Community center . No. Its way more than that. Comcast is partnering with 1000 Community Centers to create wifi enabled so, students from low income families can get the tools they need to be ready for anything. Comcast along with these Television Companies support cspan two as a public service. It is an honor and a pleasure to be able to introduce dr. Ricardo nuila. I think introductions are all way of giving people their flowers in realtime. Ricardo is an associate professor of medicine, medical ethics, and Health Policy at Baylor College of medicine where he directs the humanities expression and arts lab also known as the heal program. He is a writer with pieces appearing in texas monthly, houston chronicle, the new yorker, the new york times, the atlanta, and of course the new england journal of medicine. His short stories have appeared in the best american short stories anthology, mcsweenys, and the new england review, which awarded him its inaugural emerging writers award. His debut book which we are here to talk about today, the peoples hospital, follows the lives of five uninsured houstonians as survival leads them to a hospital where insurance comes second to genuine care. Thank you for being here in san antonio. Thank you all for coming. applause as we are in conversation, i make sure that i will note for you all that we will have time to be in conversation with everyone that is in this space and for the collective knowledge in the room. Please be flooding the questions in your mind as you listen to ricardo and we will be taking abraham, specifically in the yellow shirt over here, that brilliant shirt, will move the mic around the room. I want to bring the book into the room by passing the mic to you to just get us started with a reading to bring your book to life, please. Thank you so much. I am going to read from the very beginning of the book. This is from chapter one, histories, first page. This is from the peoples hospital. The rumor we have heard was that patients arrived with hand drawn maps, our hospital marked like treasure. The stately nigerian lady who responded yes, dr. To everything, metastatic breast cancer. The boy with the black curly hair wearing red converse allstars and a judas priest tshirt that screamed mexico city, accused of when fit chest pain, real chest pain, might need bypass. We stood at these patients bedsides and wrote down their histories. We said we were sorry for examining them with cold hands. We ordered blood tests, interpreted ekgs scrolled through their c. A. T. Scans. We input diagnoses. We were not just doctors. Among us for nurses, social workers, xray 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 were not we, we were also medicine, plastic, we only cover the unit. More often, though, the needs of our patients were so immediate we found a way to work as one. We ran blood transfusions, have a written scripts, a morphine pump when nor codid not touch the pain. When covid came, we gave oxygen together, one of us twisting the knob on the valve or the other inserted the tiny prongs into flared nostrils. We consulted one another when things look dicey. If anything looked remotely like a seizure, a twitch, a roll of the eyes, we paged neurology overhead. If transportation was swamped, we wheeled them ourselves to mris, to special procedures, to the catholic, lviv in the icu, how downdraft and we looked when we did this, like beaten dogs. We found out ways to make things work. Not enough money for your meds . We googled the four dollar 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. When our work was done, once we could envision someone not dying within 24 hours of our discharge order, once the first chemo had gone in, once we could be sure their chief complaint was addressed, the thought still lingered in our minds. What brought them here . What are their stories . Ben taub hospital, the largest hospital in one of americas most diverse cities, we are heathrow if you replace the emirates and the Virgin Atlantic planes with greyhound buses. There are no atriums with pianists here playing here comes the sun to welcome you, know soothing sounds of Running Water from hidden speakers or from an actual indoor waterfall. There is no starbucks. Our cafeteria serves some form of barbecue most days for lunch and packaged salads topped with eggs or chicken strips. That is unless you prefer the full menu mcdonalds located inside the hospital that is open 23 hours a day. We do have a gift shop but it looks more like a convenience store, heavily stocked with greeting cards, not the pun filled ones, the kind to get the point across. Condolences, available in spanish as well. If you type ben taub into google maps, you will find it crammed within the houston zoo and the 30 other institutions making up the Texas Medical Center, the largest concentration of medical facilities in the world. Some of the fields most important innovations took place in this medical metropolis. The First Successful bypass, the first artificial heart transplant, the first beat liz artificial heart imagine that, just a constant worrying. The first silicone breast implant, one of the first civilian helicopter ambulance, the bubble boy all here not that the patients at ben taub no this. Some may have heard that md anderson is wearing a top in the country in cancer care or that at houston methodist you might find yourself fortunate enough to have a robot operate on your prostate. The tv ads air in spanish. It is possible that at night our patients look out their windows and behold the sparkle of so many new glass buildings, some of them named after the billionaire sheep who sell in the oil that becomes their gas. More likely, they are looking out in the direction of the zoo tour the parking garage and bus stop, wondering how they will get home. That was just the first few pages. By page 14, i had to put the book down. It was simultaneously pulling my heart out and putting words to an experience in the American Health care system that i have had and that i have witnessed. I didnt know i needed words to be put to them and even more so by someone who is a doctor. The first question i have for you has been, i know what the book meant for me. I think im still processing the depth and breadth of what it means to me. I am curious to know who is the book for. Know who is the book i mean, i dedicate the book to the people who worked at ben taub hospital with me. We feel like such underdogs. I feel like because it is a public Health Care System so, ben taub hospital is the flagship hospital of the public Health Care System in houston. You know, here in bexar county, you have something similar. I think that working there we can also, we can be in the shadows of such, the wealth of hospitals. Really, we feel like we are actually doing great work there and the statistics show that. The american mentality is that the public Health Care System is for everybody else. That is what this book is really about, to dispel that. It is to show moments where patients have been issued from in the private Health Care System and how Public Health care is one of those ways that we can bring costs down, which is an enormous problem in American Health care, while providing universal basic Health Care Access to everybody. We dont turn anybody away. We take care of every Single Person. This book is dedicated to the people but it is also for everybody to know that we can solve the Health Care Problem if we understand what we are seeking and if we look at some of the great models that are out there. I want to pick up on underdogs. Yeah. Throughout the book, you are making really complex, very many perceptions of the hospitals that exist. The people who are not there and maybe should be there, but also underdog is a perception that might exist more internally. It makes me curious about what the perception is naturally at the hospital. Unpack for us a little bit about the perceptions going with the very many actors that you talked about over the course of the book. Houston being a diverse city, the fourth biggest city in the United States, one of the most uninsured cities in the country, but you would find is a whole milieu of people including people who just cannot afford Health Insurance or who cannot get, who have lost their job. Its an increasing amount of people who are left in the cracks of our Health Care System. Those people feel like underdogs because they look at these large institutions of the Texas Medical Center and they cannot get care there. Let me give you an example. One of the principal subjects in my book, stephen, he earned 75,000 a year. Hes a restaurant manager. He elects for the lowest plan because he is a real texan. Why on gods green earth what i pay for insurance . I think it is a rocket. At the beginning of the covid pandemic, he starts to feel a lump on his neck. He soon realizes that is what is causing him a fever. He goes to the emergency room. You have to pay 660 just to sit there. They take him through they shuttle him back and forth between a different hospitals in that network. A doctor finally sees him. They have done look at skin. You have tonsil cancer. The next word is however. However, we cant do anything about it. You have to leave. For stephen, that is a punch in the gut. A social worker has to come in afterwards to say to go to the Public Hospital. Go to ben taub. For stephen, that is more of a punch in the gut because he is like, that is for people who are homeless, who are drug addicted. That is for people in jail. What we are finding, what his experience is told in the book, but what he finds is his preconceptions about the public Health Care System are different. That is one of the things that i wanted to portray about health care in america. Public health care can be a very good. We can come together and think about solving it so people like stephen dont get into those situations. It also lays bare for us that there are ways in which local government can create interventions. What i appreciated so much is the history and information about the leaders and the policy makers, that very persistent over decades worked diligently combined with voters to approve things like making the gold card happened. Can you talk about what the gold card is and shed light on the role of local government particularly thinking what i have in mind is that we are in texas, we are in the legislative session. This part of the book just peels back the layers and layers and layers of how much is at play for someone to get care. Here in san antonio, you have something called care link. Its very similar to the concept of gold card. Its not a Health Insurance but it is Financial Assistance to help people who are uninsured or cant afford health care. In houston, that came about because there was a voter referendum in the 1960s. At that time, there was only one charity hospital. It relied on funds from the county in the city and each of them tried to dump it on the other. It was called Jefferson Davis hospital. Mostly, it was African Americans and immigrants, patients who came and had to go to that hospital. Atrocious conditions to the point where opeds started to be written about it and there was a voter referendum to fund a public Health Care System. That is the sea that was planted in the 1960s. What comes about from that is a Health Care System a lot like what you have here in bexar county. There are clinics outlining there are specialty clinics, hospitals. It is a local system that has been cultivated by public leaders over the years. The big texas cities have it for a lot of Different Reasons because the state does not want to take, want to give dollars to health care and allow the county to do that. As the counties have grown in the urban centers, they have realized something. In order to keep people out of emergency rooms, you have to provide them health care. We just have not found that out as a nation, right . Other countries have thought about this and put it together. Well, there are real incentives toward that system of keeping people from corporate medicine. We are piecing together Health Care System will get to that level. I really hope we do. Its something that i hoped would be something that we would think about. About. Th there is a scale that you are providing for us throughout the book in terms of the ways in which we as individuals invests in if you are constantly bringing in the positionality of, for example, you as a doctor within the hierarchy of the hospital or how race and class affect our positionality as showing up for care with that very same hospital. Another intervention, thinking about the policies or the Ballot Initiative which allowed property taxes too phone Something Like the gold card. You are showing us things like policies that are more common when it comes to Maternal Health in california. We now see that at ben taub unlike other areas of the country. That to me is another intervention and policy change. You are talking to us very specifically about who those people are that are doing the resources and making the policy happen. It showed me the type of leadership that it takes at this moment that we are in to identify and implement and provide the data and bring everyone along as well. Im thinking about the pads and the ways in which nurses have to be brought along in terms of making that possible. Ben taub hospital is a Teaching Hospital at its core. Because of the faculty who work there who are interested in the academic and evidence based, they can glean the studies and implement them at the hospital level. With the culture is like is utilizing the best of your resources which is a huge contrast to the working Health Care System which is really just designed to extract as much money as possible from patients. We have to realize that, for instance, the fundamental of health care, the way it is financed in the United States, is fee for service. Its very different from other places. I mean, what that means is that doctors and practitioners are compensated for every service that they provide. You can bill for every service. That is something that even in 1910 doctors fought through a lobby to hold on to that power, great . It is different in other European Countries. That is one of the reasons why we have such a disparity in how much we pay and what we get from the Health Care System. 18 cents of every dollar in the United States goes toward health care more than anything else, okay . That is more than, around double what the western European Countries spent. Our outcomes in infant mortality, Maternal Mortality are not nearly as they should be the way that European Countries have. Even president nixon called it illogical incentive of the American Health care system which is to incentivize paying for sickness rather than to prevent illness. That is why costs are out of control and that is one of the reasons why in an academic environment where you can think about systems and how to prevent catastrophes like that, that is why there is cost saving and thats why it helps patients. Thinking about it both in terms of the data that we are sitting on and the fact it is a Teaching Hospital, when you were unpacking what you call algorithmania. That you were unpacking this, seeing the pitfalls of chasing that. Could you talk to folks about what that is and, second to that, i am curious how it changed your teaching now as a doctor who has that perspective. Algorithmania is what i call the practice of following decision trees without reconciling that with the connections that you make with patience, the history. I will give the example of chest pain. Someone comes to the emergency room and feels chest pain. The practice in much of medicine is just to rule out a heart attack. You can do that by a series of steps, ike g, vital signs, a brief exam. At the end of the day, if you rule that out, many of those patients are just discharged. They dont know why they have chest pain. Maybe the next time they feel that chest pain, maybe they are still feeling that chest pain, they have to come back to the emergency room. Algorithms become the practice. When algorithms become a practice instead of a tool, trust me, i use algorithms. I have to use a decision tree. It helps you. It helps you understand how to, what diagnosis. It can guide your diagnosis. So much of our Health Care System is based with billing to achieve these diagnoses. The algorithms become of the practice instead of talking to the patient, connecting and saying, well, i actually think that your chest pain is due to esophagus reflux. Making that connection, that is an example of when we are trying to rule out algorithmania rather than actually trying to diagnose. How has it showed up in your teaching . In teaching, i have bedside rounds. We try to listen to the patient. I practice so that first of all, i think that we need to improve our attention. We all feel this. We all are wanting to have our phones around us. Our attention is being bombarded at all times. I ask my students, think about it from the perspective of the patient. If you look up and there is a team and everyone is kind of doing their own thing, you dont think that they are thinking cohesively about your problem, right . We try to practice attention. We listened to words and it can make a big difference in the relaying of a symptom when someone says i cant breathe or i cant breathe in, for example. Okay, breathes in, maybe that can target me more toward asthma. I need to look for crackles. Things like that, you know . We are really trying to focus in on the language to avoid algorithmania so that we can also communicate to people so that they understand what it is that they are diagnosis is and maybe they wont have to come to the hospital again unnecessarily. There is such a myth that you talked about in the book as well. I am feeling it inside of me as i listen to you speak. That sounds expensive. There is you talk about the recent universal coverage is still being debated, these are your words, not because american supposed in principle. It is because americans fear the cost. Rightfully so. We have an extraordinarily expensive Health Care System. I think that money is the problem. Its not that we lack money, its just that there is too much. It is so greased by modern, so transactional, that we have to start to dampen that down and think about actually utilizing resources that we have. Its fee for service, right . I giveee for the example in my hospital that we have three working mris. Its not like a hospital right push about an air already willing the patient mri. I think its a good enough for a couple of reasons. Number one is that sometimes you do not need an mri. When i have a patient who i feel needs an mri stat, like if i feel there is spinal cord being compressed and i think its absolutely time sensitive, i will call the radiologist myself and say that i need it stat. That is a conversation that happens between me and the radiologist to prioritize that patient. That is in contrast to when you have a wealth of machines available. You get a lot of unnecessary tests. That is how things start to amount and i think that we need to go back to being more precise in medicine and not rely on just in access of it. There is so much waste. There is a figure out there in the hundreds of billions. I have it in my book. I have it about how much it would cost to give Everybody Health care in the United States. It is the exact amount of how much we waste in the American Health care system. We have to think about curtailing our waste so that we can be more equitable and give people and allow people to have better Health Care Access. I appreciated the way you wrote it. We are all paying somehow. We all pay somehow. All of us are affected by this, whether we can see it immediately as a crisis on a given day or not. There is a question i really enjoy asking people like you who seem to think deeply and they think about their work as a vocation as you have written about. What do we have to risk . Toward the end of the book, you used the word relinquish. You put it side by side with this. We are all paying somehow but we also are sacrificing. We also have to sacrifice. We are sacrificing fairness in the system. We are sacrificing equality. We are sacrificing quality of care because even what i am considering costly is a myth. I think you talk about privacy. I felt that very seriously myself as you were describing award. That sounded oh, can i pay for my own room . What do we can you talk more about this idea of relinquishing . I think we do need to consider how much health care has become more and more private, not just in the way that we are deciding that every person has to pay more and more for their private health care, but also how it unfolds in the hospital. Its getting more and more private. That leads to increased cost. I give the example of Florence Nightingale. She invented this ward in the crimean war. Patients are on the periphery. The nursing station is in the middle. That allows doctors and nurses to look at all the patients. It is ventilated. If you go to an emergency room now in a private hospital, its labyrinthine. You are put into a little hospital rooms, little rooms. Its very difficult for the doctors and the nurses to monitor unless you have electrodes. That leads to more and more costs and everything. The award that i the main ward at ben taub for many years was an emergency room nightingale ward. First of all, you know, Florence Nightingale showed the mortality plummeted when it went 80 down. It was helpful. It was also costeffective. In our American Health care system, we do things differently. We try to privatized, privatized, privatized so we can charge more and more and more. That is something that we need to think about relinquishing if we are getting to the point where so many people are still left uncovered and we are paying so much for health care. They are intertwined. The more that we are paying out of it, the more it is going to be difficult to achieve equity for everyone. Another scale in this book is that you are writing to us as a person on the receiving end of care or helps facilitate your family to access and consider care. There is such a deep vulnerability in the stories that you brought in specific to your family and your grandmother and your dad, your wife. I am curious to know the choices for moving into the process as a writer, the choices of bringing in that vulnerability and what it does to your overall book. The major mental hurdle that i had to make in order to get to this book done, much initial thought behind this book was that i just wanted to pick these peoples stories. Nobody knows how difficult it has been for these individuals to get health care. They are odysseys. I was like, i want to depict that journalistically. It became clear that it was just it is hard for a reader to understand that. They dont have my lens of realizing. It doesnt have to be like this. I felt like i had to i did not want to write a medical memoir. I did not want my stories to overshadow any of the people stories. I realized that my lens was important. I had to figure out how to make it so that my story fit the argument that i am making and also this greater narrative of these patients stories and how they are unified. I realize that it was just a resistance that i had and i had to go through the process to learn it. For instance, one of my early readers was like, you know, it was not until patient 222 that you told me your dog was a doctor. I feel like you are withholding information. I was like, yeah, i think i am. I just i had to go back to the drawing board and really come up with a structure and allow myself to be a part of the story in the right measure. I think any book worth reading is one that i have a sense that only this person could have written this book. As i read the way in which you and your own story within the five people that you share, your patients, and put it within the context of the larger system, i thought, oh, only this person, but not to mention because you just shared with a reader that if you were not going to be a doctor you were were going to be a writer anyway. You worked in Public Health in many different ways. So much of that makes complete sense in the way that you have brought your whole self into this book and what you have shared with us. There is a component of the book, hope is in the title. You evoke imagination and you evoke vision. You use words like bold. You say our imaginations are constrained by the reality of what has been rather than perceiving what could be or that at a Public Hospital the patient becomes the communities customer and the doctor serves society. That sentence alone forces us to think a minute about what could be. We were also talking about something called the disastrous syndrome. It is just about there is a general sense that we collectively know that it is not working and that it is bad. There is a starkness in that. Did the process of writing this book, and i will also add that the burnout of doctors that you address as well, did the process of writing this book, something for you in terms of how you think about facing burnout yes, no, mostly yes. It did shift. I feel like i got, one of the important things about writing this book was something that, again, another mental hurdle i did not want to write about the history of, it sounded so terrible to read history books about health care in america. Until you find the right book. Right. I came across the book the transformation of american medicine. I think its an astounding book. Its situates historically this conflict of doctors in america gaining power and wanting to hold on to the inner conflict. There is part of it that they want to be able to they want to be able to keep that relationship between patients and doctors a bit pure. There is also this other side which is the incentive portion, the fee for service portion. They want to be able to build them directly. Think about that. We dont go to a mechanic and pay the garage and the mechanic. We pay one entity. In medicine, when you go to the emergency room, you get bombarded by all of the bills come from everywhere. Doctors, the less, everything, its because of that sort of holding on to power that that has become like that. That is one of confronting that was it, made me think, well, things are changing with the lobby of the american medical association. Things are not as homogenous. In obamacare, the lobby relinquished and said that there was knowing the history and knowing what the changes are, that brought about more optimism, even in a very sort of we are going to have to reckon with this. Were going to have to reckon with this because doctors are leaving the field. They are having i can tell you they are either leaving the field early because they are fed up with how medicine is i am not i dont mean just doctors, i mean practitioners, nurses,. There comes a point where people are like, i am done with this. There is a transactional nature, things like that, of dealing with insurances. We have to we are getting to the point where we are finally having to reckon with that. Burnout is a symptom of the medical system. I think its time to pass the mic around the room. What questions do yall have . I see a hand in the far back. I. I was wondering if you could talk about heal, what it is, why it is important, what it can do for us. Wonderful. Thank you for that question. Heal its the humanities expression and arts lab. What that is is an attempt to bring arts and humanities into medical education, okay . In the middle of the pandemic, december 2020, the association of american medical colleges released a report saying that arts and humanities are fundamental to medical education. We should be teaching doctors with tools like art and philosophy and history. That might seem really out there, but that is really the roots of medicine. What has happened is that the pendulum has swung much more to the side for a lot of good reasons. There has been a lot of scientific progress over the last hundred years. In doing that, what have we lost . Well, what they were trying to address is, like i said, burnout, just how people are not able to gather meaning from their work. There is attrition because people go in and think that they are just helping Insurance Companies rather than helping that person. They are not Building Structures of meaning in their life. Its also communication. How many people feel like their practitioner speaks with them in a way that is satisfying in that they understand . The arts and humanities have something to do with that. Even decisionmaking, you know, i think that if you select for doctors to be more scientifically inclined, when it comes to the gray zone of medicine, those of us who practice it know that so much is in the gray zone. It is really hard for people to make judgments when it feels like it should be a multiple choice answer. That is Fertile Ground for the arts and humanities. That is why we take students to go to the art viewings at the museum of fine arts and houston to understand perspective taking. We have reflective writing workshops and a medical humanities class were people, the medical students are able to listen to humanists and people who are working in the field to understand and build those ideas of meaning so that they can become more resilient and going through their profession and their practice. Beautiful. I have a question. Yes . I am a nurse. I was with the University Health system. It made a tremendous difference. Thank you for mentioning that. My question is, over my lifetime, social movements have happened. The civil rights where people did not want that. So wondering replace obamacare. There was a movement when people did not want that. This is going to take a social movement for us to really rethink and restructure health care . Thats a really good question that, im one of these people that hopes that it doesnt, that we can, like, we just pound the pavement and people, people know that there is unity, to a large extent, you know . People knowing about the Health Care System is broken, people knowing that they are paying too much for is, people recognizing that corporate interests are above patient interests. That spreads across both political parties, you know . Now, what is going to be, like, whats going to catalyze that . Thats a great question. I hope that at the grassroots level, education and, like, coming up with alternatives, like, showing people that there are alternatives. I think all of us feel stuck in the stranglehold of, like, corporate medicine and so, i am hoping it doesnt need to be so. But i agree with you that, it like, it feels like if you look at it historically, like, the social movements, thats what happened in the uk for, the National Health service to be born. It was in large part due to the war, world war ii. I hope we can find our way out of that and what it might mean. Weve run out of time for questions. However, there is a book signing that you will be available for. I want to wrap us up with one last thought. Sure. The moment in the book in which you talk about how often you were asked to speak when you were attending funerals of your patients who have since passed. You said very specifically, perhaps i am asked as often to speak because these families need to hear that your loved one was worthy of our attention and our care. I am repeating that out loud to bring that into this space and also say thank you for your practice and for this book. Thank you very much. Every Single Person deserves to be cared for. We have the capacity to do it. We can do it. We cannot take these models and build on them. I feel liberated to work in a system that allows me to focus on them. All right, thank you, ricardo. Thank you to the attendees. A round of applause, please. A reminder also that the festival marketplace has book sales and signings. The next event will come in shortly. They are asking us to boogie out of here pretty quickly. Thank you, everyone American History tv, saturdays on cspan two, exploring the people and events that tell the american story. At three pm eastern, watch the second part of the Calvin Coolidge centennial Conference Marking the centennial of the 30th president s ascension to the white house. And i 30 pm eastern, former white house photographer pizzas out for president Ronald Reagan and barack obama talks about the daytoday workings of the presidency including the history making moments he witnessed, exploring the american story. Watch American History tv saturdays on cspan two and find the full schedule on your Program Guide or watch online anytime at cspan. Org slash history. A healthy democracy does not just look like this. It looks like this. 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