EP. 96: A DOCTOR FOR THE PEOPLE

Jan 23

WITH RICARDO NUILA, MD

A physician-writer discusses the joys and frustrations of practicing at an urban safety net hospital and how he perseveres to serve patients in a healthcare system that often feels broken.

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Episode Summary

Ben Taub Hospital, located in the heart of Houston, Texas, is the city's largest hospital for those who cannot afford medical care. Texas, in turn, is the US state with the country's largest uninsured population. Amid chaotic emergency rooms and busy hospital wards serving the most financially and medically vulnerable people, Ricardo Nuila, MD finds meaning and beauty through stories he hears from his patients. In addition to his duties as a hospitalist at Ben Taub Hospital, Dr. Nuila is an associate professor of medicine at Baylor College of Medicine, where he directs the Humanities Expression and Arts Lab, as well as an author whose writings have appeared in the Atlantic, the New Yorker, the New York Times Sunday Review, and more. His 2023 book, The People's Hospital: Hope and Peril in American Medicine, explores the ups and downs of American medicine through the lens of patients he has encountered at Ben Taub.

Over the course of our conversation, we discuss what it's like to practice in a safety net hospital, the power of narrative medicine in connecting with patients, and how clinicians can hold onto their strength of character, even when working in a system that often feels broken and indifferent to human suffering.

Ricardo Nuila, MD is an internal medicine doctor and hospitalist at Ben Taub Hospital in Houston, Texas.
His writings focus mostly on health disparities, how policies affect real people, and the interface between art and medicine. His works have appeared in Texas Monthly, VQR, the New York Times Sunday Review, the Atlantic.com, and the New England Journal of Medicine. He also covered Hurricane Harvey and the COVID pandemic for the New Yorker. His short stories have appeared in the Best American Short Stories anthology as well as in McSweeney’s and other literary magazines.
He also directs the Humanities Expression and Arts Lab (HEAL) at Baylor College of Medicine. This lab develops educational materials and experiences that weave the arts and humanities into medical education.
In this episode, you will hear about:
• 2:25 - How Dr. Nuila became drawn to both medicine and creative writing
• 6:07 - The characteristics that define different types of hospitals
• 12:06 - A patient story that exemplifies the experience of being a doctor at a public safety net hospital
• 20:33 - How Dr. Nuila finds deeper meaning in providing care, even when faced with systemic circumstances that a doctor can’t fix
• 25:34 - Dr. Nuila’s advice for how to get through the moments when you feel like you are “at war” with gaps in the system
• 42:32 - How narrative medicine and storytelling can make more effective clinicians
• 45:45 - Dr. Nuila’s advice on how to make a career in medicine meaningful
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] Ben Taub Hospital, located in the heart of Houston, Texas, is the city's largest hospital for those who cannot afford medical care. Texas, in turn, is the state with the country's largest uninsured population. Amid chaotic emergency rooms and busy hospital wards serving the most financially and medically vulnerable people, Dr. Ricardo Nuila finds meaning and beauty through the relationships he forges and stories he hears from his patients. In addition to his duties as a hospitalist at Ben Taub Hospital, Dr. Nuila is an associate professor of medicine at Baylor College of Medicine, where he directs the Humanities Expression and Arts Lab, as well as an author whose writings have appeared in The Atlantic, The New Yorker, The New York Times, Sunday Review, and more. His 2023 book, The People's Hospital, explores the ups and downs of American medicine through the lens of patients he has encountered at Ben Taub. Over the course of our conversation, we discuss what it's like to practice in a safety net hospital, the power of narrative medicine in connecting with patients, and how clinicians can hold onto their strength of character, even when working in a system that feels broken and indifferent to human suffering.
Henry Bair: [00:02:18] Ricardo, thank you for joining us and welcome to the show.
Dr. Ricardo Nuila: [00:02:22] It's an honor. Thank you for for having me. Henry. Really appreciate it.
Henry Bair: [00:02:25] We're going to dive deep into your work in helping the most vulnerable patients out there. But before that, can you tell us what first brought you to medicine?
Dr. Ricardo Nuila: [00:02:34] Yeah. I was born into a family of doctors. My dad was a doctor. His dad, my grandfather was a doctor. My dad's brother was a doctor. So it was one of those situations where you almost feel like you're moving toward that direction. I wouldn't say that my dad put pressure on me, but it's such a wonderful field to, I mean, I have kids right now and I can tell them exactly what I do, you know, like they... They have a concept. There's this nascent concept of helping others that's inherent in medicine that I think I grew up with. And I could see that my dad was very excited by medicine. He he really loved being a doctor. It was his identity. So I drifted toward that. And it wasn't until college, really, where I started to kind of question it, because I started to fall in love with writing, and I had to figure out how to make those two work. But initially, I think it was just my... The experience within my family.
Henry Bair: [00:03:29] How did that conflict pan out between creative writing and doctoring?
Dr. Ricardo Nuila: [00:03:32] I think I'm still kind of working through that conflict. I think it's like ever... And it's one of those things where I feel like this is... It's a good thing to have a conflict. It's a tension that each side puts on the other.
Henry Bair: [00:03:42] Maybe it's not even a conflict. You know?
Dr. Ricardo Nuila: [00:03:44] Well, you know, there's a conflict for time always, and there's a conflict for it's gotten to the point where, you know, I feel like it's one thing, you know, meaning that if I'm writing, I feel like I'm working on being a doctor. And when I'm practicing medicine, I feel like I'm working on writing, and I really do feel like that. And that's wonderful. But there's clearly times where you feel like you could give time more toward one than the other. I think, you know, the way that it resolved itself or it became something that I just had to amalgamate together into my life was just... In college, I decided to become an English major, and it's because I loved books so much, and I just wasn't in love with the bio major and the track to get to medicine. You know, I wasn't so enamored by, like, you know, a major in science.
Dr. Ricardo Nuila: [00:04:36] And I ended up talking to one of my professors in scriptwriting because I had decided, you know what? I got into medical school after taking the mCAT and everything, but I just couldn't see my life without writing. And I really feared at that time that I go down this path. Medicine. It's all done. I'm just never going to write. I went to go see him, expecting him to kind of tell me, yes, yes, yes, quit medicine, go forth and write. But he said you'd be crazy to leave medicine. My first instinct was like, oh gosh, he just thinks I'm not a very good writer. But he actually was like, no, you can go to graduate school in English or in creative writing and learn technique, but where are you going to get your stories from? And that really stuck with me, and I've had to really dissect that advice. And I feel like I live with that advice.
Dr. Ricardo Nuila: [00:05:30] I feel like that the hospital where I worked at kind of just gave me that wrapped in one, which is that there are people whose stories have not been told at this hospital, and it's such a privilege to try to tell those stories. And I think that patients give me a gift of their stories. And the gift that I give in return is to try to help them as best as I can, as as their doctor. And, you know, again, there's tensions on either side. It sounds really nice sometimes in practice, it can feel like it's overwhelming, but I feel like it's it's driven me for the last like 20 years or so.
Tyler Johnson: [00:06:07] So when I was young, before I did my medical training, I just assumed that a hospital was a hospital was a hospital. And it wasn't until medical school, and really mostly until residency, that I really started to appreciate that that was not the case. And in particular, at my residency program, we had a quaternary care research, you know, very fancy hospital. And then we had a VA hospital, and then we had a county hospital. And it wasn't really until I started to go back and forth between those three hospitals and started to see painted in stark relief the differences between them, that I started to appreciate the fact that if a patient shows up to hospital A or hospital B, or hospital C, or maybe their insurance dictates that they go to one of those, that their experience can be very different depending on the hospital that they show up to. And I think that for most patients, right, unless you have had so many medical problems that you've shown up to multiple different kinds of hospitals or multiple different hospitals, you may not appreciate that either, especially because many of the differences, certainly not all of them, but many of them are sort of behind the scenes from a patient perspective. So can you just talk us through a little bit? What are the differences that define different kinds of hospitals? And in particular, what are some of the characteristics of a county hospital or any less well resourced hospital that define what the experience is like there for doctors and patients?
Dr. Ricardo Nuila: [00:07:32] Yeah, that's a great question. And I had a very similar experience to you in residency, which is that we had three hospitals, VA, larger private academic hospital and then the county hospital. I think the county hospital has been like the flagship for education. And so almost, you know, entering medical school, it was just known that, you know, Ben Taub hospital is where you learn medicine, this is where it gets cases from around the world. And I think that I met that with a measure of trepidation. I was like, whoa, this is this is going to be very intense. But also just, I mean, being a Houstonian, I had heard about Ben Taub as the public hospital where people who can't afford to go get health care elsewhere go. And so there was a part of me that was probably just like, you know, just not aware of who the people who go to the hospital is or are and just almost was like, well, that's a tendril of medicine, not medicine, medicine. So it was this, this strange dichotomy that I felt when I went into it.
Dr. Ricardo Nuila: [00:08:35] Now, I mean, your question about how it's all different, that's something that I feel like it's taken literally like decades for me to unpack of, like how it's different. But this is the way I look at it is, is that the VA is a very interesting system that is federally funded health care for veterans who qualify. And it's organized in a very like top down level, federal level. It has a really interesting referral system so that if you're in a rural community and you're a veteran, you can refer to like cities. And that's one of the places where a lot of people, clinicians will practice so that they can be part of that referral system, but also for research, you know, it's really plugged into research. The private hospital, I felt that as a resident and as a medical student, it is like the the workhorse of medicine in America, which is like it just churns people through like and it's so driven by insurance. It's so driven by health insurance decisions, length of stay. And it is the location where, you know, if you're rotating as a resident or a medical student, you just see, like many people being admitted into the hospital, many people throughput going through. And it's just... And you see ICUs that are filled and anything that can be done medically is done medically. That's what the feeling was for me at the county hospital. The reason I just gravitated toward that was because it felt like it was personal responsibility there. It felt like there's a lot of people who can't afford health care. We have a system that can try to help, but it's really up... Contingent upon you whether or not these people get health care or not or what their experience is going to be leaving, you know, what's the handoff going to be? And so, like those conversations that you have in Spanish with the patient, those conversations that you have through a Vietnamese translator. Everything that you do to kind of impart some level of education to people who are just not going to have it at their fingertips or or, you know, that they're just not going to be able to be privy to. It's going to be helpful, and you're going to see it manifest in the patients like families. There is gratitude shown.
Dr. Ricardo Nuila: [00:10:58] I loved it from the beginning, in part because it's just like I was one of the only people that could speak Spanish on my team. And so I was like, oh, being a student who felt like I wasn't very good at medicine. And then all of a sudden I'm like, oh, I can speak Spanish, I can help these people. It just opened my... But I was interested in the people. And so that became a way to like... The more I delved into social histories, the more I understood all the, the roadblocks that people had to go through in order to get the health care that they needed in the clinics and whatnot. It was helpful for putting together that final plan, and that's I see it as the location where a social medicine is practiced in the United States, which is like that. The doctor's identity is more than just being a person who writes an order, but is more of a communicator, of an amalgamator, of a lot of different threads, of what influences a person's health and tries to help solve difficult problems with the patient at the bedside. That's what I saw from that area of health care.
Henry Bair: [00:12:06] Can you share with us perhaps a patient experience you took care of someone, a story that you observed that really solidified for you that this is the most meaningful, the most impactful place you can practice medicine?
Dr. Ricardo Nuila: [00:12:23] You know, I'll give you an example that's fresh in my mind from last from like two weeks ago, that is. Strangely enough, it sticks with me because I'm almost rankled by it. Because there was, there was it was not a clear cut and wonderful and like, thank you, doctor moment. It was actually kind of the opposite, but it clued me into just the meaning of what we're doing there. It was it was a person who was young and had an arrhythmia that she had had an ablation years before. We didn't have much information, but she lived uninsured, and she lived going back and forth between Texas and South Dakota for personal reasons. She had a son that was in the military there, and so there was a lot of like not getting clear medical care, medical history as well. In the hospital, she had an arrhythmia. It was just really PVC burdens, just a lot of PVCs. But it had started to deteriorate her life, meaning that she was getting tired. She was fatigued. She felt like her heart was about to like slow, slow down enough that she was going to faint. She never had fainted, though, and she just couldn't get health care anywhere. She couldn't, you know, she was uninsured, like I said. But it was strange. It was like she had been denied by Medicaid like the year before. And so it was just like she was in this, like, crack where she couldn't afford to get any of the Obamacare plans. She couldn't qualify for Medicaid, which is like a crack that's much bigger than people realize in Texas. And I met her on the wards. I was trying to get the cardiologists at our hospital to see her, and it just so happens that, you know, EP is so overloaded at the hospital.
Henry Bair: [00:14:10] Sorry to interrupt you there, but for those who may not be aware, EP stands for Electrophysiologists. Who are the cardiologists who specialize in dealing with abnormal heart rhythms?
Dr. Ricardo Nuila: [00:14:21] Yeah. So she was admitted for for this symptomatic bradycardia, possibly. You know, like due to the aberrant contractions that she was having, it wasn't life threatening, but it was enough that it had deteriorated her life. And and so our hospital has been so overwhelmed and overloaded that we're like, literally like the E.R. is just constantly full. And so our pressure is always like, there's people waiting. We need to get things moving. And so this patient I just was like, when it was clear that Cardiology thought that she could follow up in clinic, even though it was going to be a very hard follow up to put together. I was just like, I think you could go home. And she she just she just refused almost. She was like, I you don't understand. I have two young kids. Um, I feel like I'm going to die. And it was dramatic because at one point, you know, I kept her in the hospital. I kept on asking cardiology to come by, and, and and they did eventually come by. And then she she didn't want me as her doctor anymore because of all this stuff. But it what it boiled down to the meaning behind that was just like, damn. I mean, like I had to remind myself, like, we are. We're like, she said, I'm going to go to another hospital and I know that they're going to they're going to throw me out. So if y'all are throwing, if y'all are discharging me right now, I know I don't have anywhere to go and I'm just scared. She had reason to be, but she, if she was, also could not be comforted because of her prior experiences with the health care system.
Dr. Ricardo Nuila: [00:15:55] And so it's rough out there for people. It's really rough out there for people who are who are uninsured, who have care that is just, you know, discombobulated. That is not coherent. The reason it was meaningful for me is because it's just a reminder that it's not all like, oh, thank you, doctor for it. Sometimes it's wars out there with physicians on the front line, meaning like, you feel the pressures on all sides and the war is like you have to look at yourself and be like, what's right to do in this situation? How do I help this person? How do I make sure that this is like, not going to end up being another person that has gone through many? And how do I make sure that our hospital is not one on the list of many places where she said, like, I just didn't get good care there. And and that's hard. That can be really, really hard sometimes when you're facing a lot of pressure. But it was meaningful to me.
Tyler Johnson: [00:16:46] Yeah. So this whole discussion brings me to think about the fact that, you know, I think medical oncology really remarkably, in fact, I would argue probably more than any other branch of internal medicine over the last 20 or 30 years has seen this absolute explosion of new therapies such that even most of the cancers that used to be forget about uncurable, but virtually untreatable. Now, many or most of them have really effective treatments. And, you know, I'm signed up for this email alert through the American Society of Clinical Oncology that every time the FDA either approves a new medicine or approves an old medicine for a new indication, I get an. Email alert and it is striking how often I get email alerts. This is something that used to happen rarely and now it happens all the time. And yet, at the same time, it's also true that there is a growing recognition among oncologists and the entire oncology community that having all of the best, coolest, most effective new drugs in the world doesn't matter if the patients who need the medicines don't have what turns out to be the very complicated social support system and social network that is required to be able to get the therapies right. So for the most part, chemotherapy, for example, requires one or sometimes multiple visits to a cancer center that come in sort of sets, sometimes every week, every two weeks, every three weeks. But it's just to say that depending on how close you live to the cancer center and a bunch of other things, just getting to the appointments can be difficult, let alone then having the care that you need. If you're really tired or really nauseated or feeling lightheaded or whatever. Between the chemo treatments for however you're functioning at home.
Tyler Johnson: [00:18:39] All of this brings to my mind a patient that we recently treated who was a young father of multiple children, and this patient's wife had died a number of years before, and just being able to have the support needed to get to all of the appointments and then to get the care that was necessary in between the appointments, it wasn't so much that there weren't good therapies available, but just being able to get to all of the things and get all of the necessary care turned out to be one of the greatest hurdles in this person, getting the care that they needed for what was otherwise a treatable and potentially even curable cancer. And so I guess I feel that very much in my bones, hearing all of that that you're talking about.
Dr. Ricardo Nuila: [00:19:28] I totally agree. And I think recognition is is the first step. And then just the just the passion that some oncologists show toward those social factors. I visited Parkland System in Dallas, which is a safety net system, much like what Harris Health is in Houston, except in Dallas. And they built this new cancer center that I was able to tour with the oncologist, and I was just so impressed at how deeply the oncologist had thought about the social factors that are preventing their their patient's care. It was great also to see clinicians thinking at this level, you know, thinking like, oh, we have like multiple social workers here, but we also have like, you know, like people who make wigs. I know that that existed in in the private world and it's usually kind of like farmed out and everything, but it's just like, I just love to see it publicly done. It was such great proof that it can be done publicly for everybody. I think that I agree with you. Oncology has been such a leader in this.
Tyler Johnson: [00:20:33] Yeah. So I want to flip this question around a little bit in the following sense. I remember having this feeling when I worked briefly in an emergency department as a medical student, or actually even more so when I worked in an inpatient psychiatric unit in downtown Philadelphia when I was a medical student, when I was working there at the inpatient psychiatric unit, there was this pretty consistent cast of characters in the psychiatric unit who I got to know some of them multiple times, even just working there for six weeks. These were people with serious underlying mental health problems, such as schizophrenia, that made it difficult for them to function consistently in society. And so what would happen is that they would come in to the inpatient psychiatric unit. We would see what was going wrong, we would get them on medications most of the time, medications that they already knew that they needed and that they had already been on previously. They would see great improvement with their medications and then they would be discharged. But then within a few weeks of being discharged because of a lack of money or a lack of a stable place to stay or a lack of a stable job or what have you, they would run out of the resources necessary to get those same medications, eventually run out of the medications, develop the same problems that they had been having intermittently, often for many years, and then end up right back in the inpatient psychiatric unit all over again. And it was, you know, just like a rotating door that they would come into and out of and into and out of because of these deeper underlying systemic problems. And so all of that is just to say that I have to wonder. I remember thinking even back then, and I only worked there for six weeks, that it seemed to me that it would be difficult to ward off feelings of, for lack of a better word, uselessness or powerlessness. If I were working in that kind of a system indefinitely. And so as someone who works in a system where you have to confront those kinds of issues frequently and where you, I'm sure, recognize that the problems that you're treating in the emergency room, even if you treat them effectively, are not going to address the larger underlying systemic issues that are often going to bring some of the same people back for some of the same reasons soon enough. How do you ward off those feelings of powerlessness and of feeling like you're not making enough of a difference?
Dr. Ricardo Nuila: [00:22:54] That's a very good question, and one that I think about a lot. And what I can say is, is, is that some of it has to do, at least for me, with focusing on those moments where you where you do find like you have moved the needle and I'm lucky, like, I think we have very similar patients like to the psychiatric patients that you mentioned, but we also have patients who like, are just to give like a prototype, like undocumented, uninsured and get a diagnosis and they get treated and you see them move on and you see them thrive after that. And you can see that if you can grasp the meaning of that and, like, hold on to it and treasure that, I feel like that... That helps a lot.
Dr. Ricardo Nuila: [00:23:42] I try to look at like the, the good parts of every single day. You know, I had a rough week last week for sure. But in general, like most people are appreciative. And even those people who, if you take that little wider like angle lens, see, okay, the likelihood is that person because they have alcohol addiction or whatever, they're going to be coming back and back. It's still those moments right there where you can connect with somebody and you can maybe say it in a specific way, like, you know, these are the resources. This is why I think, you know, this is the phone call I'm going to make. And you just leave it there and you just say, okay, I mean, I push the envelope a little bit further in this way, and that's the best I could do, right? There. And I feel like that gives you a daily meaning that is helpful, that daily demonstration of kindness, that daily thoughtfulness.
Dr. Ricardo Nuila: [00:24:36] So, I mean, I take a journal, you know, and I just kind of like, write down like interesting stuff from the day, you know, and I think I'm better able to process all that when I can kind of like, take a step back and read all that stuff, you know, and think about. It's kind of a writer's diary. It's not like a Dear Diary thing. It's more like, this made me crack up or this was like very interesting. And if you refer back to it, your mind starts to put the pieces a little bit more together and the puzzle starts to look like an image, at least to me. And I think that that's one of the things that keeps me, keeps me going, you know?
Henry Bair: [00:25:15] So those are some good insights and advice to keep a sustained, you know, throughout our time working in such a hospital, I do want to ask about specific instances. Earlier, you talked about what it feels like to actually be feeling like you're on the front lines of a war, right? Like trying to help people. Well, it gets rough out there. It's really tough.
Henry Bair: [00:25:34] And what that made me think of were two recent experiences I had. So two Sundays ago, I was working in the E.R. and I understand the way the E.R. works is slightly different from inpatient, but nonetheless, this was something that really stood out to me. So this was it was like Sunday afternoon patron comes in unsheltered, came in for upper respiratory tract infections, cough, headache test positive for Covid. Not much we can do just because you don't really do anything for Covid. This person was not high risk. Pretty young like 40. He was in a wheelchair because one of his legs had been amputated for like a bone infection like years ago. Unrelated to this presentation in the emergency room, I asked my attending physician, okay, so we know we have a problem now. It's Covid. What next? And the attending said discharge. There's nothing. You know, we're not gonna admit this person. So I go talk to him and he said, uh, where am I going to go? And then I wasn't really sure what he meant by that. It's like, uh, aren't there shelters you can go to? And he said, well, it's past 6 p.m., so I can't go in now because apparently shelters have curfews, which I embarrassingly, I did not know until that point. And then this was the first day that Philadelphia where I, my, my hospital is started snowing. So it's terribly cold outside and it's like 6:30 p.m. and he has no shelter to go to. So then I ask our social worker on call in the emergency room, what can I do? And she says, well, this person has Covid. So automatically that rules out most shelters. You will have to contact the state to help him get placement. And then I said, okay, how do you do that? And then social worker says it's like a long social work process. Or like you can also try to call them, but they're probably not going to be working because it's Sunday night. So then I go back to the attending and said, this person has no home, has no like no appropriate attire, no food, nowhere to go. What are we going to do? And then he says, he's got to go. He can't... You can't just stay in the hospital. You can't say in the emergency room, there's... There are people out there in the waiting room who need the beds, you know? And so I had to literally wheel the person out and basically leave him on the streets.
Henry Bair: [00:27:47] It felt terrible. This was like the worst, probably the worst moment I have felt in an intern year. In six months of intern year so far. And first of all, that's just like a really painful thing to have to do and come back and then immediately, you know, on my list, I have six other people to see. So you can't even think. You can't even pause to think too much about it. Right? And then part of me was also thinking, why is this even my job? Like, I was angry at the system for like, why is it my job to worry about placement? Right? I'm supposed to be diagnosing and treating and whatnot.
Henry Bair: [00:28:16] So that's like one experience and then the other experience the week before that was an inpatient setting. Person came in and he was withdrawing from opioid use, and he was somewhat belligerent. We were trying to give him put him on Suboxone because he also had this xylazine. I don't know if you're familiar with it. So Xylazine is it's animal tranquilizers, and it is in a lot of the drug supply in Philadelphia. And often people who acquire their heroin off the streets unknowingly have a lot of xylazine in their system, and it causes terrible anxiety and shakes and things like that. So we're trying to give him all these symptomatic like treatment medications, and he is not accepting it. And he's being rude to me, rude to the nurses. And I could not figure out what to do. He wanted a fentanyl. He's like, that's the only thing that works. Or Dilaudid. And we said, no, not really. That's not really what we can offer. We have other things we can offer, but not those things. And then he just gets up and leaves. And my first thought was relief. My first feeling was relief like, oh, thank goodness, go. I don't have to deal with you anymore. Which, you know, five seconds after that I obviously caught myself like, why am I thinking these thoughts? But it's just in those moments when you are at war, not necessarily with a patient, but with the system that has brought the patient to this point, that's just like a reflex almost, right?
Henry Bair: [00:29:44] So I guess having told those stories, it sounds like you deal with these kinds of situations on a rather regular basis. And yet, as your first story illustrated, you were able to find meaning in that. I'm just wondering, having heard that, like, what would you tell me in those moments? Like, how do I get over, how do I work through those feelings? Um, what advice do you have?
Dr. Ricardo Nuila: [00:30:06] I mean, it's still a privilege to be able to see the truth for what it is, for how like reality really plays out. Because you can read an article or you can see people commentating on like what is like the opioid epidemic about, but you know it because you've seen it. You've had to deal with it, you have felt it. And that's the writer part of me talking. Trust me, trust me. There's times where I'm like, screw this writer part because I'm like burnt out sometimes, like, but when you have like, I'll give you an example, like, uh, last week again, it was really, really hard week for me. And in the middle of the week, I would walk through the E.R. to see some of my patients, and I, and I would hear this banging like bum, bum, bum. And I would look and like in one of, like, the E.R., kind of like there was a glass kind of like curtain kind of thing. And there was a very tall guy who was completely naked and banging on it, you know, and I was just like, oh my gosh, you know? And I was like, this is getting really hard, right? And I was and honestly, my in my thought was like, thank God that's not my patient. And every time I walk by, it'd be like, boom, boom. And I saw even something like somebody like walked by at the same time. And I was like, oh my, what the hell is going on here? And then like, I saw the sitter being like, it's cool, it's cool. He's just, you know, he's just autistic. And it made sense to me. And it was just like, okay, well, that's I'm still glad that that's not my patient.
Dr. Ricardo Nuila: [00:31:26] Well, of course, the next day he's admitted to me they've tried to get him into another place in the E.R. it ran and he came to be my patient. And the moment that I put in the the the admit order, there's a crisis intervention called that. I have to go there, like, right there, you know, and the crisis intervention is people like, holding him down because he's walking through the E.R. he's very autistic. So he has no, like, recognition of how to behave. And and he doesn't want to wear the clothes over there. And even though these crisis interventions often resulted in him getting like benzos, B-52, all of these things, they wouldn't touch him. He was still banging. He was still like slapping at nurses. The point is, is that like, there came a point where I was just like, stop. It's better just to do nothing and just leave him be and like, be in the in the room. And he walked around in the room and I was just like, there's just no way that anybody can handle him outside. He needs to be here. We have to do this because society doesn't work outside if we're not doing our job. And like getting him through an episode right now and like, somebody's got to do it. Fine. I'll do it, you know? And I felt like, you know, the whole idea of, like, when crisis intervention was called being like, everybody go back, we're going to listen to the sitter. We're not going to listen to... We're going to be like, we're not going to overmedicate him. We're just going to try to solve this problem without medications. And just like thinking like somebody, what, somebody who is autistic, like, let's go get him tactile stimulation instead of giving him like, you know, like benzos, things like that. Like, I'm not saying that like I changed the course of, but I was just like, I'm pretty sure that by dealing with it, by absorbing that, like, I saved a lot of, like of the strapping him down and restraining and giving him that. And I just feel like I was privy to something that is a real part of the way the world works. And I saw it with my own eyes. I saw that this is actually how things are for some people, and there is an institution out there that can help people because like later on his group home came the person who cares for him. She needed a little bit of respite, but she was actually good with taking him back. I mean, that's just, I don't know, I get meaning out of that. I get meaning because it's like, that's the way reality really appears and I'm contributing positively toward that. So recognition of that helps.
Tyler Johnson: [00:33:55] Uh, I, you know, it's just, I don't know, this whole conversation gives rise to such strong feelings in me as someone who went through my own medical training and now helps to see people through their medical training for the following reason I, you know, so we've had a number of guests on the show over time who have talked about moral injury. And Henry, as I listen to you tell those stories, in particular the first story, I'm just heartsick at the thought of that. Right. Like, here you are. I mean, I you know, you and I have known each other for long enough and had enough conversations to sort of know how each other is wired. And I know that you come into medicine with these very idealistic and altruistic goals. You're here to help and to heal and to, you know, make the world a better place. And yet, here you are as an intern, and you are tasked with taking this patient who literally has one leg in a wheelchair, no appropriate clothing, no place to go, no money to speak of, and you have to take him out of the emergency department and wheel him out to the street and effectively leave him there, surrender him to the cold and you know, to whatever is going to come that night.
Tyler Johnson: [00:35:02] And I, you know, to be clear that this is in no way a criticism of you. It's a criticism of a system and of a of a world. I guess that requires such things to happen. Because, of course, on the one hand, I mean, what are you supposed to do, right? Fix the homelessness crisis from the Bay of the emergency department? I mean, obviously that's not realistic, but at the same time, tasking the youngest person on the medical team with doing such a, you know, viscerally terrible thing that stands in such stark contrast to the very reason that most people went into the medicine, went into medicine in the first place. It just makes me heart sick. And, you know, I don't even know exactly what the question or the point here is, except that I hope that someone who is working with you, one of your seniors, or your attending or someone took you aside. And even if they didn't apologize per se on their own behalf, I mean at least acknowledged the cruelty of the situation. And I don't know, I guess apologized on behalf of the universe or something.
Dr. Ricardo Nuila: [00:36:02] I mean, trust me, I've been that guy who has done that. I have discharged people to the streets knowing that they're going to the streets. But what has helped me about that has just been there's this narrative that's in my it's like, I'm not doing it just to be an asshole. Sorry for the language, but I'm doing it because, like, I'm weighing, what is your capacity for being out there versus like, what is like the pressure from the other people who need to come into the emergency from the emergency room, like I've seen with my own eyes, like, like there are like so many people waiting there and they need help. And I have that conversation directly with the person. I'm like, I'm sorry. Of course I would not want like if I was up to me, if we had a lot of spaces, you would stay here indefinitely. You know, there's like, but this is the pressure that I'm dealing with and, and I find like. So I know that like I believe that there is moral injury. I, I hear it, but I also resist it because I find that like accepting some level of responsibility is a bit liberating in that and helps rather than to kind of like, say like moral injury almost sounds like it's put on to me.
Dr. Ricardo Nuila: [00:37:11] And I and I understand we, we live in a system that, that, that we've inherited and that is so fraught with terrible incentives. And I get all that. But I also feel like taking on a bit of that responsibility and being like, I'm sorry, I'm the one who's making the decision here. And these are the reasons. And accepting that responsibility liberates me a little bit. I mean, that's a very existential viewpoint. I feel like, you know, but I think that that's part of the narrative. That I put on to it to kind of help me deal with it, and it helps me deal with it, which is that like, yes, it's it's injurious to me to to know that. But I'm but I'm doing the best that I can in this situation. These are the reasons why I'm doing it. And I'm looking at that person and saying I'm not like filling out the discharge. And they're going to be surprised. I'm having a very, like transparent conversation about this with this person to let them know that this is the situation. And I'm not saying that works all the time, but a lot of times people are very understandable about that.
Tyler Johnson: [00:38:09] That sounds sort of like that. You know that when Sisyphus realizes that he's pushing a boulder up the mountain, then the response has to be to push the boulder up the mountain, because that's what there is to do, is to push the boulder.
Dr. Ricardo Nuila: [00:38:22] Exactly. The existentialists, you know, and I mean, that's that's one of the classes from college that's stuck with me in The Myth of Sisyphus, Camus and everything. It's there's something about that, you know, I don't think it necessarily applies to every single thing, but what can you do? You know, it's just like, I think that we have to figure out ways to, while changing the system, accept responsibility and absorb some of that so that we can continue to have like, I think that's part of resilience for for ourselves is just to be like, I understand my place in this and I need to continue on with this so that I can, like my own identity, can survive this.
Henry Bair: [00:39:01] Yeah, I don't think I've quite heard that way of thinking about moral injury or how to or a way to mitigate it. So thanks for sharing that actually.
Dr. Ricardo Nuila: [00:39:12] Well, I mean, the perspective is also just there's a dearth of doctors in the United States. And like if I left that position, you know, I could probably find a job elsewhere, maybe not in the exact city, maybe not in the exact hospital system, but I could probably find a job elsewhere. But I choose to be here. I choose to be here. And it's fraught with its problems. But I have to accept those problems. So I don't know. I think that to a certain extent, like we have to understand what the layout is, which is that like, you know, there's a lot of medical need everywhere. And like, yeah, like personally, you could, you could, you could either be like, you know, this is too injurious or you could just accept that, like that, that moment and just be like, let's make them trust me. A week ago when it was like in the middle of like that tough week, I would have probably been like, enough with all this, you know? But constructing some level of meaning in order to absorb this is very, I think, helpful.
Tyler Johnson: [00:40:11] Yeah, I mean, I, I recognize that this is a very complicated conversation, right? I mean, I talked earlier about Henry's impulse to going into medicine because he wants to heal and to cure and all the rest. And I guess one reality that is implicit in that desire is the fact that doctors go to where the mess is, right? Our job is to be where the messy stuff of life is. And so I suppose that one way of looking at sort of finding meaning in all of this is the fact that doctors are subject to moral injury, to some degree, is a reflection of the fact that we don't usually talk about moral injury per se, but it's the fact that where injury is, is where doctors are called to go. Right? And so that certainly doesn't make it easy. And it doesn't take away the burden of dealing with moral injury. But I guess that one way to reframe this, in a sense, is to say that the discussion around moral injury is a way of talking about a reality to which doctors have always been subject, but that we are now able to understand in a sort of a new framing that gives us a vocabulary to talk about it in a more productive way.
Dr. Ricardo Nuila: [00:41:24] Yeah, and I like it because it's messy, too. You know, again, I'm talking from the privilege of having a few days off from like, a really hard week. But when things are at a steady state working at the hospital, I like being able to kind of like see it for the messiness that it is and being in there and just again, being like privy to these moments where I can say, like, I've seen this. I've dealt with it, you know, with my own eyes. And it's just like people can talk about it, but like, we're dealing with it. We're actually like in there. And I mean, that's that's something powerful to that. Like you said, it's just like that's part of medicine is being in the messiness. And I think we need to remember that, that that's just like that's part of the job, you know? Yeah.
Tyler Johnson: [00:42:07] So we decided we're actually going to conduct this same interview twice. It's just that next time it's going to be on like the eighth hour of a 12 hour shift at the end of a week of you being on call. And then we'll see how your moral philosophy changes for that interview.
Dr. Ricardo Nuila: [00:42:20] Yeah, I know it's going to be really interesting. Uh, you know, I should play it back for myself to remind myself this is what you look like on your off weeks. This is how you talk when you're on, you know? Yeah, that's that's so true.
Henry Bair: [00:42:32] So a lot of what we've been talking around is the idea of storytelling. You talk about the importance of finding meaning out of the messiness. And part of that is by constructing certain narratives that make sense for you, for the patient, that bring a sense of purpose to this. Right. So I'm hoping you can tell us more about that, because obviously, you you tell stories to make points about societal ills. You use stories to engage readers who may not otherwise be aware of these problems. You teach narrative medicine. So can you share with us more about how does narrative medicine? How does how does storytelling make us more effective clinicians, in addition to just helping us find meaning? Is there something else besides that?
Dr. Ricardo Nuila: [00:43:11] Yeah, I think storytelling is a way of putting it all together. And I entered medicine as a person who was just set to write, and I just wanted to write, and I didn't know how the two were going to go together. I mean, I even remember being in the first week of medical school, and you do the whole, like class where you learn how to do the physical exam and, and the preceptor went around the room, why are you here? Like, why'd you go to medical school? And I was like to be a writer. And he was just like, he had no idea what to do with that. And I didn't expect to fall in love with medicine, but I did, because it is really bountiful for writing. And there is like, this, like, storytelling aspect to both of them. And, I mean, initially it was just like, uh, details are a lot about storytelling, so I would just care a lot about observing people observing, like how they dressed. What did that say about them listening to their words? I felt like in the presence of a patient is the way I would be in a novel that had won my interest, which is like completely absorbed, meaning like my my senses are on and I'm like smelling and I'm looking and I'm doing all of these things taking in the story, but kind of putting it together in my mind and trying to drive like this, like larger sort of picture of why this person has the problem, that they're stating that they have the problem and how can we fix it.
Dr. Ricardo Nuila: [00:44:39] And that's kind of, you know, a very rudimentary way of looking at novels or at short stories or nonfiction, you know, uh, literary nonfiction. It's just that there's a problem and, you know, there's an attempt to try to fix that problem, and it goes through a lot of observation, a lot of attention to certain details. I think that, you know, there's there's a propensity in medicine to think that just in caring for the patient, that's an art. I think that art is very different, but I think it's more technique. What you're doing with a patient and technique could be really sacred for one person. But I think that there are aspects of medicine that can become artful. And I'm still trying to kind of piece together how that is. But overall, I think that like the same like sort of mental effort that you put into constructing a story very similar to like trying to solve a problem for a patient. And I think that there comes a form and yet you write it and there comes like different lenses that you use in terms of like, what does it mean to solve this problem? How do I solve this problem? But they just fit together for me in a way that really kind of like like I said, like medicine gave me those details. Medicine made me able to touch those problems and to like, feel myself involved in those problems. And that's like, and that helped me as a writer. And, and that's the reason why I feel like the two are just really interwoven for me.
Tyler Johnson: [00:46:14] Okay. So we, uh, recognize that we're coming up towards the end of our time, and we're so grateful for your generosity in speaking to us. If you were talking to a group of medical trainees, and this was a group of people who were going to go into a field where they were really going to be in the mess, as we've been talking about, if they were to ask you, how do we prepare ourselves so that we can continue to find meaning in the midst of the mess that is often inherent in working in the medical system? What advice would you give them about how to find meaning in spite of all of that?
Dr. Ricardo Nuila: [00:46:51] I'd say be worldly, be thoughtful of like people, cultures, like nuances. And the easiest way to do that is to read, right? If you read, you're downloading a lot of information cultivated by like a thoughtful mind about, like an issue, an idea, a person, a story, you know? So I think reading is so important also, just like identity, meaning like, what do you want from this profession? What do you want from your job? I think it's a really wonderful job that if if you want to know a lot about human nature and, and be involved in doing something about like on a one by one basis, I think, I think it's amazing, this job, I mean, and you can sense that, you know, yes, there's there's moments where you have the revolving door and everything, but there's moments where you're just like, I changed that the course of that person's day right there, you know, and and I think that, you know, in order to prepare for that, I think you have to have like a lot of mental tools for that. You have to have like the ability to think abstractly. So like, read like philosophy, read like literature, you know, those teach you how to be attentive, how to give your attention to something. Those teach you like things like tolerance for ambiguity. The world is not black and white. What can I accept of the world when it's in a world of gray? You know, I think all of those are really just important to go into, you know, and important mentalities to have important frames of mind to have when you're going into the profession.
Henry Bair: [00:48:33] That was really insightful. And, you know, certainly you've I think you've illustrated through the arc of your career how you have demonstrated that to be the case. Right? You've lived it out. Right? That embrace of of storytelling and cultural competency and openness and embracing the messiness, all of that. Certainly that was demonstrated over the course of our conversation here. So with that, we want to thank you so much, Ricardo, for taking the time to join us and for and for sharing your own personal journey. It's been a true pleasure talking to you.
Dr. Ricardo Nuila: [00:49:02] You've given me like a new phrase that I want on my gravestone embraced the messiness. You know what I mean? That's that would be a good one for for the grave. So thank you very much for having me. Thank you for the conversation. This was really great. Thank you, Tyler and and Henry. Much appreciated.
Tyler Johnson: [00:49:19] All right. Thanks so much.
Henry Bair: [00:49:25] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.theDoctorsArt.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:49:44] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:49:58] I'm Henry Bair
Tyler Johnson: [00:49:59] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.