It is an honor and a pleasure to be able to introduce dr. Ricardo new zealand i am a big fan of bios because i introductions are a way of people their flowers in real time. Ricardo is a writer and practicing doctor. He is an associate professor of medicine, medical ethics and health policy. Baylor college of medicine, where he directs the humanities expression and arts lab, also known as heal the heal program. He is also a writer with pieces appearing in texas monthly, houston chronicle, the new yorker, the new york times, the atlantic, and of course, the england journal of medicine. His short stories have appeared the best american short stories anthology mcsweeneys and the new england review, which awarded him its inaugural emerging writers award. His debut book, which were here to talk about today, the peoples hospital, follows the lives of five uninsured houstonians, as struggle for survival leads to a hospital where insurance comes second to genuine care. Thank you for being here in san antonio and at the book festival. Thank you so much for. Thank you all for coming much appreciate. As we are in conversation and make sure i note for you all that we absolutely have time today to in conversation with everyone thats in this space and draw from the collective in the room. So please be flagging the questions that are in your as you listen to ricardo and well be taking an abraham specific lee in the yellow shirt over here that brilliant books shirt will be moving the mic around the room. I want to bring the book into the room by passing the mic to to just get us started with reading to bring your book to life. Please use so much. So im going to read from the very beginning of the book. This is from chapter one histories. The first page, this is from the peoples hospital, hope and peril in american medicine. Right. The rumor we heard was that patients arrived with handdrawn 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 wearing red converse. All in a judas priest tshirt that screamed mexico city acute lymphocytic leukemia. The grandmother, the saris snagged in the guardrails chest pain real chest pain might need bypass. We stood at these bedsides. We wrote down their histories. We said we were sorry for examining them with cold hands. We ordered blood tests, interpreted the ekgs scrolled their cat scans. We input diagnosis is we werent just doctors among us were nurses social workers xray techs. The who rode up and down the hallways 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, became tribal. We werent we we were ortho plastics. The foreign nurses. We only covered the unit more often though the needs of our patients were so immediate we found way to work as one. We ran blood, heparin drips a, morphine pump when norco didnt 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 like a seizure, a twitch, a rolling of the eyes. We paged neurology. 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 beating dogs, we figured out ways 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 hospice that used to be a tutor style home. And 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 them here . What are their stories . Ben taub hospital, the largest safety hospital in one of americas most diverse. We are heathrow. If we replace the emirates and the virgin planes with greyhound busses. There are no atriums with pianists here playing. Here comes the sun to welcome, you know, soothing of Running Water from hidden speakers or gasp from an actual waterfall. There is starbucks or cafeteria serves some form of barbecue. Most days for lunch and packaged salads topped with eggs or chicken strips. Thats unless you prefer the full menu. Mcdonalds located the hospital thats open 23 hours a day. We do have a gift shop, though. It looks more like a convenience. Heavily stocked with greeting cards, not the pun filled ones. Rather the kind that get the point across. Condolence is available in spanish to. If you type ben taub into google maps, find it crammed between the houston zoo and the 30 other institutions that make 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 meatless artificial heart. Imagine that. No loved hub, just a constant whirring. The first silicon breast implant. One of the first civilian helicopter. The bubble boy all here. Not that the patients at ben taub know this. Some may heard that md anderson is rated 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 aired in spanish to. Its possible that at night our patients look out their windows and behold the sparkle of so many new glass buildings, some of them named the billionaire sheikhs who sell the oil that becomes their gas more likely, theyre looking out in the direction of the zoo toward the parking garage and bus stop wondering how theyll get home. If that is just the first three pages by page 14, i want to put the loot down. It was simultaneously pulling heart out and putting words to an in the American Health care system that ive had that i have witnessed, that i didnt know i needed words to be put to them. And even more so by someone whos a doctor. And the first question i have for you is then, i know what the book meant for me. I think im still processing the depth and breadth of what it means to me. And im curious to know who is the book for . I mean, book i dedicate the book to the people who work at ben taub hospital with me because we feel such underdogs. I feel like that because its a public Health Care System. So ben taub hospital is the flagship hospital, the public Health Care System in houston. And, you know, here in bear county, you have something similar. And i think that we working there, we can also we can be in the shadows of such you know, of the wealth of hospitals and but really we like were actually doing great work there. And the statistics show that the american mentality is is that the public Health Care System for everybody. And thats what this book is really about, is to dispel that is to show moments of where patients have been issued from the private care system and how Public Health care is of those ways that we can bring costs down, which is an enormous problem in. American health care, while providing basic Health Care Access to because we dont turn anybody away. We take care of every Single Person. And so thats this this is for is dedicated the people but its also for to know that we solve the Health Care Problem in america. We understand what were seeking and if we look at some of the great models that are out there, i want to pick up on underdog. Because throughout the book making, really the very many perceptions of of this that exist for the people who are not there and maybe should be there but also again underdog is a perception, right that might be exist more internally. And makes me curious about what the perception is nationally of the hospital evidenced by some of these deaths. But unpack for us a little bit about the perceptions given the very many actors that you talk over the course of the book. Yeah. So houston being a diverse city, the fourth biggest city in the United States and one of the most uninsured cities in the country, what you would find is a whole milieu of people there, including people who just cant afford health. Right. Or who cant get up. Who have their job and its an increasing amount of people who are left in the cracks of our Health Care System. And those people feel like underdogs. They look at the glass, they look at these large institutions of the of the Texas Medical Center throughout, you know. And they cant care there. So let me give you an example. One of the principal subjects, my book, stephen, he earns 75,000 a year. Hes a restaurant manager, but he elects four his the lowest plan because hes hes actually a real texan hes just like why in gods green earth would i pay for insurance . I think its a racket. Right and but at the beginning of the covid pandemic, he starts to feel a lump on his on his neck and. He soon realizes thats whats causing him fevers. He goes to an emergency. Well, his is so bad that they at the private hospital, they tell him, you have to pay 660 just to sit there. They take him through some, you know all. They shuttle him back forth between different hospitals of that network and then doctor finally sees him, has done the cat scan and says you have tonsil cancer. But then he says next word is. However, however, we cant do anything about it. You have to leave. And for stephen, thats punch in the gut. Social worker has to come in afterwards, say go to the Public Hospital to ben taub. And for stephen, that is even more punch in the gut because hes like, thats for people who are homeless, who are drug addicted. Those are. Thats for people in jails. But were finding what he his is told in the book. But what he finds is is that its his about the public Health Care System are different and you know, thats one of the things that i wanted to to, you know, about health care in america that Public Health care can be very good. And thats one way that we could come together and, think about solving it. So that people like stephen dont get in those situations. It also lays bare for us that. There are the ways in which local government can create interventions and i appreciated so much the history and information shared with me around the leaders and the policymakers that very persistently over. Yeah. Worked diligently. Combined with voters approving things like making the gold card happen. Right. Can you talk about the gold card is and it sort of shed light on the role local government particularly thinking i have in mind is again yes were, in texas. Yes. Were in the legislative session and the part of the book is just peeling the layers and layers and layers of of how much is play for someone to get care. Yeah. So here in san, you have something called carelink, which is very similar to the concept gold card, which is that its not a Health Insurance, but it is Financial Assistance to help people who uninsured or cannot afford health care. And in houston, that came about because, there was a voter referendum in the 1960s. It at that time, there was only one charity hospital. It relied on funds from the county, the city, and each of them were trying to dump it on other. It was called Jefferson Hospital and and it mostly africanamericans and immigrants were, the patients who couldnt afford health care at the time. And had to go to that hospital. Atrocious conditions, you know, to the point where op eds started to written about it. And then there is a voter to fund, a public Health Care System, the seed thats planted in the 1960s. And what comes about that is a Health Care System. A lot like what you have here in bear county right there is that theres count that theres, you know, outlying it there specialty clinics theres hospitals and its a its a its a its a local system that has been cultivated by public leaders over over years very specific to texas like the bigger tech the big texas cities have it for a lot of Different Reasons because the state doesnt want to take, you know, one want to give dollars to health care and allows the county to do that. But as the counties have grown in the urban centers, theyve something in order to keep people out of emergency rooms, you have to provide them health care. We just havent found that out as a nation right. Other countries have thought about this and put it together. Well, part of the book is well there is there is real incentives for that system of people in emergencies. And thats from medicine. So thats you know, its its really an its a model to think about when were thinking about how to piece together. Finally, a Health Care System. If we get to that level. I really hope we do. But its its its something that i hoped would something that we would think about. Theres this scale that youre for us throughout the book in terms of the ways in which we as individual exist within and are served by systems and institutions. Right. And that youre constantly bringing in the position ality of, for example, you as a doctor within the hierarchy of a hospital, or how race and class affect our position ality as showing for care within that very same hospital and another intervention thinking right the policies or Ballot Initiatives that allowed right property taxes to fund Something Like the gold card. At the same time youre showing things like policies that are more common when it comes to Maternal Health in california that we now see at ben taub unlike other areas of the country. And that to me also is another intervention and a policy change. Right. And youre talking to us very specifically about who those people are that are doing the research and making these policies happen. And it made me think about what you would say is the type of leadership that it takes at this moment that were in. Yeah. To identify and implement and and provide the data and bring everyone along as well. Right. Because im thinking about even just the pads and ill leave you to explain. But the way in which nurses had to be brought along in terms of making possible. Yeah. It, you know ben taub is is is a Teaching Hospital at its core and because of the fact 80 who work there who are interested in the academic and evidence based they can you know they can glean the studies and them you know at that the hospital level so that what 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 possible from patients, you know, more, you know, just we have to we have to realize that like for instance, the funding of Like Health Care, the way its financed in the United States is fee service, very different from other places. And i mean, what that means is, is that, you know, doctors and practitioners are compensated for every service that they provide. So if you can bill for every service thats something that in 19 tens doctors fight through a lobby to hold on to that power. Right. And its different than in the in in in other european and. Thats one of the reasons why we such a disparity in how much we pay and what we get from our health care. 0. 18 of every dollar in the United States toward health care more than anything else. Okay. Thats compared thats more than thats around double what you know, the western European Countries spend and our outcomes in infant mortality Maternal Mortality are not nearly as high as as as as as they should be like the way that European Countries have. So were just even even president called it the illogical incentive of the American Health care system which to incentivize paying for sickness rather than like to prevent illness. And thats why costs are out of control. And thats one of the reasons why in an ever in an academic environment where you can have people think about like systems how to it how to prevent you know catastrophes like that. Thats why theres cost saving and thats why it helps patients right thinking about it both in terms of the data that were sitting on and, the fact that its Teaching Hospital. When you were unpacking what you call them and mess it up algo algorithm mania. Yeah so that right you are at that point a doctor as youre unpacking this as youre seeing the pitfalls of chasing that, could you talk to folks about a share, what that is . And then second to that, im curious how it changed your teaching. Yeah. Now as a doctor has that perspective. Yeah. So algorithm mania is what i call the practice of following decision without reconciling that with that, with the connections you make with patients, the histories. So its, its, ill give the example of chest pain. Somebody comes to the emergency room and feels chest pain and the practice in. Much of medicine is just to rule out a heart attack. And you can do that by a series of steps, vital signs, you know, a brief exam. But at the end of the day. So if youve ruled that out many of those patients are just discharged but they dont know why they have chest pain. And so maybe the next time they that chest pain or maybe theyre still feeling that chest pain, they have to come back to the emergency room. Right. Its not that if you algorithms become the practice when algorithms become the practice instead a tool like trust me, i use algorithms i have to use decision trees. I mean, it helps you but kind of understand how to like what diag