[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today is part two with Dr. Ricardo Nuila. If you didn't have a chance to listen to part one, I'll just repeat a little bit of his biography here. Dr. Ricardo Nuila, MD is an Associate Professor of Medicine at Baylor College of Medicine. He sees patients at Ben Taub Hospital in Houston, Texas, part of the Harris Health System, where the focus is really on a given individual's health care problem, regardless of the ability to pay. He is also a writer and is involved at Baylor College of Medicine with a humanities program, and how to integrate the humanities into medical education and the importance of that. A lot of his writing focuses on healthcare, disparities, politics and medicine, as well as art and medicine. I really enjoyed part one talking to him about how to talk to patients, how there's nuance and complexity in what we say while being as accurate as possible and telling the truth to patients. We talked about the Emily Dickinson line, tell the truth, but tell it slant. Today, we're going to focus on disaster syndrome, burnout, and how Dr. Nuila avoids burnout. And how disaster syndrome has a link to the building of the publicly funded Ben Taub Hospital. Here we go.
[00:01:24] Can we move on to disaster syndrome? What you mean by that?
[00:01:28] Ricardo Nuila: Yeah, sure. Disaster syndrome is a term that I came upon in a book called The Hospital written by Jan de Hartog, which was published in 1965, I believe. He's a great writer. He wrote this book about the formation of the Harris County Hospital district in Houston that came from a charity hospital, from Jefferson Davis Hospital. That was the only place where people who couldn't afford healthcare could go. And by his op eds and his detailing of just how charity was not enough, in op eds and in this book, taxpayers in Houston, Texas decided to provide health care for people who could not afford it. So we have a public health care system now, in large part because of this book.
[00:02:17] One of the things that he talks about is disaster syndrome. It was something that he, as a Dutch ship captain, had encountered. While he was helping to save people from these large floods that occurred in the Netherlands, he came upon this couple, a doctor and his wife, who had been helping in a village for three days without any resources at all. When Jan de Hartog came with relief and with supplies, they encountered resistance. The resistance was like, hey, we did the best we could do. And so they almost felt bad that somebody had come to help them. He calls this disaster syndrome, and he says that it happens when you are in the throes of a disaster, You just think to yourself that there's nothing that we can do about this, so we might as well just dig in and just accept these circumstances as forever. We're just beholden to this. There's just nothing that we can do. It resonated with me the way he described it, and I feel like we see it a lot in physicians throughout the country now; how we think about our large societal questions these days, like the behemoth that is reforming healthcare, I think we feel a lot of disaster syndrome that and we almost feel any sort of relief like that contradictory feeling of resistance.
[00:03:37] Christine Ko: Yeah. Do you think it relates to physician burnout?
[00:03:41] Ricardo Nuila: I think it does. Burnout is tough to wrap your head around. I think it's super complex because I feel like the responsibilities in many ways are higher for physicians now. The work which revolves around not just diagnosis, but also this system of insurance and billing. Everything like that creates a lot of basic like angst. I think disaster syndrome is connected to burnout. That's the argument that I make. There is real attrition from our field, people who are leaving our field. I think that's a major societal problem. There's something about the field that is making it so that people leave. We need to take it seriously. I was educated in Texas and I received a lower tuition because the state subsidized my education. Society is putting their resources into us. So if I leave the field early, it's not good for anybody. And that's happening a lot, so we have to take it seriously. And disaster syndrome, our thought that, you know what? We're just beholden to this, to the way it is. We resist any change because we're just in these conditions. Changing the paradigm for medicine is easier said than done. But I suggest the example of a public healthcare system, where it's mission driven. I still earn a comfortable salary, but profit motive is not the number one thing. Again, we're talking about nuance here. I can still earn a living, but it's not number one. I think that makes a huge difference in alleviating a lot of that disaster syndrome. "Comfortable living" is tough because it's, again, that's the same thing: 6 percent is different to one person to another. And one of the things that I think is worthwhile to think about is, what if we traded some of that money, not all of it, trading some of it for more freedom to be able to practice so that we're not beholden to like billing and insurance codes. How does that look? I get a glimpse of that by working in a public health care system where my decisions aren't really controlled by insurance companies. That's the experience that I wanted to demonstrate in the book.
[00:05:55] Christine Ko: Yes. I recently spoke to Cass Sunstein about habituation where he says, basically most human beings, we get used to what is around us, what's on our plate. We get used to it. And I think that relates to this disaster syndrome and burnout that to reform healthcare does seem just so difficult. I'll just speak for myself. It's, Oh this is the way it is. I just have to live with it. But I do find inspiration from reading about the Harris Healthcare System, reading about what you're able to do in a system that's publicly funded like that. And that the residents of that area decided even to do that. I think it's amazing.
[00:06:37] Ricardo Nuila: It's an example that is still within our reach and that continues to provide inspiration. Just as an example, last November, Harris County residents went to the polls and voted overwhelmingly to give more support to the hospital system. They gave 2. 7 billion worth of bonds to rebuild hospitals, to increase outlying clinics. The way that the vote shaped out, this was a bipartisan vote because it was overwhelming. There are hints of this optimism and beauty in our profession. We have to recognize what is good, and build from there rather than get bogged down. Some of that is awareness, just going through like the day to day and really trying to look for where to build from. Part of disaster syndrome is just not understanding that each of us is an individual and faces moral choices on a daily basis and not trying to build one step at a time.
[00:07:35] Yes, it's a huge process. What happened in Harris County, the seed was planted in 1960s. I'm writing about a hospital system in the 2020s. But man, those people who have been part of the process, that's been helpful. We can all stand to be part of a larger process that is improving things, and I think that we all make decisions on a daily basis on whether we are part of that or not.
[00:07:56] Christine Ko: I love that. I was going to ask you how you avoid burnout, but I think you just answered it... by looking for those hints of optimism.
[00:08:06] Ricardo Nuila: Yeah and I think that it's really important that I do look, I have that discipline to look for it because I think that the arts and humanities give you that architecture of mind to look for it. It's not all flowers for me at all times, but I just take stock in the little moments. My colleagues, they're hospitalists like me, will reach out to me and say, I find no meaning in my life and no meaning in my work. And I think to myself, gosh, we have that great opportunity to influence people at every turn. You can, if you do it in the right way, that could really positively impact the life.
[00:08:42] Christine Ko: I'm rephrasing, so it might be wrong, but you've trained yourself to look for those hints of optimism or good things, and the arts and humanities helps with that. Why do you think the arts and humanities helps with that?
[00:08:57] Ricardo Nuila: Arts and humanities are geared toward beauty. They look at different slices and depths of life. How do I put this? An example that I would say is that if you're a musician, and you trained your ear, you'll hear a certain like rhythm caused by a truck driving around, then you'll be like, that's really interesting, and you'll start to think about how that can shape your own music. You'll hear those rhythms and those sounds everywhere. What the humanities does is it just decorates your mind. For instance, masterful works written by like Cormac McCarthy. The passenger. It's about a physicist in New Orleans and also about diving, but you just get tuned to some of the things that person sees. It puts a little depth to your mind where you can recognize things. And maybe you start to bring that into your own personal interactions, and you start to look through your eyes in a different way. You start to see things a little bit more, the relationships a bit more, start to see the beauty. That's the architecture that I'm talking about, that the humanities gives you this architecture for meaning that you can grasp and you can tap into. It's a hard life out there, I feel, but it's also a beautiful life. And we have to see those and balance those.
[00:10:08] Christine Ko: I really love how you put that. I never thought about it that way, that the arts and humanities are really about beauty. But I think you're right. And I think the way medicine is right now, it's about fixing. Not that I want people to be sick, but I think there is beauty in disease.
[00:10:28] Ricardo Nuila: Yes. There is beauty in disease for sure. There's this logic to it. There's this logic that tells you about this connection, meaning these rules apply, and they also apply in other realms, in other things that I've seen.
[00:10:42] And even though, certainly, disease is not something that you wish upon that person, but the process of it reinforces this idea of this logic governing us all.
[00:10:53] Christine Ko: Do you have any final thoughts?
[00:10:55] Ricardo Nuila: How do we help people think in a bigger picture way? It's like microscopes. If you are just looking at one objective, you have to zoom out sometimes to see. This is really a part of our profession. We need to contextualize that for patients. We need to zoom out for ourselves too. That person who says, I've lost meaning in my life is not zoomed out enough. To see, gosh, I actually have a position where I can help people, or, I'm in a position of security, things like that. That's what we're trying to do. And we feel very fortunate that we're able to.
[00:11:28] Christine Ko: I love it. Thank you. Thank you so much for spending time with me and talking to me about this stuff.
[00:11:32] Ricardo Nuila: Thank you so much for inviting me, and thank everybody for listening. I appreciate it.