this interview.

[00:34:18] Ricardo Nuila, MD: Thank you for having me. I appreciate it very much.

[00:34:21] Host Amber Smith: My guest has been Dr. Ricardo Nuila. He's an internal medicine physician and an associate professor of medicine, medical ethics and health policy at Baylor College of Medicine, and he's a writer whose most recent book is "The People's Hospital: Hope and Peril in American Medicine." "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.