Ben Taub could be a model for health care
Without the middleman of insurance, Harris Health allows doctors to focus on their patients’ well-being
Early in my career, during my internship, I was slated to take care of patients on Ben Taub’s general wards, meaning those hospitalized for some degree of organ dysfunction — kidney disease, liver cirrhosis, pneumonia, infections of the skin. Every morning, I pulled into work listening to a Wilco song. I wasn’t superstitious, but one line seemed to encapsulate all the illnesses I was witnessing and my general feeling of ineptitude, and it comforted me to recite it: “Maybe I won’t be so afraid.” I have no idea when this ritual stopped.
I arrived on the wards and printed out a list of my new patients. Then I visited each hospital unit and started reading through the charts. Everything was paper then, meaning you could flip and flip and flip — through orders, test results, the notes of other doctors — and still not get to the bottom of what exactly was happening. One patient had a particularly large chart, actually two charts ducttaped together: a man I’ll call Alvaro to protect his privacy. It was so heavy and had been flipped through so many times that, like on an old book, cracks had started to show in its gray spine.
I read about Alvaro’s many surgeries: hip surgery, belly surgery, large portions of his intestines removed. For months, he couldn’t eat, his only nutrition delivered through an IV and then a tube in his stomach. It started as colon cancer. It had spread throughout Alvaro’s body to multiple organs and joints. Over the prior nine months, he’d only spent a couple of weeks out of the hospital. Otherwise he was in the ICU, then the wards, then the ICU again with septic shock from an infection of the blood, then a rehab center, then again the ICU.
And now Alvaro was here on the wards, in Ben Taub, my new patient. After flipping through the chart, I draped a stethoscope around my neck and went to meet him.
“English or Spanish?” This was the first important question I asked.
“Español,” he said.
When I was a medical student, professors used to praise me for the translations I provided. They had no clue. I’m the son of Salvadoran immigrants and, as such, grew up with Spanish everywhere — at the dinner table, at my parents’ parties, every summer visiting my grandparents in the hills outside the capital. But apparently reading and studying English influenced me more, and I speak Spanish like a gringo. It is something I’m constantly aware of, a part of who I am and how I’m seen, like a tic. Except at Ben
Taub. The patients here rarely mention it. Even my Spanish is
music to their ears.
“Any bleeding?” I asked. Alvaro shifted his head a little. “I don’t think so.”
“Can you lean forward?” I said, giving him a little push.
He took two short breaths like a weightlifter in the clench and stayed right in place. “Not really,” he grunted.
When I was on my way into his room, the nurse had stopped me. There was a decision I had to make, the quicker the better. “MAP is 60,” she said.
“Want to give fluids?”
It took me more than a second to realize what she was saying. The mean arterial pressure tells us if our vital organs are receiving an adequate amount of blood and nourishment. If this number is too low, then organs aren’t receiving the blood supply needed to survive.
My new patient’s MAP was right at the cutoff. Patients with low MAPs usually have to go to the ICU. Alvaro had just come from the ICU, and the nurse wanted to know if we could give IV fluids to bring up the MAP or if we needed to send him back.
I told the nurse to give me a minute. In thinking about what to do about the MAP, I had almost blinded myself to what was in front of me: a scared man, struggling to live as much as to die. I went back into the room, sat down beside Alvaro, and listened to his story.
Alvaro told me about the past nine months of his life — not about the pain or the vomiting or the bloody stools constantly filling the bag attached to what remained of his intestines, but how he had become a burden to his family.
His daughter stayed with him in the hospital most nights and worked during the day cleaning offices. She had to. If you’re poor and people depend on you, you can’t not make money. She had kids at home, too, school-aged kids. Alvaro told me she should have been taking care of them, not him.
Somehow, in this moment, my Spanish didn’t stumble. “You know that it’s OK if you die,” I said. As ever, I could hear a note of gringo, but the accent sounded muted, unimportant.
He was the same age as my grandfather; maybe that’s why I said what I did. Or maybe seeing the fear in his eyes when we discussed what might happen next, that this could go on, gave me the courage to be frank.
When I came out of the room, I saw the nurse talking with a woman I quickly recognized as Alvaro’s daughter. I buttoned my white coat and wove my way into the conversation.
“How is he?” the daughter asked.
I told her what Alvaro had told me, that he didn’t want doctors to resuscitate him if his heart stopped, that he didn’t want a breathing tube inserted under any circumstances. What this meant was that he wouldn’t be returning to the
“The time we give to Alvaro and any patient like him is more important than money.”
Ricardo Nuila, doctor at Ben Taub Hospital
ICU again, ever.
“He’s been through so much,” I said in Spanish. “I think he’s tired.” She nodded. It was still summer. The ridiculous Houston heat continued to broil outside, and yet everyone in Ben Taub wore layers and long sleeves. The AC did that to us. The daughter shivered, held her elbows tight. “I know he is,” she said.
As I started to walk away, the nurse reminded me about the MAP. “Are we giving fluids?”
“He’s DNR/DNI now,” I said. “I’ll put in the order.”
I flipped to the “Orders” section of his chart, wrote “Do Not Resuscitate” with my signature timed and dated, and slid the wobbly chart into its slot. I called my attending and told him about the change.
Immediately I turned my attention to the next name on my list, a patient staying on the other side of the hospital. I didn’t walk there with my usual quick pace, but I didn’t saunter either. Ten minutes later, I was absorbed in a different patient’s chart. That’s when my pager went off. I cursed having to be so connected and called the number back.
“This is the intern,” I said. “Just wanted to let you know that Mr. A just passed,” said the nurse.
“He’s dead?”
“The daughter’s at the bedside.”
I rushed back to the unit and met the daughter in the hallway. She was on the phone, pacing, crying, holding a tissue beneath her nose, getting words out. I didn’t want to interrupt her, and so I waited until I had her attention, and then I mouthed to her, “Lo siento.”
She smiled at me courteously and held her hand over the receiver.
“It’s OK, it’s really OK,” she said.
It didn’t hit me until after I performed what had to be done next — the death exam, the death note, signing off for Transportation to wheel the body away — that Alvaro might have still been alive if we hadn’t talked. Was that even possible? That words could mean the difference between life and death?
I knew the words I had written — “Do Not Resuscitate” — had that power, but what about our shared words? What about what I had said to Alvaro? What about what he had said to me? What about Alvaro’s story?
It’s been more than a decade since Alvaro died. I’ve cared for hundreds of patients at Ben Taub in that time, patients from Nigeria, Bhutan, Eritrea, Vietnam, Fifth Ward here in Houston, even from my grandparents’ village in El Salvador. I’m no longer an intern. In fact, now I am the one teaching residents and medical students.
Still, I try to find my patients’ stories. It’s my favorite part of being a doctor. I don’t mean their medical histories. I mean the circumstances of their lives. All of this information helps me to better empathize with them, but the stories also make medical care more efficient, more personal, and they reduce the number of tests needed to diagnose and give treatment.
In 2021, the cost of providing health care to Medicare enrollees eclipsed $15,000 per patient per year. Out of pocket costs for all Americans rose 10 percent. Health care in this country remained the most expensive in the world, and not just by a nose. More than 18 cents of every dollar spent in the U.S. went toward the medical industry, nearly double the amount seen in European countries. As a result, Americans expressed misgivings — if not sheer ill will — toward their health care system, with more than half grading it a failure.
Given these circumstances, it’s difficult to imagine doctors spending more time with their patients listening to stories. If time is money, then wouldn’t it stand to reason that to cut health care costs, doctors should act more efficiently and reduce the time they spend with their patients? This was certainly the mentality underlying the American health care industry.
What I came to realize is that there was something very special about Ben Taub that made it possible for me to sit and listen to Alvaro and other patients’ stories. The hospital is part of Harris Health, a publicly funded system that provides health care directly, without the middleman of insurance, to nearly half of its patients. The system charges the insurances of the other half without seeking to make profit. The result is something that doctors like me feel on a daily basis: the time we give to Alvaro and any patient like him, is more important than money. Could this be a model for the rest of America? Only time would tell.
Ricardo Nuila has practiced medicine at Ben Taub Hospital as a hospitalist and teaching attending since 2010. He is an associate professor at Baylor College of Medicine, where he directs the Humanities Expression and Arts Lab. His opinions do not represent those of Baylor. This essay is an adapted excerpt from his book “The People’s Hospital: Hope and Peril in American Medicine,” which is being published by Scribner this month.