One of the riveting tales in “Telltale Hearts,” a new memoir, is about the author’s great-uncle Aladar, a Hungarian Jew who was drafted to fight the Russians in 1916 and spent months in trenches, shooting and getting shot at, and waiting.
Russian troops launched an offensive that fall that overwhelmed the Austro-Hungarian soldiers. At one point, Aladar found himself on his back, staring up at a massive Russian soldier who was about to plunge a bayonet into his chest.
The two locked eyes, and the Russian looked at Aladar as if he knew him from somewhere.
“Are you a Jew?” he asked. Aladar didn’t answer, so the Russian asked again. In Yiddish.
This time, Aladar nodded, and the Russian looked around, winked, pulled him out of the trench, hugged and kissed him, and said he would take Aladar prisoner and keep him safe until the war ended. And he did.
What’s this war story doing in a book about a safety net hospital that treats poor patients in San Francisco? For the author, Dr. Dean-David Schillinger, the moment of recognition, of seeing oneself in another, is a critical part of doctoring.
One of the chief complaints about physicians these days is that they don’t have enough time and they don’t really listen. So Dr. Schillinger, a primary care physician at Zuckerberg San Francisco General Hospital and Trauma Center, has written a book about the importance of patients’ stories. He writes of the power of narrative to build trust that cuts through the barriers that often separate doctors and patients to ultimately improve care.
“What has increasingly been lost as we advance in our technologies, using electronic health records that make us look at the computer and not at the patient, and becoming more constrained from a time perspective, is the most important and common medical procedure — the medical interview,” Dr. Schillinger said told The New York Times.
“A lot of people think that’s the doctor peppering the patient with questions, but that’s not really how it should go,” he added. “It really should be about eliciting the patient’s perspective on the experience and their social context.”
Science is paramount, he said, but the patient’s story is an essential complement. “It’s when we separate the two that we get in trouble,” Dr. Schillinger said. The book is about what he thinks of as “the alchemy of science and story.”
His book unfolds like a medical version of “Arabian Nights” as he describes a woman who experiences severe, unexplained breast pain despite negative mammogram results; a diabetic patient whose blood sugar plummets so severely that it almost kills her; and a man who crawls on his hands and knees for no obvious medical reason.
At one point, he becomes so frustrated with a man who isn’t taking his blood pressure medications that he threatens to “fire” him as a patient. Another time, he drives to low-income neighborhood where a longtime patient lives to find out why she isn’t showing up for her cancer treatments.
The roots of most of these predicaments are not medical, Dr. Schillinger writes. They are rooted in social and economic problems that medicine alone can’t cure.
Ultimately, however, “Telltale Hearts” is about a burgeoning area of medical research: the ways in which socioeconomic factors like poverty, racism and marginalization — and associated ills like food deserts, housing insecurity and exposure to pollution and violence — shape the health of many Americans, as well as society’s obligation to do better.
In 1991, amid the AIDS epidemic, Dr. Schillinger started working at what was then San Francisco General Hospital, the safety-net hospital that served the city’s poor and homeless people.
In 1994, he became a primary care physician there, after caring for mostly middle-class insured patients at the University of California, San Francisco Medical Center during his residency.
“At San Francisco General, my patients were just dying a lot faster than at the university hospital,” he recalled. “But I’m the same doctor for both of them. And they’ve got the same diseases. Something is amiss. So what’s going on?”
The phenomenon was first described in 1971 by Dr. Julian Tudor Hart, who practiced in Wales. While Dr. Tudor Hart worked 12-hour days, six days a week, taking care of a low-income population, his colleagues who treated well-off patients wrapped up by 5 p.m. and had weekends off.
Dr. Tudor Hart’s research into the disparity gave rise to what has been called the inverse-care law: Physicians are always much busier in poor neighborhoods, and, in the end, the people who need the most care are the least likely to get it.
At his own hospital, “health care meets social reality,” Dr. Schillinger said. “We see the end consequences of marginalization playing out in physical disability and pain and suffering.”
Dr. Schillinger weaves his own family saga through the book — his father was a Holocaust survivor, and he himself almost dropped out of an Ivy League medical school. He even includes his experience as an ill patient struggling to get his doctors to listen.
The book doesn’t sugarcoat the toxicity that can infect a medical workplace.
Dr. Schillinger talks frankly about the callousness that may develop among those working inhumanely long shifts in overtaxed emergency departments. There, doctors he trained with early in his career referred to the patients who straggled in toward the end of their shifts as GOMERS — people whom they just want to “Get Out of My Emergency Room.”
The book is a cry for social change and a plea for the profession “to recognize the patient as one of our own, not just someone to manage and get through the conveyor belt of care,” Dr. Schillinger said.
“It’s about finding our shared humanity in a world that is constantly pressuring us to take shortcuts and to rely on impersonal ways of managing very complex human problems,” he said.
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