Illustration of doctor, in lab coat and white coat, sitting on bed and comforting elderly patient.
Illustration by Ken Ellis / Stick/Illustration by Ken Ellis / Stick
Early in my career, during my internship, I had to take care of patients in the general wards of the Ben Taub, i.e. those admitted for some degree of organ dysfunction: kidney disease, cirrhosis of the liver, pneumonia, skin infections. Every morning I got to work listening to a Wilco song. I wasn’t superstitious, but one sentence seemed to encompass all the illnesses I was witnessing and my general feeling of helplessness, and it was comforting for me to recite it: “Maybe I won’t be so scared.” I have no idea when this ritual ended.
I arrived at the wards and printed out a list of my new patients. Then I visited each hospital unit and started reading the charts. Everything was paper back then, meaning you could flip and flip and flip through — through orders, test results, other doctors’ notes — and still not get to the bottom of what exactly was going on. One patient had a particularly large file, actually two files taped together: a man I’ll call Alvaro to protect his privacy. He was so heavy and had been leafed through so many times that, like an old book, cracks had begun to show in his gray spine.
I’ve read about Alvaro’s many surgeries: hip surgery, abdomen surgery, removal of large portions of intestine. For months he was unable to eat, his only nourishment being provided through an IV and then a tube into his stomach. He started out as colon cancer. It had spread throughout Alvaro’s body to multiple organs and joints. In the previous nine months, he had only been out of the hospital for a couple of weeks. Otherwise he was in ICU, then on wards, then back to ICU with septic shock from a blood infection, then in a rehab center, then back to ICU.
And now Alvaro was here in the ward at Ben Taub, my new patient. After going through the file, I put 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 praised me for the translations I provided. They had no idea. I am the son of Salvadoran immigrants and, as such, I grew up speaking 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 has influenced me the most, and I speak Spanish like a gringo. It’s something I’m constantly aware of, a part of who I am and how I’m seen, like a tic. Except at the Ben Taub. Patients here rarely mention it. Even my Spanish is music to their ears.
“Any bleeding?” I asked.
Mr. Alvaro moved his head slightly. “I do not believe.”
“Can you lean forward?” I said, giving him a little push.
He took two short breaths like a weightlifter in a grip and stood still in place. “Not really,” he grunted.
As I was entering her room, the nurse had stopped me. There was a decision I had to make, the sooner the better. “MAP is 60,” she said.
“Do you want to give liquids?”
It took me more than a second to figure out what he was saying. Mean blood pressure tells us if our vital organs are getting an adequate amount of blood and nourishment. If this number is too low, organs don’t get the blood supply they need to survive.
My new patient’s MAP was right on the edge. Patients with low MAPs usually need to go to intensive care. Mr. Alvaro had just arrived from the ICU and the nurse wanted to know if we could give intravenous fluids to bring up the MAP or if we should send him back.
I told the nurse to give me a minute. In thinking about what to do with the MAP, I had nearly blinded myself to what was in front of me: a frightened man, struggling as much to live as he did to die. I went back to the room, sat next to Alvaro and listened to his story.
Alvaro told me about the last nine months of his life, not about the pain or vomiting or bloody stools that constantly filled the pouch attached to what was left of his intestines, but about how he had become a burden to his family.
His daughter stayed with him in the hospital most evenings and worked cleaning the offices during the day. She had to. If you’re poor and people depend on you, you can’t not make money. She also had children at home, school-age boys. Alvaro told me she should have taken care of them, not him.
Somehow, right now, my Spanish hasn’t stumbled. “You know it’s okay if you die,” I said. As always, I could hear a note of gringo, but the accent sounded muffled, 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 continue, gave me the courage to be frank.
When I left the room, I saw the nurse talking to a woman who I immediately recognized as Alvaro’s daughter. I buttoned up my white coat and pushed my way into the conversation.
“As he is?” her daughter asked.
I told her what Alvaro told me, that he didn’t want the doctors to revive him if his heart stopped, that he didn’t want a breathing tube inserted for any reason. That meant he would never go back to the ICU, ever.
“He’s been through so much,” I said in Spanish. “I think he’s tired.” She nodded. It was still summer. The ludicrous Houston heat still boiled outside, yet everyone at Ben Taub was wearing layers and long sleeves. The AC did this to us. Her daughter shivered, gripped her elbows tightly. “I know it is,” she said.
As I started to walk away, the nurse reminded me of the MAP. “Are we giving liquids?”
“Now it’s DNR/DNI,” I said. “I’ll place the order.”
I navigated to the “Orders” section of his chart, wrote “Do Not Resurrect” with my timestamped signature, and slid the wobbly chart into its slot. I called my assistant and told him about the change.
I immediately turned my attention to the next name on my list, a patient across the hospital. I didn’t walk there at my usual brisk pace, but I didn’t stroll either. Ten minutes later, I was engrossed in another patient’s medical record. 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.
“I just wanted to let you know that Mr A just passed by,” the nurse said.
“The daughter is at the bedside.”
I ran back to the unit and met my daughter in the hallway. She was on the phone, pacing her up and down, crying, holding a handkerchief under her nose, speaking words. I didn’t want to interrupt her, so I waited to get her attention, then I said, “Lo siento.”
He smiled politely at me and kept his hand on the receiver.
“It’s fine, it’s really fine,” she said.
It didn’t strike me until after doing what had to be done next – the death examination, the death note, the signing for the transport to take the body away – that Mr. Alvaro might still be alive if we hadn’t spoke . It was possible? What words could mean the difference between life and death?
I knew the words I’d written — “Thou shalt not be resurrected” — had that power, but what about our shared words? And what I had said to Mr. Alvaro? And what he had told me? And the story of Mr. Alvaro?
More than a decade has passed since the death of Mr. Alvaro. I treated hundreds of patients at Ben Taub during that time, patients from Nigeria, Bhutan, Eritrea, Vietnam, from the Fifth Ward here in Houston, even from my grandparents’ village in El Salvador. I am no longer an intern. In fact, now I’m the one teaching the graduate students and medical students.
However, I try to find my patient stories. It’s my favorite part of being a doctor. I don’t mean their medical histories. I mean the circumstances of their life. All of this information helps me better empathize with them, but the stories also make medical care more efficient, more personal, and reduce the number of tests needed to diagnose and provide treatment.
In 2021, the cost of delivering health care to Medicare enrollees eclipsed $15,000 per patient per year. Out-of-pocket costs for all Americans increased by 10%. Healthcare in this country remained the most expensive in the world, and not just for a nose. More than eighteen cents of every dollar spent in the United States went to the medical industry, nearly double the amount seen in European countries. As a result, Americans have expressed doubts — if not outright hostility — about their health care system, with more than half rating it a failure.
Given these circumstances, it’s hard to imagine doctors spending more time with their patients listening to stories. If time is money, then wouldn’t it make sense that in order to cut health care costs, doctors should act more efficiently and reduce the time they spend with their patients? This was certainly the underlying mentality of the American healthcare industry.
What I realized was that there was something very special about Ben Taub that allowed me to sit down and listen to the stories of Mr. Alvaro and other patients. The hospital is part of Harris Health, a publicly funded system that provides health care directly, without insurance intermediaries, to nearly half of its patients. The system charges the other half’s insurance without trying to make a profit. The result is something doctors like me hear on a daily basis: the time we dedicate to Alvaro, and to any patient like him, is more important than money. Could he be a role model for the rest of America? Only time would tell.
Ricardo Nuila has practiced medicine at Ben Taub Hospital as a hospitalist and teacher since 2010. He is an associate professor at Baylor College of Medicine, where he directs the Humanities Expression and Arts Lab. His views 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,” published by Scribner this month.