Surpassing:This safety-net hospital doctor treats mostly uninsured and undocumented patients

As a doctor in a so-called "safety-net" hospital,Surpassing Ricardo Nuila's daily practice looks quite different from that of his colleagues who work in private or not-for-profit hospitals. That's because safety-net hospitals treat everyone who walks in the doors — regardless of insurance status.

Many of Nuila's patients at Houston's Ben Taub Hospital are dealing with serious illnesses as a result of not being able to get access to basic preventive care. "What we see is that patients' lack of health care has meant that the disease has been able to grow within their bodies," he says. "Their cancer is widespread, or we find that they have an infection that has not been treated or discovered."

In his new book, The People's Hospital, Nuila writes about his experiences at Ben Taub, which is the largest safety-net hospital in Houston. He says despite the hospital's budget constraints, the doctors and nurses there still manage to provide quality health care. By limiting the number of patients a practitioner can see in a day, Ben Taub allows physicians to spend more time with their patients than is typical.

"My cap is 15 patients in one day," Nuila says. "That's compared to some of my colleagues in the private world, who I've heard admit up to 24 patients in one night, or don't carry a cap."

Because resources are tight at Ben Taub, there is an emphasis on using them mindfully, Nuila says. Instead of ordering an MRI with the push of a button, for instance, he might talk to the radiologist directly, to find out if extra imaging is really called for. "There are benefits to further discussion between medical professionals about emergencies and how to deal with these emergencies," he says.

Overall, Nuila says, working at a safety-net hospital allows him to keep his focus on medicine: "I like that I have the time to be able to hear my patients' stories, that I don't have to think about billing all the time, that I can sit with them and hear about why they came to the hospital and learn about their lives — and that, no matter what, we are going to be thinking about how best to help them, regardless of whether they have insurance or not."

Interview highlights

On treating undocumented people at the hospital

It's not considered illegal. ... The law EMTALA — the Emergency Medical Treatment & Labor Act — that was passed in the 1980s, that states that anybody in the United States, whether you're a resident or not, whether you have health insurance or not, can go to a hospital and receive an exam and stabilizing treatment. So that's a right that everybody in the United States has, regardless of citizenship. What's different about the safety-net hospital is that we have clinics and we have chronic care also — and that was under question by certain politicians, who ultimately found that it didn't make any sense to question that. Because when you get in the way of preventive care, when you get in the way of primary care, those patients end up coming to the emergency room and they become much more expensive. ... So, [the politicians] decided that the financial gains were more important [than limiting care].

On explaining the American health care system to uninsured patients

The patients are all so different — some have had multiple family members in the United States before, so they understand the landscape a little bit better. But yeah, it can feel very, very contradictory when I tell patients that, well, "You need health insurance for that." And they will say sometimes, "Well, in Mexico or in Guatemala (or whatever), I don't necessarily." And it's hard to explain that in the richest country in the world, there's little available for people without health care insurance.

Now, I'm happy that in Harris County [in Texas], where I work at Harris Health, we can provide a robust set of services. But somebody who lives outside of the county doesn't have availability for those services. And that's one of the things that I've argued, is that the line between Mexico and the United States is not as important as the line between Harris County and Fort Bend County, for instance, in some of the treatments that we give to patients.

On speaking Spanish with patients

That's one of the reasons that I love my job and I love the hospital where I work — I can speak Spanish. ... The people are so happy to hear somebody attempt to speak their language, and not just on a translation basis, but the flavor of the language and also thinking about the locations [they come from]. For instance, when I ask somebody where they're from and they say Mexico or El Salvador, it's never enough for me to hear just a country. I need to ask a region so I can situate it in my mind, the map, and draw a relationship that I have with that region. And so I think it helps a lot for building trust with patients.

On his reaction when very sick patients put their faith in God

I don't dismiss it. Because I feel that science and medicine, we don't know everything. There's a lot of mystery in this world and I think faith is important. I'm not saying that faith in one particular religion is important, but faithfulness is important. I think that in my experience, when people demonstrate faith, whether it's in their God or whether it's in the treatment, they do better. It's not my job to take away that person's faith. What I tell people is that I'm just doing my job, which is [that] I'm a human being, and I need to tell you ... the recommendation from doctor human beings for this illness and for the treatment, but that I'm just a person and I don't know. And that's the truth – we don't know everything. We have very good ideas. When somebody is close to death, we can prognosticate quite accurately if that person's going to die or not. But I can not tell exactly when that is going to happen. And I don't want to rob somebody of their faithfulness.

On struggling with thoughts of suicide after the suicide of a friend and colleague

I think everything was a struggle. And I think that seeing somebody like Dave, who I admired so much, who was a friend, my best friend in the hospital, who I could speak with and who was so knowledgeable and intelligent — just to know that that is a risk for me as I grow older. Dave was also a very good father and it's something that I've struggled with, parenting.

It felt so much like a pressure of trying to be a good father while trying to be a good doctor, while trying to be a good writer. They can work together, but there are moments where they feel like they can just implode on themselves. And I think that knowing that that had happened to my friend weighed on me and made me think, Is this going to be me? Is this the fate that so many of us who care a lot that we face? ...

Therapy helped. I found a therapist who was very attuned to people who were creative types. ... That listening really helped. My relationships improved. When I was at my lowest, I could look at my relationships with the people who were around me, who I valued the most, and I can see that at that moment they weren't great relationships. And somehow over time, those relationships started to improve and that helped immensely. I think that writing also helped me too, at the end of the day.

On hospital staff losing their sense of meaning with their job because of burnout

For me that just demonstrates a real fundamental problem with how health care is administered in this country. If something like medicine, where you are helping people on a daily basis, if you can't see the meaning behind that, that's a bad omen. Whenever a patient tells me, "I'm thirsty" and I go get them ice water, I feel really good that day. Something as simple as that. With my Spanish-speaking patients, they can say one phrase to me and I will feel satisfied for that day — when they say, "Que amable," which means you were very kind in the way you said that. And I feel that that gives me a lot of meaning for the day. But I feel that the pressures and the mechanism by which health care operates right now obfuscates that for so many people. And that's sad to me. Now, I take a little bit of heart in that the medical field is really taking this seriously and is trying to do something about this. There is an added emphasis now on bringing in the arts and humanities into medicine.

If you or someone you know may be considering suicide or is in crisis, call or text

9 8 8 to reach the Suicide & Crisis Lifeline

.

Audio interview produced and edited by: Sam Briger and Thea Chaloner. Audio interview adapted for NPR.org by: Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin.