Conversations: Ricardo Nuila, MD

 

SYNOPSIS

 

Emily speaks with writer and physician Ricardo Nuila about his debut book The People's Hospital, a love letter to Ben Taub Hospital in Houston, Texas, and exploration of how its unique business model may help solve our broken healthcare system.

 
 
 

LISTEN

 
 
 
 
 
 

GUEST

 

Ricardo Nuila is a writer and hospitalist based in Houston, TX. His work has been featured in The New Yorker, Texas Monthly, The New England Journal of Medicine and Best American Short Stories. His first book, The People's Hospital: Hope and Peril in American Medicine was featured on NPR's Fresh Air with Terry Gross. In its review, The New York Times notes that Ricardo is a "skillful writer who humanizes his points in meticulous and compassionate detail.” He is the director of the Humanities Expression and Arts Lab (HEAL) at Baylor College of Medicine.

 
 
 

RESOURCES

 
 
 

CREDITS

Hosted by Emily Silverman

Produced by Emily Silverman, Jon Oliver, and Carly Besser

Edited and mixed by Jon Oliver

Original theme music by Yosef Munro with additional music by Blue Dot Sessions

The Nocturnists is made possible by the California Medical Association, and people like you who have donated through our website and Patreon page

 
 
 

TRANSCRIPT

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The Nocturnists: Conversations
Emily in Conversation with Ricardo Nuila
Episode Transcript

Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman
You're listening to The Nocturnists: Conversations. I'm Emily Silverman.

We all know that healthcare is broken. Some people support nationalized healthcare. Others support Medicare for all or a public option. Others prefer to keep the federal government out of healthcare as much as possible and combine cash pay practices with insurance for catastrophic situations only. These philosophical differences are the source of much gridlock and antagonism in politics, and too often it seems like we're getting nowhere fast, as healthcare costs continue to soar and the national life expectancy continues to sink.

But today's guest works at a safety net hospital in Houston, Texas called Ben Taub, whose unique business model of public healthcare that is local, may serve as inspiration for those of us who believe health care is a human right.

Ricardo Nuila is a writer and hospitalist, and his debut book, The People's Hospital: Hope and Peril in American Medicine is a love letter to Ben Taub Hospital, filled with stories of its faculty, staff, and patients, all mixed in with Ricardo’s own experiences growing up with a physician father, finding his way as a doctor himself, and listening to Wilco and Arcade Fire in the car on his way to work, which he mentions in his book and you'll hear me mention at the top of the interview, and so much more. Ricardo is an associate professor of medicine at the Baylor College of Medicine, where he directs the Humanities, Expression, and Arts Lab, also known as HEAL.

His writing has been featured in the New Yorker, Texas Monthly, New England Journal of Medicine, and Best American Short Stories, and focuses on health disparities, health policy, and the connection between art and medicine. My conversation with Ricardo covers a lot of ground, including the way that he was torn between writing and medicine early on in his career, the unusual history of Ben Taub Hospital and its business model, the collision of political ideologies that occurs there, and the ways that we can work together across differences to put people over profits.

But first, here's Ricardo reading from The People's Hospital.

Ricardo Nuila

The rumor we heard was that patients arrived with hand-drawn maps, our hospital marked like treasure. The stately Nigerian lady who responded, “Yes, Doctor,” to everything (metastatic breast cancer). The boy with the black curly hair wearing red Converse All Stars and a Judas Priest T-shirt that screamed Mexico City (acute lymphocytic leukemia). The grandmother with a sari snagged in the guardrails (chest pain, real chest pain, might need bypass). We stood at these patients’ bedsides; We wrote down their histories; we said we were sorry for examining them with cold hands. We ordered blood tests, interpreted EKGs, scrolled through their CAT scans; we input diagnoses.

We weren't just doctors. Among us were nurses, social workers, X-ray techs, the people who rode up and down the hallways in the middle of the night waxing the floors. Some of us wore white coats with frayed sleeves and busted pockets, others tight-fitting scrubs embroidered with our names.

In our bad moments, we became tribal: we weren't “we,” we were ortho, medicine, plastics, the 4A nurses; we only covered the unit. More often though, the needs of our patients were so damn immediate, we found a way to work as one.

We ran blood transfusions, heparin drips, a morphine pump when Norco didn't touch the pain. When COVID came, we gave oxygen together, one of us twisting the knob on the valve while the other inserted those tiny prongs into flared nostrils. We consulted one another when things looked dicey: surgery if we found boils, ID for antibiotics, and if anything looked remotely like a seizure—a twitch, a rolling of the eyes—we paged neurology overhead. If transportation was swamped, we wheeled them ourselves, to MRI, to Special Procedures, to the cath lab, even the ICU (how downtrodden we looked when we did this, like beaten dogs).

We figured out ways to make things work. Not enough money for your meds? We googled the $4 list at Walmart. Muscles too weak? We dug up a refurbished walker from the basement. Dying and homeless and alone? We called in a favor from the hospice that used to be a Tudor-style home. And when our work was done, once we could envision someone not dying within twenty-four hours of our discharge order, once the first chemo had gone in, once we could be sure their chief complaint was addressed, the thoughts still lingered in our minds. What brought them here? What are their stories?

Emily Silverman

Thank you for that reading. I am sitting here with Dr. Ricardo Nuila. Ricardo, thank you so much for being here today.

Ricardo Nuila

Thanks so much for having me, Emily. This is wonderful. This is a dream come true to be on the show. So, thanks.

Emily Silverman

The first thing I want to say is I believe we have a pretty similar taste in music. So in your book, you mentioned driving to the hospital, listening to Wilco and listening to Arcade Fire. And I don't know if we're maybe a similar generation or something like that, but, I just really…

Ricardo Nuila

It's internal medicine. Internists like Wilco and Arcade Fire. No, I think it is generational, but that Wilco song, that lyric, I remember it as a resident. “Maybe I won't be so afraid,” and in just thinking, I just don't want to be afraid anymore. And so sometimes the music really captivates what you're feeling.

Emily Silverman

I recently went to an Arcade Fire concert here in San Francisco just a few months ago, and I remember standing in the audience and looking around and thinking to myself, we're old.

Ricardo Nuila

I know, I know. It's so…they're not stopping through Houston, and Win Butler's from Houston. He had a show when I was in residency here where he was at The Pavilion where he used to work and he noted that, he noted the people that he worked with and they went all throughout the stadium in a conga line and it was just amazing and it was an homage to Houston. And yeah, now it seems like it's almost like the way somebody would look at Bowie or you know, the way we're looking back at these bands that we love.

Emily Silverman

Yeah, yeah. We were rocking out like it was 2008. So, I do want to get to the book...

Ricardo Nuila

We could talk about music. I don't mind that at all.

Emily Silverman

So I loved this book. And before we dive in, I just wanted to talk a bit about you and your family and your background. So your dad was a doctor. Tell us about him and growing up around medicine and the decision to pursue medicine yourself.

Ricardo Nuila

Yeah, I was born into a family of doctors. My dad was a doctor. His brother was a doctor. Their dad was a doctor. I grew up in Houston. My family is from El Salvador. My dad immigrated from El Salvador for residency. And I think he came with the intent to go back to El Salvador, but Civil War happened and he found an opportunity here. I think he came thinking neurosurgery, and he found himself going into OB/GYN, and so he moved to Houston and opened a practice. And it just seemed kind of like a predestined thing that I would be a doctor, not because they put any pressure on me, but just because I would see my dad at work and I saw the pride that he took in his work. I knew that what he did was to help people, and he would take me to the hospital on Saturdays. Now I'm a parent and I know that's a nice ploy to take care of your kids. There's a fascination that kids have with hospitals that I had also. And so, all of those experiences made it so that it was clear that I should try to become a doctor.

Emily Silverman

And was writing always something you loved to do as well?

Ricardo Nuila

It wasn't. It was in high school that I had a class where the teacher gave us an assignment to write an essay. I wrote an essay and I got a D minus. It was a very challenging class. It was sophomore year and we were told to read Cormac McCarthy and Willa Cather. I think that it took a teacher to call me out on, you're not understanding what's on the page. And in college I was a pre-med and I didn't really love my bio major because it was memorization and I preferred reading and interpreting literature. And then I got to the point where I changed to an English major, and one track was the pre-med stuff, the other track was writing more and more in depth. I mean, it became classes on script writing, for instance. So that by the end of college, I'd gotten into medical school, but I really thought that I was giving up on writing if I went to medical school. I went to one of my teachers who taught a script writing and dialogue class and I said, “I'm going to leave my medical school admission because I don't think that I want to leave writing.” And he said I'd be crazy to leave medical school. I took it as, okay, you think I'm a bad writer, but he said, “You can go to writing school and learn technique, but where are you going to get your stories?” And that's really been what's brought the two worlds together.

Emily Silverman

So the book, as you describe it, is a love letter to a hospital, the hospital that you work at, Ben Taub Hospital. What is Ben Taub Hospital? And maybe you can tell us a little bit about the history of the hospital and just orient us to this place, this character in your story.

Ricardo Nuila

Ben Taub Hospital is a county funded hospital in Houston, Texas. It is the teaching hospital for Baylor College of Medicine. And if you grow up in Houston, you know Ben Taub as the location where you'd go if you got shot. So that's what I knew about it. But I found this remarkable location where people actually got health care who couldn't afford health insurance and they got good health care. They came from all different parts of the world because Houston's such a diverse city. I was getting a little bit more cynical about medicine at the time. I was seeing my dad and he was just waging war with insurance companies on a daily basis. His whole idea about medicine had turned towards cynicism. I became very optimistic going to Ben Taub and seeing that you could just focus on medicine. And so I really loved that I could sit and listen with people and that I could learn medicine. That's how I fell in love with it because I felt useful. I felt like it was a place where people could actually get health care and became the fuel for the stories that I wanted to write.

Emily Silverman

In the book, you talk about how the patients who go to this hospital have all different insurance statuses. So 7% privately insured. 20% Medicare, Medicaid, and you say 63% uninsured. So tell us about that 63%. Who are they? And how have they fallen through the cracks of insurance in the post Obamacare era?

Ricardo Nuila

There is not one way to describe these people. They are people caught in different phases of their lives, there are different types of people. You know, Texas is a state that has not expanded Medicaid, so you can't just be poor. You have to be exceedingly poor to qualify for Medicaid. So that just widens the spectrum of the type of people who don't have insurance. There are many people who are undocumented or who are documented, but do not want to pay insurance because there's this Texan ethic of, well, I don't want to get ripped off. And some people don't like the insurance. They call it a “racket.” You have people who are divorced and lived very comfortable suburban lives, divorced, and that's when they get ill. The way that people have access to healthcare, if we can envision this net, these are the people who fall through these cracks for some reason. So it's hard to say that there's one type. There's plenty of people who are working jobs in construction who, they're not offered healthcare. There's such a wide variety, it's really hard to speak to one type of person that goes there.

Emily Silverman

A lot of this book is about the unique business model of Ben Taub Hospital. So tell us, what is the business model and how is it different from other safety net hospitals. I'm in San Francisco, I've done a lot of work at San Francisco General, which I believe is largely funded through the city department of public health. But Ben Taub is a little bit different. So talk about how they are able to make ends meet and take care of people.

Ricardo Nuila

The history of Ben Taub is that in the 1960s, the charity hospital at that time was called Jefferson Davis, and the city and county governments were fighting to offset the cost onto the other entity. The county wanted the city to pay, the city wanted the county to pay. Ultimately, the patients who needed healthcare were caught in the middle, and so the conditions were deplorable. In comes a really remarkable person, who is a University of Houston creative writing faculty member. His name is Jan de Hartog. He was a ship captain, a war hero, a Nazi freedom fighter, he’s Dutch, writer, also playwright, and he finds himself in Houston. He's Quaker, and he decides that he's going to volunteer at this hospital. He volunteers, and he sees the atrocious conditions. He writes op-eds about it in the Houston Chronicle that tell the world that at a time where Houston's growing, this is the time when the Astrodome, the first domed sporting facility, is being built. This is the time of NASA, that Houston has deplorable conditions for its poor. This becomes a matter of civic importance. And so what ends up happening is that it becomes a political movement to have health care for people who can't afford it that is actually funded. The way that schools are funded. This happens at the County level and it's its own taxing authority. De Hartog writes this book, it gains a lot of notoriety, and the citizens of Houston vote in favor of a hospital district. Over the next 40, 50 years, this hospital district becomes a healthcare system. It becomes a system that is funded primarily by property taxes. But the way that it works is that there are thresholds for financial assistance, for the healthcare providers. It's not an insurance, meaning that the healthcare is not paid for in full by policies or by some level of negotiation between hospitals and policies. What it is, is that they tally how much the person has consumed of healthcare and if you are earning below a certain threshold, it used to be 200% of the federal poverty level, now it's 150%, then you pay nominal fees basically for your healthcare. Beyond a certain threshold, people will pay sliding scale for the costs of their healthcare. But one of the key concepts of this healthcare system is that the healthcare costs are not profit oriented, and so the costs are actually lower. So when you're paying sliding scale, you're actually paying the amount that is actually cost rather than what is being sold to you.

Emily Silverman

Thinking about it as analogous to a school, that's really unique because I don't think that that's done anywhere else in the United States, is it?

Ricardo Nuila

Dallas has a hospital district. In fact, Houston followed Dallas's lead. Places in the south who were more reticent to have robust Medicaid offerings, the cities started to develop some of these. San Antonio. A lot of them are in Texas. One of the real stark differences that you see is that it's a county by county issue. One of the most difficult conversations that I have is with patients who are from right outside of the county line. They're in the Houston metropolitan area, but they live outside of the county, and so they don't qualify for the county based benefits of this healthcare system. That's one of the difficulties that we encounter in this system is that in the metropolitan area, it's still county based.

Emily Silverman

You mentioned Texas and the south, and these are parts of the country that skew more conservative, Republican. You talk about how Texas is really reluctant to expand Medicaid, for instance. And in your book, you say, “a whole array of competing ideologies collide at Ben Taub,” and you say, “as a place it serves as a model for how to blend conservative values with compassionate care.” And you talk about some of the different characters who work at Ben Taub. One of them is this Dr. Ken Mattox. Talk to us a little bit about that. It's just kind of unexpected. I imagine like a gun toting swaggery, I think he was a surgeon, like walking the halls at this like safety net hospital. Like tell us a little bit about what it's like to be in the walls of this space and all the different colliding political ideologies and how that all makes sense.

Ricardo Nuila

Yeah, it doesn't make sense because we cling so much to certain principles that we forget that in practice sometimes people with different ideologies will see a person and just say, we need to do something about this. And we forget that we have a lot of similarities because we cling to our ideology. So that's one of the things that's unique about Ben Taub, I feel like, is that it's Houston. It's a blue-purple city in a red state. It's a strange thing to make sense out of. But the way that I've seen it in practice is that people like Dr. Mattox, stark conservative, like you said, just think that the private healthcare system doesn't make any sense. And he takes pride that the county has been able to find out a way to make it cheaper and better. And he works toward that. And that's juxtaposed versus the people, who are a little bit more left leaning, who want to see universal healthcare, who see the undocumented and say, “they deserve just as much as everybody else.” And what's interesting is to see this in practice. It's kind of America, right? That a lot of us will focus on our differences rather than, well, there's a problem, let's just try to solve it. In practice, what it does, these competing ideologies, I think it leads to better health care. One of my real goals with this book was not to preach to the choir, was to really think about how we can bring these things together. And some of the things that I hear about the healthcare policy debates are that people who lean left don't take seriously how costs are out of control. And that's a big issue for the right. And on the right, I don't know if the people on the right take as seriously that universal healthcare and care for people who don't have access is of utmost importance. And so that's what was amazing to me is I work in a place where this achieves it and nobody knows about it.

Emily Silverman

And the way that you depict it is you pick a handful of patients and you walk us through each one of their journey or odyssey to Ben Taub and some of them arrive there with gratitude and relief and some of them arrive there a little bit skeptical. Like we said, Texas is a conservative place. And so there's one patient in particular, I think Steven it was, who shows up and he's sort of like, well, I don't want to take a handout. And so how did you decide which patient anecdotes to use as a way into this portrait of Ben Taub? And were you working mostly from memory or did you go back and interview them? Or what was that process like of profiling these different patients?

Ricardo Nuila

It sounds like it was mapped out nice and neatly, but at first I was like, I just know that I love Ben Taub, and I know that there's really interesting stories. And as a writer, I wanted to depict parts of people's lives that I knew that people did not know about. I can credit my editor for saying, “you have to clarify the ideas behind them,” because the writer side of me was interested in the scenes, in just the depiction of people's lives. I think that was what took so long, was really clarifying the ideas and drawing out arcs for the ideas that match the arcs of people's dramas, and aligning them. I had to do a lot of research and understand the big concepts behind what was going on in the hospital. And then the other major part was that I was very reticent to put myself in the book. I did not want to distract from the people's stories. It took a long time to realize that I needed to be a guide on this and I had to be thinking about these things also. So all of those had to be drawn out.

Emily Silverman

I can really relate to this thing you describe of primarily being interested in people and their stories and the medicine and perhaps the policy or economic or political piece of it coming later. I know for me I was never really interested in health care economics. I was never a legal or policy wonk. I had no idea how everything was set up and paid for, and it was really through my journey of getting super burned out and trying to understand. Why is our workforce so burned out and starting looking at the individual and then zooming out and looking at the culture, but then having to zoom out again and looking at the system and following the money for lack of a better term. And so I had to educate myself on that later. And so was it a similar journey for you because this is such a policy heavy book and so well researched. Was that natural to you or was that something you had to work harder at?

Ricardo Nuila

Yeah, I had to work hard at that. There was a part of me that realized that words like Medicaid impacted people's lives as profoundly as any drama, and that how to depict that as a writer is really tough. It's kind of crazy to think back on how naive I was when I set out to write this. I didn't know the history of private health insurance. And ultimately, you have to contextualize all this, you have to make it a real narrative so that people understand why it's a big deal when one of your patients, who has been paying into the system working as a gas attendant, and he gets disability insurance going $100 more than the threshold, takes away a liver transplant opportunity for him.

One of those stories really hit home with me because I was seeing it and feeling it at the hospital with him and seeing health insurance taken away from somebody at a moment of critical need. So, I really had to go and reinvent what I thought about this book. Find the right books is the biggest part of this. For instance, Paul Starr's book, The Social Transformation of American Medicine. When I pitched this book, I hadn't even read that book, and that book is fundamental. Somebody had done so much incredible research. So that's part of the process of writing. If you cast a wide enough net, you'll find these things and then you go down that route and then you situate it into your narrative.

Emily Silverman

For the audience, I believe the liver transplant story that you're referring to, that's Geronimo, right?

Ricardo Nuila

Correct.

Emily Silverman

Just to give the audience a flavor of the types of patient stories that weave their way through this, can you just explain to them what happened where he was on Medicaid and then got on disability insurance, but then was too rich to be, like, can you kind of paint a picture of that dilemma? Because it was so Kafkaesque.

Ricardo Nuila

It really was.

Emily Silverman

Which culminates in writing this letter to the congressman. So yeah, maybe just briefly can you encapsulate that for the audience because that's such a perfect example of the intersection of human drama and health policy.

Ricardo Nuila

Sure. He was my age, 36 years old at the time when he had liver failure. And the only way to help him because he was so decompensated was through a liver transplant. And it so happened that people directed him to the right avenues, applied for Medicaid, got Medicaid, but the month after it was conferred to him, it was taken away because in Texas disability payments count as income. He had worked as a gas station attendant, just like all of us who pay into Medicare, Medicaid, and Social Security. And so when his liver problems became so robust that he had to apply for disability, the person at the social security office made him put in for the disability. It was a formula that was calculated. He got a check for 900 and something dollars, which was 100 more than what you could make in order to keep Medicaid in Texas. Again, you have to be exceedingly poor to have Medicaid in Texas. At the safety net system, there's no transplants that are offered. You have to have health insurance and that's pretty much across the board in the United States.

One must have health insurance or be extremely rich to get a liver transplant. So he had insurance, but it was taken away and his liver is failing, so this shocked us that it could come down to 100 bucks for a gas station attendant in disability payments that could mean the question between life and death. Again, this is a person who's 36 years old, and so it just propelled our team to look deeper into the question, if he refuses his disability payment, can he qualify? Ask questions of the system.

Emily Silverman

I just wanna take a minute to talk about the system, which in your book you refer to sometimes as “Medicine Incorporated” or “Medicine, Inc.” And you say here, “It's tempting to imagine that Medicine Inc. was hatched by a small group of moguls gathered together in a secret location, maybe in the cone of a volcano, in a plot to fleece the American public. The truth is far more complicated. Those whom Medicine, Inc. benefits most— doctors, hospitals, pharmaceutical companies, and middlemen like insurance companies—didn't create this behemoth on purpose. Medicine, Inc. is the product of patchwork and the struggle of these groups along with policymakers to accommodate the foundational building block that is private health insurance. Private health insurance is the root of our healthcare problems.”

And so I'm wondering, how did writing this book shape your opinion? Your political opinion, your opinion about health policy. What is your opinion? You say private health insurance is the root of our problems, so are you on the team of Medicare for All, or a public option, or something even more extreme like the National Health Service in Europe, where the payer isn't just public but the hospitals are public? How public should we get? And where have you landed on that?

Ricardo Nuila

I will tell you this, I am a card carrying moderate, you know, meaning like I believe in moderation. I believe that in listening to all the sides, we come together and we negotiate principles and ideologies. But yes, what I believe in right now is that we need a public healthcare system, which a lot of people would say is extreme. And I think it just really shows how extreme America is with regard to this question. Because even on the Democrat side, I think a lot of people are not behind a public healthcare system. I don't think a lot of Americans know what that even means. I've had the experience of working in a public healthcare system, and so, my opinion right now is that what we're experiencing in healthcare, where you go to the emergency room, or you go to your doctor, and you get bill after bill after bill, all of this is a manifestation of an extreme of corporatized medicine.

Emily Silverman

And it's getting worse…

Ricardo Nuila

It's getting worse with private equity. And so I think that the only way that we can save healthcare is to compete with corporate medicine. And the only way to do that is to come together as a people, to recognize that we can gain something, all of us, with the public healthcare system. And that competes with, because imagine if you are a young person and you get to decide, I am either going to pay for my health insurance or I'm going to rely on the public system that's already there, what opportunities does that give you in your life? I think quite a bit. It's also a manifestation of autonomy, because right now, you're bound to this system of paying and paying, and it's corporatized. That, to me, is what is extreme. I think that we're just actually trying to balance that other stream. One of the reasons I'm not on the team for Medicare for All is that I do think people should have choices to be able to get an extra insurance. And Medicare for All, one of the ways that it works is if you get rid of health insurances, but I think people should be able to decide if they want extra healthcare and we should be able to get as little healthcare as we want, but our system is set up in a way where it ratchets up the health care for the purpose of profit and it obfuscates everything so that the onus is placed on the patient to be a great consumer, but it's impossible to be a good consumer in this system.

Emily Silverman

In the book, you briefly touch on this idea of direct primary care. You talk about Dr. Zubin Damania and some of his work in Las Vegas, and I've been looking a little bit into this concept of direct primary care where the patient subscribes to a doctor's office and pays a monthly fee and they pay that fee whether they're healthy or whether they're sick. And it seems to help a bit with the incentives because the doctor's incentivized to keep you well as opposed to the fee for service where it's sort of like the sicker you are the better for the business because they get to profit off of your sickness.

So I'm curious what you think about something like that, which also might help recenter primary care because right now we're just so obsessed with super, super specialists and like surgeries

Ricardo Nuila

Totally..

Emily Silverman

..and procedures and the relationship based medicine of primary care should be the cornerstone and I think is now like a footnote and sometimes even viewed as below what an MD should be doing to work at the top of their license. So anyway, I'm curious if you've thought at all about that kind of subscription model where, you know, we pay lawyers by the hour, maybe we pay doctors by the month, and is that something that could ever work?

Ricardo Nuila

I've thought a bit about it, and I just see these enormous forces of corporatized healthcare. I just don't see how there's going to be competition with them, and that could be my own myopia, other than through public means. And so, I love the idea of subscription models, but I'm wary that it's going to be crushed because they just have armies to be able to guarantee that the market is so difficult for somebody who has a very good idea. That's one of the reasons why I am a proponent of thinking really big, meaning the people's investment to liberate healthcare. I hope I'm wrong, but I'm wary that these forces are just so great that the only way to do this is democratically, is to recognize that there's a problem and to say public investment is the only thing that can liberate us from this.

Emily Silverman Yeah, that makes a lot of sense. When I spoke to some of these doctors who are doing this monthly subscription model, they too were kind of like, you have no idea how powerful big insurance is. They were like, you think you know? But once you really get into the belly of the beast and see what they're willing to do and how much money is on the table, they're like, you have no idea what we're up against. And so you're right, it may be the case that switching over to the centralized power of government is the only way to compete.

Ricardo Nuila And that's one of the reasons why I think it's interesting, Ben Taub, is you have conservatives who believe in public healthcare, but they believe in it in a local model. So that, to me, is an interesting point that we could talk about. In the 1950s, the government invested in the Hill Burton Act, which was to basically directly inject into the healthcare infrastructures by building hospitals. There's different ways to look at what government control of healthcare is. I've seen the VA. I make the point that the government can do some good things in the VA, but I understand the trepidation that people have about like a fully controlled governmental system.

I just think that we can't let these words and these ideas get in the way because healthcare is so damaged right now that we have to question our own assumptions. That's one of the things that this book is about. We have to really come together and think about what are we willing to question in order to gain what we want, which is I think everybody in America wants more personalized health care, meaning that they want a doctor to be able to think with them and they want cheaper health care. Well, I think if that's the case, we have to really question how corporatized healthcare has driven us over here.

Emily Silverman Yeah, I learned so much from this book about a different type of public health care, which is exactly what you just said, is sometimes we get stuck in this dichotomy of Medicare for All, and you know, the convoluted private system that we have right now and really thinking about how to get creative and some of these other options, like you said, the local way of executing public health care, what does that look like and how Ben Taub's model is so unique and how nobody really knew about it. And so what are your hopes for this book? Do you envision it being used as a teaching tool in public health schools, medical schools, nursing schools, sparking conversations about this local public option? How do you see these patient stories and also your own story and also this portrait of Ben Taub living in the world?

Ricardo Nuila I just want anybody to be able to tap into something here in this book, whether it is the drama of healthcare, the words, the prose, whether it is the history and just learn a bit more so that we can all have a conversation democratically about how healthcare experience can be better. I'm worried about our field, Emily. I'm worried about, that this magical, beautiful thing that you can sit with somebody, listen to some of the medical problems they're having and help it out is becoming so cynical and so programmatic. And I know that there's complexity. I'm not trying to say that this is a panacea, but I think that we need to really reshape the way we think about these things. That's what the book is trying to do. It's just like, let's throw out ideologies and really try to think about how we can get back to that. And this is a model that I feel like in my years working there has helped me do that. I mean, I don't think about billing. I feel so fortunate to work where I work. I work on salary, where I can put all of the pressures that I think a lot of doctors work under, I can just channel that into the conversations that I have with patients. I feel lucky, and that's really where this comes from is just like, I feel like I live in a world where I have the ability to practice medicine the way that I want to practice it. And I feel so fortunate for that. And so this is just kind of a dissection of how that is and maybe see how we can possibly do it. And of course, it's also recognizing how difficult it is for people who are trapped, the sicknesses that they endure, where they can't get access.

Emily Silverman I love what you just said about how you feel good at work, you're able to channel your energy into the patient interaction. It's just so good to hear that because you're right. We are sort of watching a slow crashing train right now with healthcare and I do a lot of these interviews and I'll often ask people at the end of the interview, like, what do you see in the future of healthcare? And maybe I'll stop asking because most people, they say, you know, I don't think it's good. I think we're. kind of headed for catastrophe. And so it's a little bit of a bummer to end interviews on that note. But I think it's also important to be real about where we're at. And, you know, a lot of people listening to this podcast are doctors, nurses, medical students. And one question is like, what is our role here. There's so many stakeholders in this problem. You have government, you have private insurance, you have pharma, you have big hospital systems, you have private equity, you have frontline workers, you have patients. In that landscape, do you think clinicians and clinician leaders are awake enough to these issues? Do you think we're sufficiently railing back and fighting? Do you think we need to do more? Do you think that we're just so overloaded with the actual clinical work that we just don't have the time to do it? Or maybe we're ignorant and just don't know enough about it? Or what message would you deliver to this community, you know, our audience, the listeners? How do we make our mark in this moment and do our part in steering the ship away from disaster, if that's even possible?

Ricardo Nuila I think we're conflicted. Doctors en masse have opposed universal health care, whether that be through insurance or health systems. There's been multiple reasons for that, but one of them is a financial incentive. I'm not saying that every single doctor has thought about that consciously, but that's clearly the case. We earn more than our European counterparts. There's just no doubt about that. And so there's a conflict that we feel here. Are we going to have to give up a little bit of the money that we earn? And it is so dang hard to earn it too. But I think we need to reset our mind about benefits that we feel. It is a benefit to go into work and to feel like you are not contributing to this overbilling of patients or this overconsumption. I'm not saying that we all have to earn the same amount. I'm totally not talking about a communistic system where everybody earns the same or anything. The models that are in England for public health are that doctors seeded a little bit of the finances so that they could have more control of the medicine. And I feel like that is the lesson that I think we should think about. Can we control how medicine occurs in the United States a bit more and that be our benefit instead of the finances because right now It's kind of like you're burnt out. Here's an extra shift. You can earn more money. That's the carrot that this system is putting in front of us, but I think as doctors we really have to think about what we want I think we can hit a bullseye here where we can earn what we feel like we put in but we shouldn't be greedy, and I think that we need to recognize as a benefit how good we feel about our profession and right now it's as low as it can get. That's why we have to reshape the way that we look at the interplay between finances and what other benefits we're looking for from medicine. And I think that if we do like British doctors did and say like we will control medicine as it occurs in this system. That's a benefit and that can make a lot of doctors maybe more happy.

Emily Silverman It's such an underexplored topic. And I think because money is so taboo to talk about in general, but even among doctors, and also just acknowledging the complexity of it. Physicians have so much more debt these days than they did.

Ricardo Nuila Yeah, totally.

Emily Silverman And also there's almost like a hierarchy within medicine where you do have the interventional radiologists in the community making half a million dollars a year, but then you have primary care, psychiatry, family medicine, pediatrics, infectious disease. I had a friend of mine who was an infectious disease doctor talking about how the ID fellowship slots just didn't fill really this year. And she said a lot of her friends were saying, looking at two options, I can either take care of sick COVID in the ICU and make ICU money, or I can go into ID and get death threats and not pay off my loans, which would you rather do? And so you're right. So much of this is driven by incentives. And this is a good reminder for me to think about ways to keep having these conversations about doctorhood and money and how it's all tied up and how to talk about that. So that's something that I'll definitely be taking away from this book. Thank you for being here. And is there anything else that you'd like to leave us with?

Ricardo Nuila Just, thank you for all you do. Everybody who listens is interested in patients in some way. Don't lose that. That's just the most important thing, is to be able to be attentive and listen to other people. That's the beauty of this practice, that we can sit down and just try to figure out problems with another human being. That's what I look at when I go into the hospital, and I feel like everybody has the capacity for this, and so I appreciate you, Emily, for making this. I think everybody responds to this show because they see that in the show.

Emily Silverman Well, thank you so much for that. I'll take that compliment with me for the rest of the day. And for the audience, please pick up a copy of The People's Hospital: Hope and Peril in American Medicine, authored by our Dr. Ricardo Nuila. Ricardo, this has been a great conversation. Thank you for being here today, and thank you for teaching us about you and this place where you work. I just learned so much, so thanks.

Ricardo Nuila Thank you so much for having me, Emily.

 
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