Ladies and gentlemen, i am tonya, i want to thank you for coming in this evening. We have a great lineup of different authors throughout the year. We do upwards of 400 events. This handy little flyer will tell you more information about more events coming up. Right now were so happy to welcome a new northwest arthur, will claim here as long as we can, rachel pearson. [applause] thank you so much tonya can you hear me . Thanks so much for coming out. Were excited to share the book with you and hear your questions if you have any. This is a book that i wrote primarily based on experiences i had a medical school. Is working in texas where i cared for folks and marginalized communities. A free clinic some border clinics and county hospitals in central texas. This was eyeopening and lifechanging. Im excited to share with you tonight. One thing to know is that it deals with a really heavy things. So at the same time it has stories about our family, stories about our friends. Im gonna start off with a section that i think is funny. This is based in west texas in a time townwide to my Family Medicine rotation. A little town called for davis. In the story i was riding into town with the dr. Who takes care patients in that town. We pulled in a little strip of the town with 1000 inhabitants. The mcdonald observatory. The clinic is on one end of the town. The dr. Said hi to everybody and set me off to see the first patient. Its mr. Houston. Talk it down to me. He is a rancher in his 60s with strong arms. I think i told myself picking up a hay bale. Yes, he did the wife said, down there. I understand i said. This is been better for me and in my surgery rotation a helped repair hernias. He told me the whole story. How he picked up the hay bill and felt the sudden pain in the groin area and it didnt go away. Pull your genes down a set after a while and i will check you for a hernia. He shrugged his shoulders and said well, alright and unbuckled his belt. Sure enough when i pressed my finger against the opening of his canal and had him cough a bowl i felt on my fingertip. And i said thats a hernia. He said well heck. Yep i said as i repeated. Well heck misses house and said pointing at her genitals. His genitals. Its broken. Yes man, i said but its not too broken, we can fix it. Dang it to heck mr. Houston said, putting his hands on his hips. I sure his home you can fix it. Thats right said his wife. You can play a short supply of the dr. Take a look. I stepped down upon the dr. In his office. How is mr. House and he asked . He has a hernia said, he got it from a can of handbell. My goodness he said. Its a leftsided indirect tourney i said. You checked in for it . I sure did, did a lot of hernia rotations. Well good for you he said. Blushing a little bit. In the exam room dr. Had him pull his jeans down again. Yep, thats a hernia. Well, heck mr. House and said. The dr. Turned to me, you sure did learn to do a hernia exam. Yes sir, i said. Thank you. She did real good job mr. House and said. Yes, sir mrs. House and said well thank you. You can play your genes up now. I reckon we will schedule you for surgery and alpine he asked . Yes. Well, heck mr. Mrs. House and separate and then she pointed to his genitals settle is still work . Yes, maam dont let them fool you, it will work. Then doctor lukey kissed them both on the top of the head and we stepped out. That was a really lovely place to train where doctor cares so much out of his patients. Out there we also cared for folks who do not have regular access to primary care. So some of those stories are bit more difficult but i wanted to start out with something light. The story is more from the heart of the book so i went to medical school in south texas and i started my school my island was hit by hurricane. Hurricane ike. In the aftermath the hospital which had historically been a charity hospital, the kind of hospital where someone in texas who could not get care for for her patient could get on the bus and know that they would get care there. That hospital changed very abruptly we stop doing any charity care and the patients who are on though program were sent form letters that said for example, due to the devastation caused by hurricane ike the doctor susan will no longer be your dr. And that included patients who have cancer were patients who had chronic disease, patients read complicated disease i what happened after hurricane ike very much to find my experience as a medical student in the kind of dr. But i am becoming. So this story is about the dr. Who is the head and that cancer surgeon. She refused to abandon her patients even when they were dropped. This is about her and what she did. What is a surgeon without the operating room . What is a good dr. Do when the institution she works for tells her to abandon patients who obviously need her help . Susan began to find her own answers to these questions by driving up the coast. Her patients were scattered but many lived further up the coast in areas that had not been flooded by ike. These patients to have gotten a form letter. Susan cannot reach them by telephone to the weeks after hurricane ike she began to climb into her volkswagen and drive out to find them. She was a custom to all the free time i can granted her and she began to fill with the practice of medicine. The weather was beautiful. Sunny and cool, the most perfect october you could dream of after your town was destroyed. The felt like a vacation for a while, leaving the wreckage behind and driving to the seaside town listening to variations. These towns were starting the intact compared to galveston. The oak trees were alive the restaurants were open, people had lawn chairs and swing sets in their yard. Susan would drive to the nearest point she could find for her patients address. If she cannot find the house should ask around at Corner Stores and churches until someone knew where her patient live. Susans patient spanned the width of american poverty. Some werent houses and somewhere in trailers and summering garage apartments with third floors where the electricity came from an extension cord and Running Water would be an issue. She began to learn that every little house matter how humble could feel like home. Should go to the door of the trailer and someone would offer couple tap water. Afterward to be invited to sit in the folding chairs out front. She was conscious of her own comparative wealth and grateful for her modest car that was not too shabby to seem doctrinally but not stick out in any neighborhood. On the, her patients did not seem surprised to see her. It was as if they were sitting at the edge of the bed waiting for her to walk in. There are people at every stage of treatment. Susan explained that they had a great chance of surviving. There are people who have feeding tubes in their stomachs and tracheotomys and their throats. Somehow gotten search already and some who had not. What are we going to do they would ask her . Whats the plan . Thats when the easy autumn feeling grew thin and shaky. Susan did not know exactly what to do. Some of her patients were convinced the interruption care was a temporary thing and that you can be taken back as soon as they could. Others have begun to seek care elsewhere. Others were too sick to do anything at all. She had to tell them is true. Should no longer be able to treat their cancer. Susans patients when asked what happen if they do not take care and this was worse. Head and that cancer is often a punch it leads to death or goes to your braid relative to an artery. You can hemorrhage out of your mouth and nose and drowned in your blood. Susan began forcing herself to tell the truth. Not all those details, but the truth. You will die she would say, you will die because of this. I know you said i said he had a 70 chance of being alive but that was with treatment. Without treatment your mortality rate will be 100 . This is not an easy thing to say and sometimes she failed. She would dancer on the issue and do applications for medicaid even though she knew the planes would work that she tried to force herself to sit strongly. You will die. That was awful also. It was too much. Sometimes the conversations were arduous to hourlong affairs with the patient saying, tell me again how this that im not going to get care and so she would try to repeat it. A time or two she arrived at the patients house and sat silently in her car for a few minutes then turned around and drove back to galveston, to heartsick to have the conversation again. She felt the conversations had to happen facetoface. She cannot fathom the form letter. The innocuous language that meant bleeding and suffocation. Her patients deserved, at the very least to hear it in person, to have it made plain. So she would return to the home into these impossible conversations. She was an unfamiliar territory beyond the guidelines of how to discuss at best. At the surgeon she was trying to confront diagnoses and she knew how to tell people treatment was not working and to tell a person that their disease cannot be cured. Many of her patients decide before because Cancer Patients do. But this felt different. She cannot blame the cancer itself, the disease that humbles all of medicine, the situation felt unnatural and she was not sure who to blame. The insurance system, the state, the hurricane, another employee . At times she blamed herself. She felt like a useless novelty, surgeon who cannot operate, a cancer dr. Who cannot cure. She had some idea that she could stand by her patients, she could go to their houses and land their hands and comfort them. She could clean their wounds, change their tubes and write prescriptions for their pain. Each encounter began with the washing of hands and sometimes to wash her hands she had to begin by washing the dishes in the sink and then putting them away. Her patients were alone and sick and things like dishes had been forgotten. As strange as it was it was also deeply familiar. The same old rituals of doctoring acted out in a trailer park outside vermont. Clean hands, vital signs, history taking, care sometimes a neighbor would be sick and she would see them too. Yes some patients did not want this. They did not want her comfort with the laying on of hands or doctor who follows the ethical imperative of abandonment. They wanted surgery, radiation chemotherapy and cures. They wanted to live. [applause] there are some sad stories in here as well. How are we on time . Them going to read one more story this is about a time when a lady was super sick and a volunteer managed to push and push until she got care. The volunteers name is jaclyn. Where will start in story they had already diagnosed her patient with Cervical Cancer. Where worked in galveston we all too often able to diagnose patients with cancer by getting biopsies and having them read by pathologist. We are not able to get them treatment. That a student run free clinic you cannot do chemotherapy, you cant do surgery or radiation. When there is not a robust safety net, patients may dive diseases that you know are treatable. The sun doesnt and like that, so bear with me. Jaclyn was raised in south texas and gloria was raised in el salvador. Jaclyns parents immigrated from cuba and hers was a family of doctors. Her fathers father was not tomorrow just in cuba. Then repeated residency in detroit to become a general practitioner. Jaclyns father became an oncologist. Her mother once refused to move to port arthur because quote, it smells. Jaclyn had a nanny whom she loved. Theres a catholic shrine on the entryway to the house and her mother often tells her to pray. Her father says that she will need got us a position. When he stopped living in a world of blackandwhite and spent time in the gray area you will need god. Gloria, this is the patient had a husband and a chauffeur in el salvador. After she and her husband both lost our jobs way promised to give 3000 to bring her north. She worked for a while in a shrimp factory in virginia saving money to bring her daughter north. The daughter married an american citizen and doesnt involve herself much with gloria. Certainly not enough to pay for glorias and her brother to come northward as for his husband, they moved to galveston to live with the nephew and work in a kitchen. She wore gloves that made the skin of her hands cracked. One day jaclyn met her. Theres a part in which i will pass over it talks a lot about the data around Cervical Cancer. Cervical cancer is a cancer that the government has committed to funding and diagnose treatment for. In general if you diagnose Cervical Cancer can get them treatment. Gloria was undocumented. Latino women and undocumented women and women in texas are more likely to get Cervical Cancer more likely to die of it. It is a dilemma and because she was undocumented we couldnt get her into programs to fund her treatment. So we started planning for her treatment. The met diagnosis and staging while we tried to find charity care for gloria. If jaclyn wasnt the student in charge she would translate. I hugged her and held onto her own hands and said make up lessee. Meanwhile, gloria by the time she was rejected at three hospitals jaclyn gave her the bad news. Jaclyn is no longer practicing catholic but sometimes after these encounters she would call her father, itll work out he would say. This is why you should go to church. If it doesnt work out jaclyn thought shes going to need to pray to somebody. The rejections cap coming jaclyn gloria kept picking up more elaborate plans to get gloria the care she needed. Somehow jaclyn convinced to convince us see stan to find out if she had cancer the rest of her body. One of the doctors got on her case for dedicating so much to this one patient. Do you think shes trying to play you . For what . Jaclyn thought. The scan came back negative showing that it had not spread. The same dr. Asked why they had needed it. Jaclyn was silently grateful to see that the cancer had not invaded glorias organs. They took time and in some ways it felt like were stalling. Killing time was scratched around for someone to offer surgery and chemo. If glory had been admitted to a hospital all of these things, the biopsy, the scan and treatment couldve been done in a day or two. Weeks turns into a month and then two months. The cancer was growing. Over the course of a workday blood seeped through her underwear. Jaclyn does not particularly believe in being well rounded as a dr. She was under pressure to treat medicine as a job. Her father never loved his work at the office he was always on call always thinking about his patients. Part of me doesnt want medicine to be the way of life. But thats just the way its going to be, why is it so bad that i want my life to have meaning for my work. Some part of me wanted to stop her and tell her that life is full of meaning we dont have to take all of it from medicine. But i could no more stopper than i could stop myself. She chose medicine. She drove gloria into houston where her application for charity care was rejected by the cancer center. Gloria told jaclyn to trust in god. Faith. The day came when jaclyn and gloria were trying to figure out if she could go to houston to get Emergency Care coverage under the hospital care district but gloria had nothing that showed her address at all. Maybe we can get you in a study they said lightly patting her back. Jaclyn translated gloria burst into tears. I. E. Tell me i wont take care she said. Im not sure i want to go on. I want to go back to el salvador to be with my family. I want to go back to el salvador to die. Jaclyn went home filled with guilt. Like america the answer came the next day. Gloria called jaclyn on her cell phone thanks in large part to jaclyns advocacy gloria had been accepted for charity care. She would begin treatment the next week. Jaclyn wept again. Should now go back to el salvador i would stay here and live. Sometimes medical students and doctors do get too involved with our patients. Sometimes we sacrifice our family lives, our art, things that keep us human. Sometimes we push and push and dont give up on the new dr. Who you think of nothing else and you actually save your patients life. Jaclyn and gloria still talk on the phone sometimes, even now that gloria has her own doctors. Glorious praise for Jaclyn Jaclyn meditates. Meditation doesnt quite feel full enough though and sometime she prays in an earnest way. Shes not quite sure whom shes praying to but sometimes she just needs to pray. [applause] thank you so much. If you have questions would love to chat. Thank you for the reading. Why do you think it is that people need to hear stories that turn out well and have such a hard time tolerating stories that have bad endings . Thats a good question. Ive noticed on this is the book and started moving out in the world that i get asked to tell the miracle stories to me the miracle stories are those of routine care were a baby is born and they do fine. Was somebodys Blood Pressure is imperfectly controlled and they dont have a stroke. I think there is a healing power in the stories of suffering. I think people who struggle with the Healthcare System who have been tonight access to care the to hear those stories and be reassured that their stories are real. That the suffering happened a mattered and can be put into words. At the same time we all have to hope, myself as much as anybody. I found myself saying over and over there so much good in the Affordable Care act that we can build the. Theres so much we can can be proud of. I myself having been through this who cared to folks in rough situations turn towards hope over and over. I think its human. Considering the current heated, insane Political Climate where liberal versus conservative is clashing in a way that it has in a long time in the healthcare issue of what were going to do as a country of people who are prolife and prochoice are more adamant than ever in their discourse, are you concerned or have you yet cut any flak, you want everybody to have specifically are prochoice are you worried about experiencing any flak . Thats also very good question. I do write in the book about working in Abortion Clinic and i share stories of women who got care there. And i tried to do it in a way with either side of the political debate, what you see is a provider is women who are struggling and for women who that kind of care is painful and difficult and challenging. I think i probably will be told by some people and thats happening already a little bit and thats okay, sometimes you have to speak out about things and i think the thing i was most worried about getting pushback was one of the overall charges the book makes and that means we learn from those communities. We make our mistakes from those communities and when i now see a private dr. With my wonderful private insurance ive seen a dr. Who made mistakes. I think thats hard for doctors to face honestly because we think of charity work we think of working in Public Hospitals is something that makes us good, something that ensures that we are world. Its harder to think about the way we benefit from a system that denies care to some americans. Its harder to think about the fact that i trained same people who would have preferred to see a fully qualified dock. But because they were denied comprehensive care they hadnt seen me. I was able to gradually sneak up on it but those hard truths are hard to look at have you reconnected with anybody . So he is a friend of mind and shivered me to galveston from the book especially because the book was critical and all of that was really thoughtful and generous with their thoughts. I think most of the doctors there are Mission Oriented people who are deeply dedicated to the care of the vulnerable and they feel a lot of pain without the policies that have tonight charity care to so many. Ive also been in touch with patients and that has been one of the great joys is one in the book, vanessa who is a cool person in the book i describe how she back committee from hurricane ike with all of her animals and its dogs, cats, a macaw, an abandoned baby squirrel, shes a tenderhearted lady and she told me that it feels really nice to tell a story in the way they recognize it. It felt true to them. What were your relationship be like with in the future . Are you working on something . Thats a good question. I hope my relationship is one that i will be a pediatrician there. But who knows. That is super reassuring and gratifying and it wasnt its not a surprise, came after some of the articles that came out of from not being able to get the patients that they needed. But i see there is doctors and nurses the respiratory therapist they wanted to the best. It was the state, it was texas not extending medicaid. Like 18 other states. It was deliberate denial of resources to vulnerable communities at a state level. Then there was the Natural Disaster component which you cannot overlook. I try to be a fair and decent human being. Its a place at the that its where i became who i am. I think i am all right. [laughter] i really hope its an ongoing conversation with them. I turned 80 in december so ive been doing a lot of thinking about death and dying. Thats my observation is that those people who are able to get Palliative Care or hospice care and who truly believe that they will be reunited with their loved ones who have passed on before them, or go to heaven and meet jesus army god, those people who truly believe that i think itd is a lot easier. For those people like me who believe after death it is oblivion like it was before i was born, the thought of death is a very frightening experience. Boy, i am with you on that. I find it very frightening. Susan became a palace to care. As well as a surgeon and she got that because some of her patients die. Never thought that was okay. She thought every patient should have had a chance to try to live. And that their preventable death was a tragedy. I do not know what lies beyond this life. I am certainly with you on the effort as to try to make as much meaning as we can overhear because whatever is after this this is finite and its overly beautiful stuff. And happy birthday. That was in december. Well, happy birthday. [laughter] i was curious when he got asked the question about the political divide if youd be willing to talk about your experience talking with more conservatives on your to her. Thank you so much. The radio tour has been a source of constant light. I have enjoyed it so much. I think it works because im from a small town in texas. The book puts forth, its not explicitly like this is what we need to do politically, but the arguments are from a bleeding heart. I have been really delighted to find that folks across the political spectrum believe that everybody deserves to see a dr. When they are ill, suffering and worried about their kid. I have been asked what characterizes why can do questions. When that comes up you acknowledge the question and you talk about access to primary care. Thats all you ever have to do. They radio tour is cool because they hear accents from people across the country and issues that i love and care about. I got invited to go fishing with the guy at the Radio Station and i was gonna try to do it. I would love to do that. Its been a pleasure. To be able to get out there and talk. Thank you so much for coming out tonight. [applause] heres a look at authors recently featured on afterwards, our weekly Author Interview program. No America President and ceo, annemarie slaughter examined how technologies impacting foreign affairs. The briscoe senator argued that americas youth are not prepared for adulthood. Msnbc host, chris hayes discussed racial inequality in the United States. In the coming weeks, Temple University professor, he is davis look at gender identity. Then will report on how low and moderate income families manage money. This weekend, utah senator, mike lee will recall the forgotten men and women who fought against the large federal government during americas founding. Jefferson is someone i respect a lot. Hes the author of the declaration of independence. Even Thomas Jefferson, this genius of the law of architecture, of science, Thomas Jefferson having obtained the president of the United States still had a very humid and jealous political heart. That has to be kept in mind. Of all the geniuses of our founders, isnt that the most central one . They understood as medicine said that men are not angels and particularly when they are in power that is when you will have powers trim problems and when you will have the checks and balances and horizontal and vertical constraints on power. Jeffersons actions would not have surprised them. They were just fulfilling the prophecy of human nature that they themselves had predicted in 1785 to make 1777. That is right. If theres one common sin it would be adultery. Worshiping as it were george washington. Almost uniformly to the point of revering him. It was all but a foregone conclusion and notwithstanding they wrote article two with washington its first president to mine. They still love the power of the presidency relatively weak, in part because they understood this concept that medicine explain so well the government provides us a deep insight into human nature. Host senator you have written this incredible book. Talk a little bit about why you wrote it. Guest im a big believer in the founding generation, one that if Broadway Musical hamilton came out i was very pleased with how popular it became