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We welcome Dean-David Schillinger, an internal medicine physician and public health leader. Dean-David discusses his book, Telltale Hearts: A Public Health Doctor, His Patients, and the Power of Story. Drawing from over three decades of experience in one of the nation’s busiest public hospitals, he shares powerful insights on how listening to patients’ stories can lead to true healing, influence public health, and shape better health care policies.

Dean-David Schillinger is an internal medicine physician.

He discusses his book, Telltale Hearts: A Public Health Doctor, His Patients, and the Power of Story.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Dean David Schillinger. He is an internal medicine physician. We’re going to talk about his book, Telltale Hearts: A Public Health Doctor, His Patients, and the Power of Story. Dean David, welcome to the show.

Dean David Schillinger: Thanks for having me, Kevin.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Dean David Schillinger: I grew up in Buffalo, New York, in a public housing project. My parents were immigrants—my father from Hungary, my mother from Chile. They were fairly well-educated, and we were able to get out of the projects fairly soon. My father was a general surgeon, so I grew up around medicine, although not the kind of medicine that you think of normally being associated with storytelling and communication.

I went to medical school at the University of Pennsylvania in Philadelphia, where there was no public hospital. They had just torn down their public hospital a few years before I got there to build a whole bunch of NIH-funded buildings to do research. I had the fortunate pleasure of doing a rotation at San Francisco General Hospital as a fourth-year medical student, which really transformed my career because, as I say in the book, we used to say at San Francisco General Hospital, “It’s as real as it gets.” I mean, it really was the peak of the HIV epidemic, and medical students were really in charge of the emergency room in many ways.

I got to have real, intimate contact with patients and their stories, and sort of fell in love with primary care at that time. The rest is outlined in the book, but it’s really about connecting with patients around their stories and how that kind of connection can uncover hidden diagnoses and help you better manage the patient’s multiple conditions. When you aggregate these stories, particularly from one public hospital, they tell a larger story of what’s broken in our public health system and our social safety net system in America.

Kevin Pho: Well, that certainly resonates with me. I am an internal medicine physician myself. I trained in Boston at Boston Medical Center, which used to be Boston City Hospital. What is it about the public hospital scenario that appealed to you? And as you said, what changed your career trajectory? What is it about practicing in that setting?

Dean David Schillinger: I think a couple of things. First of all, it’s one of the only places in contemporary American society where people of different classes, races, and ethnicities come together in one place for a common cause. When you think about how divided our society is, it’s a very unique place. It’s also where, at least from a health care standpoint, it’s where health care meets social reality. In private institutions, you have people who are quite privileged often, and the realities of the difficulties in their lives are not as apparent as they are in a public hospital.

So, caring for patients in public hospitals is inherently complex, and I’m really drawn to complexity as an internist. I find that setting extremely inviting. But most importantly, I recall— I don’t know if this ever happened to you at Boston City— but on my last day as a medical student, as I was leaving the Mission Emergency Room after a 13-hour shift, all of the graduating medical students received a letter from the mayor, who was Mayor Art Agnos at the time, whose own life had been saved after an assassination attempt at that hospital.

We received a letter thanking us for serving the people of the city and county of San Francisco. You can imagine, as a medical student, I actually—the hair still stands up on my arms just telling that story—when you’re really an underappreciated medical student, to get that kind of letter describing kind of a public servant role, it’s a very powerful message to receive as a medical student and as a practicing physician. So, that really has kept me there. We have a joke at San Francisco General Hospital, which is either you stay there for three months or 33 years, and I’m in the latter category.

Kevin Pho: So you wrote your book, Telltale Hearts: A Public Health Doctor, His Patients, and the Power of Story. Now, before talking about the key messages of the book itself, what led you to want to write it in the first place?

Dean David Schillinger: Yeah, well, these are sort of the greatest hits. As an internist, you have patients whose care just sticks out in your mind for their uniqueness, for their salience, and sometimes for the surprise and epiphanies that come from them. These just accrued over time. I’ve been working as a primary care doctor at San Francisco General Hospital now for over 30 years. Many of these stories, the first time they hit me, were quite shocking, but by the 20th time I heard the same story, I was like, you know, there’s—there are patterns going on here in what I call a narrative epidemiology of sorts.

These stories need to be told to the general public because, in the United States, we cling to this idea of rugged individualism and that people’s health is determined by the decisions that they make in their day-to-day lives. I think the stories that I tell in Telltale Hearts share a common theme, which is that people’s health and disease trajectory is determined primarily by the social and environmental conditions in which they find themselves born into and living. That comprises 80 percent of health in America. Unless we begin to really change the discourse, not only around public health but around health care itself, to understand the powerful role that social and environmental conditions play in people’s health, we’re just going to keep spending more and more money on technology and kind of missing the boat.

It’s also a critique for listening to patients and really enhancing physician well-being by understanding people’s stories and where they come from and having shared connection.

Kevin Pho: Can you tell us a story from the book that really highlights how those social and environmental factors directly affect a patient’s care?

Dean David Schillinger: Yeah, I mean, there are numerous stories in there. I think the one that many people find most compelling was a patient of mine, a fairly longstanding patient with diabetes—a grandmother of five kids and something like 12 grandchildren—who was hospitalized on the medical service for profound hypoglycemia, or low blood sugar.

This happens from time to time in people with diabetes: they take too much medication, or they don’t eat breakfast that day. You infuse them with some glucose, and they turn around quickly, and you send them home. But she was hospitalized for three or four days, and they just could not, for the life of them, get her blood glucose up. The usual medical workup ensued: Is it sepsis? Is it liver failure? Is it an insulinoma? What could be going on? They finally got the blood sugar up. They never really figured out what the cause was.

Then I saw her in follow-up in the clinic, and I went through my differential diagnosis: Are you food insecure? That you were basically feeding your family in lieu of feeding yourself while taking your insulin? “No, no, I know how to stand in the lines of church and get the food that I need for the family.”

OK, do you have limited health literacy or numeracy? “Show me how you drew up your insulin that day.” She hit it right on the mark. Every question I asked, she just answered perfectly, and I was getting nowhere. Finally, I just said to her, “Look, you’re the expert here. What do you think happened here?”

That’s when she starts tearing up and telling me the story about her abusive husband, who essentially has been using her insulin as a weapon against her, either withholding it or administering it against her will as a form of power and control. In her case, he injected a massive amount of long-acting insulin. So, the intervention was a restraining order and ultimately the prosecution of the husband and liberating herself from an abusive relationship.

The prevalence of intimate partner violence in public hospital patients is quite high. So, that’s just one dramatic example of uncovering social conditions in this case at an interpersonal level, but many of the other cases are at a more social or structural level—whether it be housing problems, food insecurity, or the criminal justice system.

Kevin Pho: That really resonates. As you said, patients are really the experts of their own body, right? Sometimes getting them to share that story, that history, can lead to the ultimate cause of really what’s going on. Unfortunately, today, as you know, there are so many business aspects that really put pressure on patients sharing their stories. Time is limited, especially in primary care. We have, like, whatever—15 minutes to see a patient, and that really condenses the time that patients are able to tell their story.

So, you’ve been practicing for 30-plus years, and you’ve seen this business evolution and the infiltration of business into medicine. How can you continue that storytelling aspect in spite of all these changes and all the time pressures and bureaucratic hassles that face you as an internal medicine physician? How can you really maintain the importance of story and that relationship despite everything else that’s going on around us?

Dean David Schillinger: Yeah, I mean, I have 20 minutes for a visit. I think the average primary care doctor across the country has something like 17 minutes per visit. I like to say, “You’ve got 20 minutes—what are you going to do with it? It’s up to you what you decide to do with it.” Also, as you know, being an internist in primary care, you have the luxury of seeing the patient back. So, I think the most important policy problem we have to deal with, apart from some of the within-the-encounter stressors that you described, is the paucity of primary care physicians in this country and the lack of policy solutions to ensure that we can have longitudinal care for complex patients. Because it’s over time that these stories unfold.

Often, some of the stories I tell in the book happen on the first visit. There’s a woman with breast pain that’s undiagnosed, and the story unfolds in an urgent care visit. But the vast majority of these stories unfold over time when you see patients back and back again.

There is some research on listening. When you compare the research done on doctors talking to patients to how doctors listen to patients, the former dwarfs the latter. There’s not a lot of research on listening, but we do know that really trying hard to avoid the lecturing style, to give space on the order of 60 to 90 seconds to patients, and to give silent pause time can exponentially increase the amount of storytelling that happens—and it lengthens the visit by, you guessed it, by about 60 seconds.

So, I think the strategic use of open time and very mindful question-asking—where you mix open-ended questions with semi-structured questions and direct questions in a mindful state—is really key. I think it’s when we’re just logging it in and not being really present, not having that beginner’s mind and true attentive state, that we lose out on the possibility of eliciting the patient’s story. But I am confident that we can still do this even in today’s world. And I think, increasingly, with what we’re learning about AI scribes, we may be finding that we can have some freed-up time to elicit stories.

Kevin Pho: Who is the main audience for your book, and what is the main message that you want them to receive after reading your book?

Dean David Schillinger: The main audience is the general public. Obviously, I think doctors, medical students, and nurses are going to read it too because we all have our stories, and it’s fun to read about our colleagues’ experiences. But the main audience is the general public.

I think the main message is twofold. One, which I sort of shared with you already, is that the way health happens in America really has to do with our social and environmental conditions. Unless we start engaging in social policy initiatives and health policy initiatives at the public health level, we’re going to become bankrupt as Medicare and Medicaid grow. So, really getting people to think about health in all policies—how the USDA makes policy is important for health care, how the Federal Trade Commission makes policy is important for health care—is crucial.

In that regard, it’s a policy book for folks who are interested in equity and policy. The second main message is that even across great degrees of social distance, as you find yourself in—I’m sure you felt this at Boston City Hospital—whether you’re dealing with a patient from across the globe or someone who’s homeless, they’re different from you. But ultimately, through the sharing of stories, we can share our humanity. Once you have shared humanity with another individual, you can’t help but care for them. I think that’s true in health care, and I think that, particularly in this divided society today, is a message that we need to remember for society as a whole—that we need to listen to each other’s stories if we’re going to be able to understand and care for each other.

Kevin Pho: We’re talking to Dean David Schillinger. He’s an internal medicine physician and the author of the book Telltale Hearts: A Public Health Doctor, His Patients, and the Power of Story. Dean David, we’re going to end with some of your take-home messages that you want to leave with the KevinMD audience.

Dean David Schillinger: Additional take-home messages? I think curiosity. It’s really important to be curious about the other and to not make assumptions. It’s so easy to take shortcuts in medicine and in general civil society as a whole. But to be interested in the guy who’s selling you food at the corner store, or the woman who’s bagging your shopping, and to have the kinds of conversations that you don’t think possible, can really enrich your life and give you greater faith in the resilience of humanity.

I think the other main messages are that places like public hospitals are few and far between, but are extremely valuable assets to society, and ways in which we can address income inequality and other ills that we have in society. We need to be very cautious about how we handle the future of these kinds of institutions.

Lastly, I really want to give a shout-out to primary care as one of the main solutions to our health care crisis in America.

Kevin Pho: The book is called Telltale Hearts: A Public Health Doctor, His Patients, and the Power of Story. Dean David, thank you so much for sharing your story, perspective, and insight.

Dean David Schillinger: Thank you, Kevin, for having me. It’s a pleasure.