Ep. 275 We’re on the Extreme Side with Ricardo Nuila – Transcript

Physician and writer Ricardo Nuila joins The Stacks to discuss The People’s Hospital: Hope and Peril in American Medicine, about Ben Taub county hospital in Texas. Dr. Nuila breaks down the difference between public and private hospitals, how medical costs are calculated, and what individuals can do to help change the healthcare system. He also shares why he thinks we need both public and private care options.

The Stacks Book Club selection for July is Watchmen by Alan Moore and Dave Gibbons. We will discuss the book on July 26th with Joel Christian Gill.


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Traci Thomas 0:08
Welcome to the Stacks, a podcast about books and the people who read them. I’m your host Traci Thomas and today we are joined by Ricardo Nuila, a practicing physician and associate professor at Baylor College of Medicine in Texas. He just released his debut book. It’s called the People’s Hospital hope and peril in American medicine. The book follows five uninsured Houstonians as their struggle for survival leads them to bend top and infamous public hospital in Houston. Today, Ricardo and I talk about how he found patients whose stories he wanted to tell the way he thinks about the health care debate, and how he approaches being both a doctor and a writer. Our book club pick for July is watchmen by Alan Moore with illustrations from Dave Gibbons. I’ll be discussing the book on Wednesday, July 26. With Joel Christian Gil, quick reminder, everything we talked about on each episode of the stacks can be found in the link in the show notes. If you want more of the stacks, joined the stacks pack, it’s just $5 a month and you get our monthly bonus episodes, our virtual book club meetups and our phenomenal community over on Discord. We have a great time and dig deeper into our book club reads share recommendations, and we even talked about a little reality TV. So if you want to join the fun or just want to support the stacks and make it possible for me to do this show every single week, head to patreon.com/the stacks and join. Shout out to our newest members of the stacks. Melanie Schlosser, Danielle, Kathy Fox, Lynn loves books and goofy Joe. Thank you all so much. And thank you to the entire stacks pack. Now it’s time for my conversation with Ricardo Nuila.

Alright, everybody, I’m really excited. Today I’m joined by Ricardo Nuila; he is the author of The People’s Hospital hope and peril in American medicine. Ricardo, welcome to the Stacks.

Ricardo Nuila 1:53
So great to be here, Traci. Thanks for having me.

Traci Thomas 1:56
I’m just so excited to talk to you. I just this book really surprised me in like the best way I wasn’t sure I saw it on a list. I wasn’t sure about it. And then I picked it up. And I was like, Oh, this is very good. Which is in a good way. But you know, sometimes you’re like, oh, we’ll see. And then you’re like, Whoa, I like this. So in about 30 seconds or so can you just tell folks what your book is about?

Ricardo Nuila 2:17
It’s about five people who I met at the hospital were work at Ben Taub Hospital, which is a public hospital in Houston, Texas. And their stories of not having received health care, because they’re uninsured or underinsured. They end up at the public health care system. Their stories are in a woven for me to piece together why public health care is actually can work in America.

Traci Thomas 2:39
And you are a doctor Yes, of Internal Medicine. And you’re a writer.

Ricardo Nuila 2:46
Yes, yes, yes, I you know, both of those. I feel like I started off in medicine. And then really kind of toward college. I was like, I really want to be a writer. And I in at the time, they felt so opposed that I was an English major, by the end of that I had applied to medical school. And I was like, I cannot go into medicine because I’m just going to have to give up writing. I went to one of my writing professors. And I told him I got into medical school but I think I’m gonna leave that at that admission and he said you’d be crazy to leave medicine. And you know, it’s he gave me some advice that I’ve had to turn over many many years. But he said you can find work on technique in graduate school for writing but where you’re going to get your stories, you can get your stories in medicine. And that kind of set me off and and really it’s been the last 20 something years have been about like bringing those together as one and I really do see them as one now I see it like when I’m practicing on the wards especially at a place like Ben taobh. To me, it feels like I’m working on my writing. Also, when when I’m working on writing, I feel like I’m working on the skills that helped me when I’m on the wards.

Traci Thomas 4:04
Okay, this is a real nitty gritty question. And I think maybe I’m only asking this because you hope people know this. And I just told you this my my husband, Mr. Stacks, he’s a doctor. So my question is, if you were an English major, when did you take all the chemistry classes that you take to get to be a doctor?

Ricardo Nuila 4:20
Those were all my electives. Basically, it was basically so I started off and I just biology was just not hitting it for me just because it was so memorizing and so and I drifted toward English and I said I’m just going to be an English major and try to you know, and I had to sacrifice some things I really wanted to study abroad but I just couldn’t with Trinidad. So you you find a way to do it. But you know, it was it was like electives or your pre meds basically.

Traci Thomas 4:48
Okay, let’s talk about the book. I’m sorry, I got so many questions for you. I’m going to try to keep it on the book, but I you know, I just I’m obsessed with the show basically. So let’s start here. Who when you’re putting In this boat together, who did you envision that your audience was? Who were you writing to?

Ricardo Nuila 5:04
Well, in a very direct way, I was writing to my editor because she was one of the first people who just knew the project from the absolute beginning and I, she had worked with other writers that I, you know, basically revere and I knew that enter is Kathy Belden. Yes, Kathy Belden.

Traci Thomas 5:24
Kiese Laymon, Jasmine Ward. She is she’s the gold standard of editors. To me, she’s the best.

Ricardo Nuila 5:31
And she loved this from the very beginning. I mean, she, you know, we put out the proposal and she made a phone call, like the moment that she read it, and she carried it through and, and we had gone through a lot of times together because this was not an easy book to write. And I had the conversation with her at one point where she’s like, You got to stop this happened the day before Thanksgiving, when I arrived, I turned in like maybe a third of the manuscripts. And she was like, she was like, I’m trying to be nice about this. And I just the way I’m nice is direct, you just got to stop and restart. She was exactly right. I needed that reset with this. But so in a very direct way, I was thinking about her because I knew I know that she had built her ear to match the general audience of the United States and readers like you like, like people who love good books. But you know, I was also I was, I was not thinking about doctors. I was I was consciously thinking, this is not for doctors, but doctors should have access to it. I was consciously thinking this is not for policymakers, but policymakers should be it should have access to it. I was consciously thinking, this is not like for the choir of people who are, you know, possibly saying, you know, like, Medicare for all, because, because I wanted it to be in the middle where it could bring two different political sides together. So I kind of it was more instead of envisioning one reader, I was trying to think of like, ping pong in between a lot of different readers

Traci Thomas 7:11
Like writing in like the cracks between, Yeah, or like in the Venn diagram of it all.

Ricardo Nuila 7:16
Yeah, yeah. That’s a good way to say yeah.

Traci Thomas 7:19
Okay. So you mentioned, there’s about five patients that you focus, or there’s five patients that you focus on in this book. And then with that, you also weave in sort of the history of the medical industry, what you call medicine, Inc, and specifically Houston’s medical system, and specifically the public hospital that’s been taught, which is sort of like your sixth character in the book. And I’m wondering, how did you source your patients? What does that conversation look like? Once you you know, you connect with them, you’re like, This is a story that I want to tell, what do you ask them? What do they say back to you? How do you even know that the patient is the right patient to tell your story with you?

Ricardo Nuila 8:00
Yeah, that’s a great question. And it took me a while to figure it out. But you know, this book wasn’t, I didn’t have a thesis going into writing this book, where I was, like, I need to look for patients who fit these ideas. It was the initial concept was like, I want to artistically render these lives and these patients struggles for health care, and what the healthcare system does. So it was more like, the when I was working with patients, that camaraderie, that rapport, something clicked, and I was just like, okay, you know, there’s, I could start to see certain things on the page, for instance, you know, like, for somebody like, Steve, in the opening, he was such an open book, he said, things, we had this banter that was both, you know, discussing our political differences, but at the same time joking around, and I was like, wow, that looks good on the page, you know, so, so it was it was more like, once you start to once I started to kind of visualize that this could work to tell a side of that have been top and public health care that, you know, people don’t know about. And that’s another thing I just there’s, there’s a feeling that goes off in me, that’s just like, wow, I didn’t know that. And if I don’t know it, I’m pretty dang sure that nobody else knows it, right? Like in the public. It’s, it’s so much like how we’re interacting with it with how I’m interacting with patients like the trust. And then I tell them what’s on my mind, I say, Listen, your story really resonates with me for these reasons, and I can’t help but think of how your story might be valuable like to the greater context of how healthcare, how we understand health care, and it could help out other people if, and I give them examples of how I’ve, I’ve written like this before, I’ll print it out. And I also explained like, my number one responsibility is as your doctor this is Secondary, I need to get authorized, you know, the there’s, there’s privacy laws I need to get, you know, we would if for it for this to happen, we would have to get authorization where you understand that I’m giving some of your private health information out. But if you authorize that, and you trust me, you know, that has that process is happen, it doesn’t happen, like off the bat, I don’t like go in, and like read a chart like, Hey, I don’t know you, but you’d be great for a book. It’s more like it’s happened, like, on the third fourth time that we’ve met, and like they’ve seen me work, we’ve we’ve already had multiple occasions. So trust is a huge part of it. And and that’s how it goes.

Traci Thomas 10:43
And then do you let them read what you’ve written?

Ricardo Nuila 10:46
Yes, I tried to give them every, you know, with, with Stephen, for instance, it was the book that I gave him to read. And same with Christian. And some of the other patients, There were articles that were predecessors to that segment in the book, and I and I, and I would give them the, the articles, that’s, that’s always the standard. Now, I do want it to go through the whole process, you know, I don’t want it. I don’t want it. I don’t want to give them what I’ve written while it’s still in process and like drafts, drafts. Yeah, that’s, you know, and, you know, nobody’s really asked me for drafts, but and to be in that’s one of the things that really kind of hit and hit home with me once was Roxanna, when you know, that I brought her like, finalized draft. And I mean, she just had so much else on her mind with her own life, that it was just like, just not as it you know, what we might think like, what I might think like, oh, here’s this, you’re gonna be very interested in how I think about you. And the whole, she’s like, well, I have my I have my own. Yeah, it’s just like, I have a life going on. Yeah, yeah. So it’s totally, which, which is like the eye openers, that all of us that I need that all of us need from, you know, a lot of times, but it’s just like, that’s, it is always the standard that I had, like, I, my goal is to give people what I’ve written, right? Okay.

Traci Thomas 12:14
You write this book about medicine, patients, medicine, Ng, your experience, it’s a little memoir to what do you feel like you’re able to bring to this conversation as a doctor that maybe is missing from the current discourse, or maybe like a medical historian or a reporter, or a public health policy person is not able to bring? And then the flip of that is, where do you think you’re limited in your abilities to tell this kind of story?

Ricardo Nuila 12:47
That’s a great question. Part of me is just doesn’t feel that strong identity of a doctor, you know, you you said at the very beginning, it’s like, you’re a writer, you’re a doctor. And and I can tell that there’s my some of my colleagues feel that identity of being a doctor so strongly that it’s almost like, I think that allows me to look at the history and the problem that doctors are a part of this whole problem, unfortunately. And it’s so complex, because I think, like, I don’t know, 80 to 90% of people go in for such great reasons. And they’re stuck in a system where they can’t do anything about it. But but at the end of the day, doctors as a whole have had issues that I have had have blocked universal health care in America, those are, those are facts, you know, right. And so I feel like, since I’m not so strongly bound to that identity, I can, I can say that, I can say that. And I think that the identity of writing is allows me to just kind of deal with the actual problem of health care, rather than one of those, you know, like the doctor identity or like, the hospital identity, you know, that’s, that’s one of the things I think that it’s also you know, being Latino and being having the the ability to speak the language of a lot of my patients build that rapport, I can tap into those stories a little bit where it might be. I think that that’s unique because I can I think there’s a lot of Central American doctors who look but and Mexican doctors, but what I mean to say is, it’s just that I care very deeply to hear people’s stories, and I and it’s like, my initial impetus is to put it in writing in this kind of like book. So I think that that’s that like, that’s one of the unique things that I bring to the table but in you know, that brings with it that sometimes, you know, I’m not as swayed by the scientific portions of interests. of medicine, you know, like, for instance, I think that, um, sometimes I really have to step back and say like, wow, I mean, what what’s going on here is amazing, like medicine is an amazing, you know, it, this is all very, very difficult to do, you know, orchestrate, like the blood tests, and like the procedures all of this involves exactitude and science and everything. And like, we have to allow for some level of inefficiencies when all of these like real engineered systems are working all at once, you know, and sometimes, I feel like because my site is so much geared toward that the philosophy philosophical human, you know, side of humanity side of medicine, maybe I can I can, I can not pay as much heat as I need to to like the scientific portions of it. Does that make sense?

Traci Thomas 15:47
Totally makes sense. It’s, it’s really interesting. Okay, so the first note I took when I read your book, it’s very early, let me find it. Page four. We’re in the introduction here, I think and we’re talking about medical costs. And this question, I don’t know if I just missed the answer in life, or if it doesn’t have an answer. But there’s so much talk about how this will cost $7 billion, or this thing, this costs $150,000 for a C section or whatever, these things that have medical procedures or medical healthcare related costs? Who slash how are these costs calculated? Because one of the things that is in the book is like, the price of medicine is different for different people in different places. So when the government says it will cost $25 trillion? How are these costs calculated? And then how are because so much of the book is like benchtop, saved X, Y, and Z, millions of dollars. But is that based on what it costs have been taught to do it? Or what it costs a private hospital? Or what it generates? Like? Where do those numbers come from? who calculates them? How do they work?

Ricardo Nuila 17:07
That’s, that’s such a great question. Because there’s not a like a standard answer for that. What I could, what I could tell you is that like, for instance, when it comes to the operations of a public hospital, there are you can track the exact money that went from property taxes to the county. And you can say that, like this afforded, like operations for this, and then you can take the number of patients, and you can divide it and you can say yes, that’s, but when you start to talk about the costs of health care that start to go into the private world, you’re starting to talk about, like, also how, like, some people formulate that according to like, what they want something to cost so that they can make product, you know what I mean? And so, right, it’s, and it’s and that’s variable based on what they can make off of, depending on the insurance companies, the insurance plans. It’s, it’s, it’s so complicated that I think that certainly, like some health economists that I talked to, would have much better answers to that than me, but it doesn’t pass the sniff test for me where it’s like you so there’s

Traci Thomas 18:19
So there’s not an actual number of like, a tavor procedure costs $75,000?

Ricardo Nuila 18:27
It’s no, because it’s because the you know, the surgeons cost could be different depending and the hospital costs. I mean, maybe a hospital could derive a cost. And I think with transparency laws, like hopefully down the line, they’re not really haven’t they haven’t kicked in so strongly, where we can trust it that much. But like, they can say, you know, Tavor will cost like, you know, what, I don’t know, like $18,000, or something like that. Because if we if you take off, but remember that it’s it’s it also boils down to like, human beings are also specific. And it’s really hard to come down to like, an average cost of Tavor for like a patient like for even 10 patients because within that realm, though, some of those patients will need extra units of blood, some of those people will need consultations, some of those will will meet will have some you know, you might even have a hospitalist like me who says I want to keep that person in the hospital extra amount of time to make sure you know, there’s so many different variables. Now of course, at the end of the day, they can probably take that and do an average, but that’s still within the realm of like the variability of like how much you know, the hos the what’s dynamic also is like the contracts that hospitals have with insurance company, all these things are just dynamic, and so it’s so hard to pinpoint, you know-

Traci Thomas 19:48
Okay, so there’s not so there’s not I didn’t miss the answer and you didn’t miss the answer. Feel a little better about myself. Okay. I want to talk about Ben taobh because I learned so much about like public, private hospitals and sort of how that works. And obviously people you need to go read the book. But Ricardo, would you mind just sort of like giving us a general understanding of like what Ben Taub hospital is and how it is different from what people might know or understand that other hospitals?

Ricardo Nuila 20:19
Yeah. So I grew up in Houston, and I grew up, you know, upper middle class. And when I heard the words bend top over the radio, it was like, somebody’s in a car crash, or there was a shooting that victims were taken to bend top hospital. And I didn’t even know that it was the teaching hospital for one of the major teaching medical schools in the city. So to me, when I growing up, it was like, this is where, you know, people who get who undergo trauma or who get shot, go to go to this hospital, benchtop hospital. And it’s true that it has a really good reputation for trauma. But what I learned is, is that it is a hospital that is funded in large part by property taxes paid for by people in Harris County, to care for people who can’t, who don’t have access or can’t afford health care, which is becoming an increasing amount of people, and a huge variety of people. It’s not what it was 2030 years ago, where it’s purely the uninsured, or the people who can’t find work or don’t have work for because work is pegged to insurance in our country. And so what Ben tab is is like the it’s it’s a it’s also an academic healthcare system, which means that the medical schools, staff it and in teaching medicine, they are following scientific guidelines. They’re trying to make it so that it’s as close to science as as as possible. You know, like, not everything can be done according to science. But that’s like, that’s the goal. So what you find at Ben Taub hospital is that you have, like less of the fat that we see in the private healthcare. You know, it’s like, if you’ve ever been in private health, if you’ve ever been to a hospital, you’ve most likely been to a private hospital. And you might wonder, do I really need that test? Do I really need XYZ? Do I really need that study? You know, Ben Taub hospital because it is like a fixed, you know, budget. And because it is an academic medical center, it’s like, basically medicine that is directed at what is needed, rather than that extra portion of what is profitable. And that is something I really had to work through for many years to understand the difference. And so I think that what I found was what’s interesting is a lot of people who go use the public system in Houston, they like it, they like it, because the system since it’s not geared toward profit, it just puts a focus on medicine. I feel like I can focus on medicine. And it’s also cuts away that extra sort of, you know, that extra layer of profitability that I think a lot of Americans maybe feel in healthcare-

Traci Thomas 23:29
Can people who are insured, go to a benchtop type hospital?

Ricardo Nuila 23:33
Yes, and it does, but it depends on the the insurance Like for instance, many people with Medicare and Medicaid go to benchtop. In fact, that’s one of the other big funders is like people who are who have those insurances, and other insurances, too, there’s like a, there’s a, a nonprofit insurance in Houston that is utilized by patients, but there are but the system because it’s trying its mission is to care for many of the people who can’t afford health care, it will not accept certain insurances, so that those people can be you know, taken care of at private hospitals. Now, the difficulty with that is is that those the private hospitals are not accepting some of those insurances, so there’s this like, huge dynamic, it’s always it’s this, it’s always it’s so it’s so much in flux, you know, and unfortunately, our patients, all patients have to withstand and, and that’s what that’s what the real story of American medicine is, is that it’s all it’s not patient centered, you know, and, and that’s the problem.

Traci Thomas 24:50
So here was my first big tough question for you. What are slash? Are there any solutions that could be implemented now that have outsized impact that hospitals, doctors, hospital administrator people could implement that would not need to be like a govern a United States Government thing like, or even local politicians like what are things that can be implemented now that could help patients and people get access to health care that’s not like waiting on Joe Biden or whoever to say universal healthcare for all.

Ricardo Nuila 25:39
I think that first of all knowledge of how things are working right now, for instance, nonprofit hospitals have this GNOME, this moniker their nonprofit, and so a lot of people think that, you know, that they are not really trying to bring money into their system. However, it’s it’s many of them operate like for profits. So one thing that we could do is really make sure that they are providing the amount of charity care that the United States government is asking them to provide for their tax benefits. So that would mean, like auditing and things like that, that’s that’s kind of a higher level thing. I think, also, I mean, I think if you’re talking about on an individual level, I think I think we all have to get to the point of asking ourselves, like, when are we over consuming healthcare? And when are we? are we consuming it correctly? If you’re going, Are you going to your primary care doctor, you know, are when you when you have a problem? When you have a medical problem? Do you ask yourself, Does this really need to be an emergency? Or is this something that I have just like pressed for time with, you know, because if we’re not going through the system of primary care for referrals, and everything like that, that does add costs, marginal costs at the at the emergency room level, if we’re going straight to specialists? You know, I think that that can lead to an inefficiency. And so we are seeing a lot of that in healthcare, that is just this excess, the excess that the people who have access to health care that they consume, affects the way that the people who do not have health care access it. So I think that some of it does entail that we need to look at ourselves in the mirror and see like, what how is it? Now that’s a very privileged thing to say, as a doctor and somebody who doesn’t require care. And I, and I know that that’s really tough, but, but I also think that there is, you know, something in there for us to really kind of conceive of that, you know, but I but I think that we also need to, we need to really start to think about how we mix public and private, you know, at the local level, for instance, in Houston, there is a bond that is going to for the next year there’s going to in November, on the ballot is going to be whether or not to amplify the public health care system and make it bigger, so make hospitals like benchtop bigger. And I think that, you know, as voters, we usually approved approach these bonds, and we don’t know what’s going on, and we sort of like but so we need to really kind of understand what’s going on. And think about that the future should be a mixture between public and private and how to bring those together.

Traci Thomas 28:34
Okay, let me ask you about private hospitals, then. So one of the things you talked about in the book is that public hospitals sort of lift the burden off of private hospitals, because like if the public hospitals didn’t, my understanding is that the public hospitals didn’t exist, the private hospitals would have to take on some of these people due to legal legalities, like a pregnant woman has to get care wherever she goes in. So if she doesn’t have access to a public hospital, that is a burden air quotes on the private hospital. The other thing you talk about is how, like, people who need transplant surgeries or like really expensive surgeries or prosthesis, in this case, and one of the cases in your book, they don’t have access to that, because it’s limited for people who can pay for it, essentially. So my question is, why do public hospitals lift the burden off of private hospitals and private hospitals don’t reciprocate in some way by donating? It just is it just like a capitalism thing where it’s just like, Fuck you, we’re just here to make money. We don’t care.

Ricardo Nuila 29:36
And unfortunately, it kind of boils down to that and I don’t think I’ve talked to some people who were, you know, on that side of it, and it’s, it’s not like they are like, you know, twisting the ends of their mustaches and counting like the sensual going in, but they’re just in that, you know, like in the mode of like, you’re imagining your inner in a large hospital system that’s private and you see like, you know, The people around you have new jobs and their jobs are really focused on like, you know, making sure that the patients are eating the right things and everything. But it’s like, that’s still based on, like growth within that system, that private health care system. So it’s like you’re adding, you know, and it’s not the same as like a, like one larger system where we can kind of determine what are the needs? What are the really startling leads on one side and give to those needs? Right. So the point, I think the like, the point is, is that, you know, on the private side, yes, like, the hospitals are supposed to provide charity care, that’s what the government has like said, but it’s not enforcing it, right? It’s not really enforcing it, it’s not auditing it, it’s not really putting those peoples to the fore. And the reason why private hospitals feel like that the public hospitals will take off the burden is really for emergency care in the law, EMTALA emergency medical treatment and Labor Act, which is like that any person can go into that private hospital for an emergency reason and have their care stabilized. It, it’s, it’s just that so many have some in Texas, especially where like, around 23% of the people are uninsured. If you walk into a private hospital, and you really have an emergency, you know, you’re gonna you might stay there for long, so the private, you know, the, those private hospitals want a public hospital to take over that care, you know, right, so that they don’t feel like they’re losing, like all that money. And unfortunately, that’s a philosophical thing. You know, what I mean? They, they it’s like, the pure and that’s what I mean, it’s just like, do you look at your hospital system as just your hospital system are part of a huge environment that is trying to help the health of everybody, right. And I feel like that if you are in a nonprofit healthcare system, you’re looking at your clients, you’re not looking at every, you know, it’s like, oh, it’s they can’t afford to be in Ark, you know, but we need to have a whole new philosophy, where, you know, we’re trying to take care of everybody, because that person’s can come into the emergency room and changed, it changed the whole way dynamic, and how we give health care. But yeah, at the end of the day, that is cap that is like that we’re just kind of like extremely capitalistic. You know, that’s unfortunately, that’s the problem. I feel like is I’m not, you know, it’s hard to say like, let’s take capitalism down a couple notches, because people will say, What are you saying, like, you know, take it all the way. But it’s like, one of the things that I feel like I learned from this book is, is that we are in an extreme system, an extreme system on the private and capitalist excited, we feel that every time we get a bill from the hospital, or from a doctor’s group, or when the insurance company, we are feeling that extreme nature of that, and we’ve become inured to it, and that is a huge problem.

Traci Thomas 33:09
Okay, you’ve said so many things that I have questions about, but I want to just quickly ask you, I don’t know, this might be an unfair question. So you can just say, Fuck you, if you hate. You mentioned before that the solution is private and public hospitals. So is that different than, like, universal health care, like public health care? Like, is that not a truly viable option for the United States?

Ricardo Nuila 33:33
I think that it depends. So, you know, there’s other models where we just say, we have one insurance and all hospitals can operate privately. And then insurance is big enough where all the hospitals are going to want to take that insurance. And that’s like Medicare for all, for instance, you know, that’s like, basically like one insurance for everybody. You know, and that’s, that’s kind of like how Canada operates it. But what Houston’s model where I’ve worked in public, the public healthcare system is a little bit more like, like National Health Service from the UK, on a smaller local scale, which means that, no, it’s not about insurance. It’s about like, we are going to, we’re going to make the hospitals and we’re going to pay the providers. And you can go to those that hospital if you need to, you know, because it’s for everybody. But if you want to pay more than there will be private hospitals that are apart from I’m Mike, there’s been some people who have written to me about like, well, you you’re not in favor of Medicare for all you lost me and I get that. But my concern is, is that the history of like American health care is is that like the private entities have found workarounds, anytime that we’ve had, like, when it’s been insurance based our solution and our solution would be like, you know, we’re going to have an insurance for everybody but you know, when Medicare Air was started in 1960. Unfortunately, the way that it was written, doctors started to build it, you know, just gratuitously. And that’s one of the reasons why health care costs went up. And so I’m a little bit wary that the way that that like something like Medicare for All will be written will a exclude some people and so it won’t be for all and B, that it will it like those special interests will get a hold of that legislature. You know, I so I’m also wary that like the special interests, like the private side is so strong that I just don’t think you’ll relinquish control. So I feel like it’s almost like we as a public need to compete with them. And that’s why, you know, for instance, okay, I’ll put it in Houston, Texas, like, I think that some of the private health care people in Houston, Texas know that the public system can compete with them, the more that people learn, that I don’t need to pay excess money to go there, I can go to the public system, you know, they lose, they lose potential clients. So right, that’s where I feel like that. That’s just my kind of cynical view of like, the way that we extract yourself from this huge mess, where it’s like, so corporate, is by the public competing with corporations. That’s why I, I kind of tend toward, and also because I have experiences in something like an NHS on a smaller side that we need to have, like a healthcare system. For all that is like public based, and that will compete with the private side.

Traci Thomas 36:34
Yeah. Okay. I hear that. There’s a conversation in your book sort of about which is connected to this. It’s like, what do people who have public insurance deserve? What kind of health care? You know, it’s like, they can get basic health care. But we talked, I said this before, like, they can’t get a transplant or something.

Ricardo Nuila 36:54
Well, depends on what Medicaid and Medicare they it’s really hard. It’s extremely hard. But Medicaid and Medicare do pay for a lot, you know, Medicare pays for a ton of kidney transplants. And Medicaid will pay for like liver transplants in Texas. So it’s just but but the rules on who gets Medicaid are so state driven, you know, it’s so difficult to say like, well, who qualifies for Medicaid? So it’s, it’s really hard to parse through that.

Traci Thomas 37:23
And so like, ultimately, this question about, like, who can get access and who can get care? And all of this stuff is like a super moral judgment of like, who is deserving or worthy? And how do we shift that conversation? Like, that’s great, well, is it possible, I just feels like I’m reading about these people, and I’m sure you feel this as you’re writing about them. And in treating them, you’re like, these are people that I’m growing to have feelings for, like care about. And they have families, and they are both good and bad people, and they have done good and bad things, and they are sick, and they need help. And the question becomes, are they worthy, because they do not have a job or were not born here, and therefore they should be on hospice, even though they’re not dying? Like, I just, I don’t know. I just, it feels like very helpless. That’s, that’s the conversation. It’s like, who deserves to be taken care of? Because if it’s your mom or your brother, you feel like it’s them, like, you want to be taken care of. So I don’t know, I just don’t really a question. I’m just kind of curious your thoughts about it?

Ricardo Nuila 38:36
Yeah, I mean, my thoughts are that I tried to put on my, my hat of moderating between both political sides about this, because I’m really interested in forging, like Unity, because I just don’t think like, first of all, in my mind, it’s just like you, if you argue on one side, and you’re not making headway, then what’s the use of Oregon? That’s kind of like my, you know, so part of me thinks like that, like, the discussions about health care as a human right are in the wrong direction. And it’s an part of, it’s just because a American healthcare should not be a human, right, because American health care is like, aimed toward profitability, unfortunately, you know, it’s like, but But I understand, but I live and I, and I understand the, like a principle that if somebody is in need, and we’re in a wealthy country, we should help those people out, you know, so it’s, it’s, it’s weird how the rhetoric can take us away from things you know, like, right. So, what I would say is, like, let’s consider like maybe ways to bring together is to think about like, what are we all, you know, sacrificing by being in the system, and I think that one of them is this is this complex. We live in this incredibly complex system of health care where we have to determine Who’s eligible who’s worthy, how much they earn. We’re sacrificing simplicity, which is like, when you look at something like the UK, everybody’s covered, everybody’s gonna be covered. And you just go to that to that clinic, you have a clinic right there and everybody’s covered. And yes, there are problems with it. It’s not rude. But But, but I want people, I think people should know that we are like beating ourselves up to make things more complex, because we’re trying to divvy it up in like, what we consider is fair. And by divvying it up, we are eliminate, we’re eliminating the possibility of healthcare for a lot of other for a lot of people and making it hard for those even habits. So I think that maybe one of the things that we one of the ways we can is just to say what can we gain from a different and I think simplicity is one of the things like you’re just covered, you’re just covered. If it’s a public good, we don’t have to say that it’s a human right, we can just say that we can all agree that it’s just helpful for everybody to be covered, you know, and that and, you know, it’s like, we don’t say that, like roads are a human right. But we know that they’re good in to overall, you know, for everybody. And I think that that’s if we can kind of Forge paths in that direction, where it just like, you know, like, maybe, hopefully, we can, that’s the moderation that could bring these sides together, because that’s ultimately the only way that’s going to happen is if like people political sides come together and start to think big ideas together like that.

Traci Thomas 41:30
Yeah. Um, one of the things that struck me, I don’t know, made me mad made me really sad made me just like, feel yucky, is a story you tell about a patient who comes in and she, they tell you, she has like a UTI or something. And you go to your little pocket medicine book, and you’re like, you know, looking for answers. In my book, you’re a young doctor, this point, you’re like, trying to make sure you like hit all the steps, you know, you’re like, you just check this out. And you’re like, I don’t think it’s a UTI. Like, I think it’s like this other complicated. Yeah, yeah. And then it comes back that it’s complications from untreated diabetes. Yeah. And I have to tell you, Ricardo that, like, I, I got so mad reading that part are so upset reading that part. Because the thing that is frustrating about American health care, is that because it’s inaccessible, and because it’s expensive. Your literal handbook did not have a very obvious diagnosis, because untreated diabetes is not a thing that should exist. Right. And one of the things I think you say in the book is that your genetics are just as important in American health in the United States health care, as your insurance coverage. As far as outcomes, health outcomes, how do you and you talk about disaster syndrome? And like this feeling of helplessness and like this feeling of like, burnout you talked about is like a number one symptom of disaster syndrome. How do you Ricardo, Dr. Reiter, documenter of these stories? How do you deal with this shit? Because like, I’m pissed off reading it. And I’m sitting here in Los Angeles, California. I’m not in Houston. I’ve never been to bend top. I don’t know these people. But like the idea that untreated diabetes was a thing that a new doctor, like couldn’t even fathom, and that a book couldn’t even contain like, it’s just like, enraging.

Ricardo Nuila 43:31
I mean, my best answer to that is that I just focus on that person right there. Right, you know, like, I, you know, I’m just thinking about this last week being and I mean, like awful diagnoses. I mean, I’m talking awful things happen to people, um, you know, metastatic cancer, for people who are less than 36 years old, you know, like, it’s just, it’s, it’s things that but all I can control is like, that interaction with that person that they feel like that I’m trying, that they feel that I care that I’ve listened, and that I but but more than that, also that I guide them for what I know, to go through the best type of care that they can get, you know, so the way that I get through that is, is that if I can leave that room thinking, okay, you know, that was a net positive in so far that you know, a person you know, that that person knows now, at least, it was a tough conversation. But he knows that this cancer is incurable. He knows at least now that this is the aim of this treatment, and he knows that we’re caring about how he can move his legs now, for instance, it’s just, you know, it’s I, that’s the way that I protect myself is just knowing that like I can, like I can feel that comprehension like I test it, you know, and I talk with them about it with people about it. And I can feel that they understand and I don’t leave thinking like, you know, I’m curing that or anything, but I’m just, I just feel like, you know, that is the best that I can do in that situation. And, you know, it’s it’s, I hate to, but I think it’s one of the most rewarding parts of the job. It’s it’s one of the parts of the job, that even though people are staring into the abyss in their lives of like this illness and sickness, when they feel something like they understand something, and they understand that people around them care and are trying to help that. I mean, I don’t know that I get a lot of satisfaction from that. And that’s one of the reasons I work where I work is because it’s you know, and there’s a lot of people who told me that they just don’t get that level of satisfaction in the private world as much. Maybe because of the, the like, you know, it’s just really tough. There’s so many different factors, but I, I care so much about that personal interaction, and that communication that that’s what helps helps me get through. Okay,

Traci Thomas 46:10
I have one more thing about the contents of the book. And I want to talk a little bit about the process. This isn’t a question, this is just a statement. In one of the sections, you talked about maternal health rates, specifically black women. And there’s this revelation in the book where I can’t remember who did the research, but that the percentage of like black population is directly tied to the maternal health rates in that place. And like, you could just look at those numbers to be able to see what the maternal health rates were. And that was revelatory for me in the same way that when I found out that black people in Africa don’t have high blood pressure. Yeah, like, it was like one of those things where I was like, Holy shit, it’s just the racism.

Ricardo Nuila 46:54
Like, yeah, it’s, it’s social. It’s like, it’s when you talked about social determinants of health. It’s like, we don’t really recognize how deep the social questions go into health, you know, and I think it’s, I think it’s going to take us even longer. I think when we look back on this time period, 50 100 years from now, we’re gonna, we’re gonna, we’re gonna kind of kind of scoff at just how little credence we gave to this idea that like our society, forms, our ideas of health and our health. Yeah, I think that I think blood pressure is is a really interesting one that you mentioned diabetes, I mean, yes. If you’re living in a food desert, if like, how you eat, who you eat with, like, you’re even philosophy about food impacts, whether you’re gonna get diabetes or not, you know, all of that is more so, um, you know, not in every case, because, like, there’s genetic factors, but like, in so many cases, and especially for something like type two diabetes, which is what’s really increasing like startingly. I mean, it’s, it’s, it’s, it’s our society has all of the seeds for all these illnesses, you know, and, yes, racism is a huge part of it. So is whether, you know, whether or not somebody can speak the language, all of that. So it’s, it’s, it’s one of the things that I’ve learned being working, where I work is just that, you know, there’s, there’s no, like, if we start to think that there’s like a pill remedy for these things, I think we need to really sort of visualize, like, how we can make life more equitable for people so that it helps, can be but but the problem is, like, like you said, it kind of does go back to that we’re an extreme form of capitalism. You know, it’s just, it’s just and so how do you, how do you counteract that? I don’t know. I don’t know what the answer to that is. But I think that the first part is like recognizing that. Yeah,

Traci Thomas 48:54
I mean, one of the examples like I think about from my life is I have identical twins, I had mono died twin. So I had high risk pregnancy, which meant that I went to my OB GYN every two weeks for basically my entire pregnancy. And I work for myself, and I work from my home. And so I could schedule my life around those appointments. And that’s what I did, because it was the best that I could do for my kids. But there are people who the best that they can do for their kids is going to work and making money. Exactly, you’re on a schedule, and they can’t make it to those appointments. And like just things like that, where it’s like, there’s so much judgment of like, oh, that person’s a bad mother, because she didn’t go to her, you know, and it goes in her chart, like didn’t come to the appointment or whatever, right? And it’s like, yeah, but she did take three buses and like, how is she going to get there when she works, you know, whatever. So it’s like, those kinds of things that I think people forget about too. And there’s all this judgment about who deserves health care, because then it becomes, oh, this woman’s a bad mom because she didn’t go to appointment or it’s like, okay, well, if she doesn’t have a house to live in, because she can’t pay the rent. Like what kind of mom is she going to be then? You know, like, how is how is that making her life better or what if she has other Children and they have school pigs. Like, it’s just like, so fucked up that so much moral judgment is put on people when the system is just so inequitable,

Ricardo Nuila 50:09
and it’s just, it’s just not there. You know, it’s like, imagine if there was a clinic that the person could trust and that like, she didn’t have to take you. Yeah, take three buses, she could just go there and like, and maybe the doctors could make medical decisions about, like, how often she she, you know, follows up and say, you know, actually, you’re more high risk. And that’s one of the reasons why I depicted my colleague, Dr. Carrie Epps is because she’s making those kinds of decisions in a public healthcare system, like they can. I think one of the things that is interesting about the history of American Healthcare is that I feel like, at some point, doctors sacrifice, like control over like health care for like money, you know, like, that was kind of like what happened. And in the UK, when they were forming the NHS, that was like, one of like, the bargaining chips, like, we’re going to take more control, government’s going to, like, provide it but but the doctors are going to have a real say, in the medical things, you know, and I just, I just feel like, you know, we can make things more equitable for people like health care can be an avenue to make things more equitable for people, if we provide access, if we just say, let’s just have a public system, you can access it, you know, if you’re, if you’re poor, here it is, you know, like, you can still get as good care and like, that could be one of the first kernels by which people can find themselves toward an equitable life, you know.

Traci Thomas 51:27
Right. Okay, we have to talk about your writing a little bit. I always ask people this. How do you write how often where are you music are no snacks and beverages? Rituals? Allah?

Ricardo Nuila 51:39
Yeah, so it this change throughout the book. And honestly, all those questions are making me say, like, Man, I can’t wait to get back to the to get to a next project. Because I’m kind of like, trying to think of like, what what I’m going to work on next right now. And I’m just like, I miss like that, like you do have routines and everything, but I have an office now in my home. And interestingly enough, I couldn’t finish this book for a long time. And I was just like, gosh, we were living in a very small week, we had two kids, and we were in like, a small house like and in one bathroom. And I was like, I have to finish the book in order to move and then one of my friends is like, Are you crazy, it’s like the opposite. She was working on a book. And it had taken her eight years. And she was just like, No, it’s the opposite you have to move in order to finish the book. And it was because of the space you know, like so I have I have a nice space. That is when I say nice, it means it’s just private and there’s a desk and I can think there but I usually work in the mornings I I try to wake up early and it’s depending on if I’m working at the hospital during the intense part parts of working on this book and I had to work I still had to write in the morning so I would get up at you know, really early to work on the book and then go to work but if I’m if I’m off it just be a little bit later and then I work throughout the morning and I don’t eat I give myself a break to go you know, you know drink coffee, I might have a cup of coffee with me at that time and I have like and I’m just you know there’s no music it’s it’s an I have a board that I write on the process is depends on what you’re doing. You know, if you’re trying to think of like how to structure things it’s like a lot of like just kind of plotting things out and think work and hoping something comes up spontaneous but if you’re really going through like a paragraph and trying to make it work I like I can sit there on that for like hours and hours and I can write like four to five hours a day and then kind of like move on. So that’s kind of how it works for me. Okay.

Traci Thomas 53:47
What’s a word you can never spell correctly on the first try?

Ricardo Nuila 53:51
What’s a word? You know? There’s so many that what is it uh sphygmomanometer which is like the-

Traci Thomas 54:00
there’s so many medical-

Ricardo Nuila 54:02
I’m sure there’s a lot of medical ones but that’s one of the ones that’s that’s blood pressure cuff and- Oh, dysdiadochokinesia that’s another one.

Traci Thomas 54:13
The one that I can never read is do odd to know do odd and asked Yeah, you don’t do do Oh, no. Yeah,

Ricardo Nuila 54:20
Yeah, Oh, because you want to say yeah, do all people say do all Dina duodenum do Oh, Deena they know. Yeah, it’s it’s it’s weird.

Traci Thomas 54:29
My husband will pull up like his little medical journal and be like, read this like Juwan duodenum on the moss stage and ostomy Yeah, I think that’s hilarious. I’m like, I’m illiterate. Okay. I’m just have a few moments left. I could talk to you for hours, but we’re gonna come off I want to know the coolest person who’s expressed interest in this book.

Ricardo Nuila 54:52
Terry Gross was definitely one of them. Because she, you know, she she’s just the legend and I love Hmm. And and I mean, Matthew Desmond is another man a dream. He expressed interest in the book. Yeah, I would say those those two, Matt, what I realized about Matthew Desmond because I met him at the San Antonio Book Festival. And we found out that we’re like, he’s, he might even I think he’s one year younger than me. And I was like, cash evicted, came out a while back, I was like, I thought to myself, he’s the Lebron James of nonfiction. He’s like, been there forever. And he’s like a master. And he’s doing these incredible, like, I saw him present on, on poverty by America. And I was just like, This guy’s he’s now he’s like, this is a second championship that he’s winning, you know? Yeah. So it’s like, it’s cool to have somebody who’s a LeBron James, kind of like, think about your book a bit, you know.

Traci Thomas 55:49
So for people who love your book, The People’s Hospital, what is another book or a few other books you might recommend to them that are in conversation with your work?

Ricardo Nuila 55:59
In conversation with my work, I would say that the the hospital, which I refer to by yonder hearts, like it’s hard to, it’s hard to find a copy. The another one is this, because this book has been so influential on me, but it’s Jack bar Zunes, from dawn to decadence. It’s about Western cultural life for the last 500 years. And it’s only because it’s just like, his sort of view of history helped me think about how to get that historical portion, which was really hard, because you don’t want it to be dry for your readers, you know, right. You don’t want to lose your readers when thinking about, like policy and everything like that. So he kind of he, like he, he, he’s like a hero and how to like, put it all together. And he gave me a model for that. I mean, I don’t, it’s hard for me to even imagine writing this book having not read the Elena Ferrante books, you know, like, it’s, it’s, I like those, those are so wonderfully done. And I also think that a lot of Tolstoy, really, and in the, in some of the Russian authors, you know, check off especially like, their short stories, Tolstoy’s Anna Karenina, again, just like, the depiction of people was really like, that was a model for me, I, when I, I know that I was like, looking at patients, and this was going to be healthcare, but at the same time, I was like, but these are people that you have to, like, look at the way that Tolstoy depicts his you know, so those are the I have, I think a lot of a lot of my influences are come more from fiction than nonfiction. So

Traci Thomas 57:42
I love that. Okay, last question. If you could have one person dead or alive, read this book, who would you want it to be?

Ricardo Nuila 57:50
Let’s say Barack Obama. And I think because I would be so interested to hear, have a conversation with him, because I feel like he was had such. At the end of the day, I feel like the Affordable Care Act was just like this litmus test, can we do it with private health? Insurance? You know, can we make a system that’s equitable? And I feel like it’s veering toward like No, and for a lot of things that he couldn’t have predicted, possibly, but I’m interested, I would just, I feel like he must have given so much effort and thought to health care, and I would just be so interested to hear like, what what his thoughts were about this, so I don’t know.

Traci Thomas 58:35
And we want to get you on his summer reading list. Out of your reading list, let’s be honest, also, we want to get you on the list, Ricardo, so we gotta get the book to him. So we gotta get

Ricardo Nuila 58:44
We gotta, we gotta get the, but I really like he’s, he strikes me as a person who like that was his that was his signature thing. It’s like healthcare. He was the guy who’s going to take what take on healthcare with no vote, no pull everybody, every politician knew that it was like a minefield. And I think he sacrificed a lot for it, you know, and, and I and I’m just so curious, how he how he sees, like, just, you know, like, healthcare in general and everything.

Traci Thomas 59:13
Yeah, yeah, yeah. Well, also Brock Obama, I have an open invitation to come on this podcast and talk about and me with that if you’re available. All right, everybody, you can get the People’s Hospital wherever you get your books. I will say I read half of it. And I listened to half and half of it on audio and it’s fantastic on audio as well. Ricardo reads it. It’s so good. So for my audiobook people, this one gets my stamp of approval in that platform as well. Ricardo, thank you so much for being here.

Ricardo Nuila 59:40
Traci, thanks so much for supporting this book for reading it for caring about it. Really, and and this has been a great interview, like your questions are awesome. Thank you very much.

Traci Thomas 59:51
Thank you, Christian. Don’t cut that part. Leave that in. Everybody else we will see you in the Stacks.

Alright y’all, that does it for us today. Thank you so much for listening and thank you again to Ricardo Nuila for joining the show. I’d also like to say thank you to Paul Samuelson for helping to make this conversation possible. Remember Joel Christian Gill will join us on July 26. Discussing the graphic novel watchmen by Alan Moore and Dave Gibbons for the stats book club. If you love the show and want inside access to it, head to patreon.com/the stacks to join the stacks pack. Make sure you’re subscribed to the Stacks wherever you listen to your podcasts and if you’re listening through Apple podcasts or Spotify be sure to leave us a rating and a review. For more from the stocks follow us on social media at the stocks pod on Instagram and Tiktok and at the stocks pod underscore on Twitter, and check out our website the stackspodcast.com This episode of the Stacks was edited by Christian Duenas with production assistance from Lauren Tyree. Our graphic designer is Robin MacWrite. The stacks is created and produced by me Traci Thomas.

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