Review of Ricardo Nuila,“ The People's Hospital”

Burnout among nurses, doctors, and staff is weighing on the American health care system. Researchers have found that two-thirds of U.S. physicians suffer from at least one feature of burnout. Concerns about “moral injury” have risen to the fore. Physicians fear that the ethical obligation to do the best for one's patient often clashes with institutional priorities, usually the business interests of hospitals and health systems. Seventy percent of doctors now work in large systems or as hospitalists. As the health system has consolidated, physician dissonance has grown.

In his superb recent book, The People's Hospital, Dr Ricardo Nuila offers a unique perspective on moral injury. Nuila, a first-generation American whose family emigrated from El Salvador, works as a hospitalist at Ben Taub Hospital in Houston, a safety net hospital and a tiny cog in the massive Harris Health System.

At first glance, the book appears to belong to a more familiar genre of first-person physician narratives that show how the features of U.S. medical care, notably corporate ownership of health care and insurance linked to employment, work against the humane treatment of individual patients.

We encounter patients who are trapped in a maze of bureaucratic indifference, arcane rules, and inadequate insurance coverage. Such as the tragic case of Geronimo, a gas station attendant who makes too much money to qualify for Medicaid, endures pointless admissions and discharges, and ends up dying while waiting for a liver transplant.

If Nuila's account only drew more attention to these needless outcomes, it would be a worthy effort. But it does far more. What makes Nuila's story different is that the main protagonist is the hospital itself. And not just any hospital or health system, no stately Cedars or sprawling Mass General, but a medical version of the little engine that could: Ben Taub.

While inspiring protagonists appear throughout, Ben Taub hospital and its institutional culture are the heroes. Nuila calls The People's Hospital “a love letter to the hospital, my hospital, where people find healthcare and revere it like treasure.” His colleagues “weren’t just doctors. Among us were nurses, social workers, X-ray techs, the people who rode up and down the hallways in the middle of the night waxing the floors. …More often though, the needs of our patients were so damn immediate, we found a way to work as one.”

The reason the process works, when it does, is that physicians and the other professionals and support staff feel mission-driven on behalf of patients despite woefully limited resources. As Nuila writes, “Healthcare workers feel useful at Ben Taub. Much of this sense of utility stems from helping those most in need, but another part comes from working in a system that takes healthcare spending seriously.”

Ironically, because doctors can’t do everything at Ben Taub, or even half of what they’d like to try, they need to consult patients and their families to set priorities and to plot a course of action. And by having to listen to the patient a fundamental bond between doctor and patient is restored.

In an era of eroding physician autonomy, Nuila feels empowered. As a hospitalist, he is happier and more fulfilled, he believes, than his peers in private practice. Doctors and hospital staff feel useful. Patients feel seen and retain their dignity. And they frequently receive excellent clinical care in an unpromising setting.

Here is a hospital stripped down to its essentials, practically devoid of funding, and left with scant resources in relative neglect to provide for the least fortunate and the uninsured. And, amazingly, it works. At least for a while. And for some. That it does so in a state, Texas, notable for its hostility to spending government funds on the uninsured, let alone the undocumented and uncovered, is a persistent sub-theme. Doctors and staff cooperate despite their open political differences. Dr Ken Mattox, for instance, is a conservative physician who dislikes government funding of health care on principle but is endlessly creative with his limited resources and fiercely proud of Ben Taub.

To be sure, Nuila deliberately accentuates the positive. He proudly cites the 2015 U.S. News hospital rankings in which Ben Taub ranked first in the country in cardiac-related outcomes. In other years, Ben Taub's rankings have tended to be middling or subpar, even in hospital rankings that include community benefit along with clinical outcomes.

Nuila's account of Ben Taub is idealized, reflecting his immense gifts as a writer and as a de facto participant-observer. He is surely one of the few physicians to have chosen between a career in medicine and being a full-time writer. Yet his core message rings true: money alone doesn’t buy good care, and resources in the absence of a supportive institutional culture don’t necessarily yield good outcomes, and sometimes the opposite.

Ben Taub is the institutional antidote, in effect, to moral injury in the profession. Nuila makes this point both implicitly and explicitly. He quotes the well-known 2018 Stat article that described “the complex web of provider's highly conflicted allegiances—to patients, to self, and to employers—and its attendant moral injury may be driving the healthcare ecosystem to a tipping point.” And counters with the advantages he finds at his safety net institution:

“Burnout at Ben Taub is different. Here the system adapts to doctors as much as doctors adapt to the system. For instance, each hospitalist can only see as many as fifteen patients in one day. Patient caps like these give doctors time to make safe and thoughtful decisions and to feel unhurried at the bedside. …Financial incentives, like bonuses for extra productivity, exist at Ben Taub, but they’re calculated at the end of an entire work year, and they’re not sufficient to affect how I manage my daily routine. At Ben Taub, I feel like I can balance medicine as a job and as a vocation. The system's flexibility has helped me keep my patients as the top priority whenever I’m working. And moral injury isn’t so much of a problem at Ben Taub, because the values of the safety-net system and the doctors are more likely to align.”

Avoiding moral injury, however, doesn’t preclude a more familiar kind of burnout among the Ben Taub staff—the crushing need of the indigent, the uninsured, and the uninsured and the absence of the collective will to devote sufficient resources to their care. A sense of shared mission is vital, but it is insufficient to counter a chronic lack of funding in the face of overwhelming medical demand.

COVID-19, and more so the rush of pent-up demand that follows the pandemic, is the straw that breaks the camel's back. Even the motivated doctors at Ben Taub can’t cope with a resource-starved environment at a breakneck pace for weeks and months on end.

The staff succumbs to what Nuila perceptively calls “disaster syndrome,” the goal of simply making it through the day and losing sight of, and hope for, a better system that could improve their daily lives at work. While gratified that patients thank him for doing his best, the author is overcome by a sense of futility in the face of the unmet human needs that he experiences. “Dave”, the division chief, and Nuila's mentor, commits suicide. To be sure, as Nuila acknowledges, such a tragic choice has both individual and social roots. In the book's narrative arc this suicide symbolizes a broken U.S. healthcare system that fails to offer a minimum standard of care even to its own citizens.

By focusing on a little hospital, Ben Taub, that punches above its weight, so to speak, Nuila puts the modern hospital in comparative relief. By some measures, hospital care is the single largest American industry. Gleaming new hospital buildings sprout up both in down-at-the-heels urban neighborhoods, such as that adjoining the Cleveland Clinic, and in rural hamlets. Like the modern corporation more broadly, few institutions are more central to the modern United States than the modern hospital. Yet there is a dearth of books and articles of every kind—from first-person observation to academic studies—that explore the day-to-day workings of the contemporary hospital and the large health systems that they anchor. We tend to read about the modern hospital on the business page, enmeshed in the language of conglomerates, private equity, acquisitions, spinoffs, and so on. As the principal driver of U.S. health care costs and its medical culture, the hospital deserves more scrutiny.

Paul Starr, the author of a landmark history of American medicine, once wrote that doctors became small capitalists to avoid losing their autonomy to large capitalists. That autonomy is increasingly becoming a thing of the past. While the competing priorities and allegiances brought about by health care consolidation account for a large part of the moral injury that physicians and medical staffs confront, doctors are facing a deeper loss of moral authority that reflects their diminished status.

The prominent pediatrician-author John Lantos, in his book Do We Still Need Doctors? wondered decades ago about fellow physicians losing their morale even as their tools improved. The more they achieved, medically speaking, the less difference they felt they were making. This is because doctors are increasingly viewed as the undifferentiated “providers” of medicine to “consumers” rather than professionals with unique skills who have built an ongoing relationship of trust with patients.

Lantos mused about a future, now far closer to reality, in which machines can diagnose illness better than humans and make more accurate clinical decisions. Would there still be a need for doctors? Lantos asked. Yes, he concluded, because doctors have both technical skills and human empathy. Unlike machines, they can interpret how medical results relate to the actual circumstances of patients’ lives. The narratives that doctors help patients construct can be as important to their futures as lifesaving drugs or surgeries.

In decrying “algorithmania” in healthcare, Nuila echoes this view. Even when much of modern medicine is nominally effective, he argues that it frequently ignores “what couldn’t be quantified. A person's identity and their desire to avoid suffering, and the circumstances of their lives.” He argues that medical cultures need to allow doctors the latitude to listen to their patients and for patients to be heard. In such a culture, as at Ben Taub, it is possible to do a lot with a little. Unfortunately, for physicians, patients, and even health outcomes in the fullest sense, the U.S. system is committed to doing only a little with a lot.