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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 and 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 normally 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 pleasure of doing a rotation at San Francisco General Hospital as a fourth-year medical student, which really transformed my career. As I say in the book, we used to say San Francisco General Hospital is “as real as it gets.” It really was at the peak of the HIV epidemic, and medical students were in charge of the emergency room in many ways.
I got to have real, intimate contact with patients and their stories, and I 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 connection can uncover hidden diagnoses, help manage patients’ multiple conditions, and reveal larger stories about what’s broken in our public health and social safety net systems 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 setting that appealed to you and, as you said, changed your career trajectory?
Dean David Schillinger: I think a couple of things. First, 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. From a health care standpoint, it’s where health care meets social reality.
In private institutions, you often have people who are quite privileged, 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 I think most importantly, I recall—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. The mayor at the time was Art Agnos, whose 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—when you’re an underappreciated medical student—to get that kind of letter describing a public servant role was a very powerful message. It’s kept me there. We have a joke at San Francisco General Hospital: either you stay for three months or 33 years. 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. Before talking about the key messages of the book, what led you to write it in the first place?
Dean David Schillinger: Well, I mean, these are sort of the greatest hits. As an internist, you have patients whose care sticks out in your mind for their uniqueness, their salience, and sometimes for the surprises and epiphanies that come from them. These stories accrued over time. I’ve been working as a primary care doctor at San Francisco General Hospital for over 30 years.
Many of these stories—when they first hit me—were quite shocking. But by the 20th time I heard the same story, I realized there were patterns, forming a sort of “narrative epidemiology.” These stories need to be told to the general public because, in the United States, we cling to this idea of rugged individualism, that people’s health is determined by the decisions they make in their day-to-day lives.
The stories I tell in Telltale Hearts share a common theme: people’s health and disease trajectory is determined primarily by the social and environmental conditions in which they are born and live. That comprises 80 percent of health in America. Unless we 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 going to keep spending more money on technology and miss the point.
It’s also a critique on listening to patients and enhancing physician well-being by understanding people’s stories, where they come from, and having shared connections.
Kevin Pho: Can you tell us a story from the book that really highlights how social and environmental factors directly affect a patient’s care?
Dean David Schillinger: There are numerous stories, but one that many people find compelling is about a longstanding patient of mine with diabetes—a grandmother of five and a mother of 12 grandchildren—who was hospitalized on the medical service for profound hypoglycemia, or low blood sugar.
This happens from time to time with people with diabetes. They take too much medication, or they don’t eat breakfast that day, and you give them 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 get her blood glucose up. The usual medical workup ensued: was it sepsis? Was it liver failure? Was it an insulinoma? They finally got the blood sugar up, but they never really figured out the cause.
I saw her in a follow-up clinic and went through my differential diagnosis. I asked if she was food insecure—was she feeding her family instead of herself while taking insulin? No, she said she knew how to get the food she needed. I asked if she had limited health literacy or numeracy. I asked her to show me how she drew up her insulin, and she hit it right on the mark. Every question I asked, she answered perfectly. I was getting nowhere.
Finally, I said, “You’re the expert here. What do you think happened?” That’s when she started tearing up and telling me about her abusive husband, who was 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 had injected a massive amount of long-acting insulin.
The intervention was a restraining order and ultimately prosecution of the husband. She liberated herself from an abusive relationship. The prevalence of intimate partner violence in public hospital patients is quite high. This is one dramatic example of uncovering social conditions at an interpersonal level. Many other cases are at a social or structural level, involving housing problems, food insecurity, or interactions with the criminal justice system.
Kevin Pho: That story really resonates. Patients are the experts of their own bodies. Sharing their story can lead to the ultimate cause of what’s really going on. Unfortunately, there are so many business aspects that put pressure on patients’ ability to share their story—time is limited, especially in primary care. We have 15 minutes to see a patient, which really condenses the time available. How can you continue the storytelling aspect in spite of these changes, time pressures, and bureaucratic hassles?
Dean David Schillinger: I have 20 minutes for a visit. The average primary care doctor across the country has around 17 minutes. I like to say, you’ve got 20 minutes—what are you going to do with it? It’s up to you. And as an internist in primary care, you have the luxury of seeing the patient back.
I think the most important policy issue, apart from the in-encounter stressors, is the paucity of primary care physicians in this country and the lack of policy solutions to ensure we have longitudinal care for complex patients. It’s over time that these stories unfold.
There is some research on listening. When you compare the research done on doctors talking to patients with how doctors listen to patients, the former dwarfs the latter. But we do know that avoiding a lecturing style and giving patients around 60 to 90 seconds of uninterrupted time can exponentially increase the amount of storytelling that happens.
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. It’s when we’re just logging it in and not being really present—having that beginner’s mind and being truly attentive—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.
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, doctors, medical students, and nurses are going to read it too because we all have our stories, and it’s interesting to read about our colleagues’ experiences. But the main audience is the general public.
I think there are two main messages. One I’ve already shared: how health happens in America has a lot to do with our social and environmental conditions. Unless we start engaging in social policy and health policy initiatives at the public health level, we’re going to become bankrupt as Medicare and Medicaid grow.
We need 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. In that regard, it’s a policy book for folks who are interested in equity and policy.
The second message is that even across great degrees of social distance, you can find commonality through storytelling. Whether you’re dealing with a patient from across the globe or someone who is homeless, they’re different from you, but through the sharing of stories, we can share our humanity. Once you’ve shared humanity with another individual, you can’t help but care for them. That’s true in health care, and it’s also true for society as a whole. Especially in this divided society today, it’s a message we need to remember: we need to listen to each other’s stories if we’re going to understand and care for one another.
Kevin Pho: We’re talking to Dean David Schillinger. He’s an internal medicine physician and author of the book Telltale Hearts: A Public Health Doctor, His Patients, and the Power of Story. Dean David, let’s end with some of your take-home messages that you want to leave with the KevinMD audience.
Dean David Schillinger: Sure, I think the first take-home message is about curiosity. It’s really important to be curious about others and not to make assumptions. It’s so easy to take shortcuts in medicine and in civil society as a whole. But being genuinely interested in the person who’s selling you food at the corner store or the woman who’s bagging your groceries, and having those kinds of conversations you didn’t think possible, can really enrich your life and give you greater faith in the resilience of humanity.
The second take-home message is about places like public hospitals. They are few and far between but are extremely valuable assets to society. They’re ways in which we can address income inequality and other societal ills. We need to be very cautious about how we handle the future of these kinds of institutions.
Lastly, it’s a call-out and a shout-out for primary care as one of the main solutions to our health care crisis in America. Primary care is undervalued, underfunded, and underappreciated. But the ability to provide longitudinal, relationship-based care is one of the most powerful tools we have in health and medicine. Investing in primary care is critical for the future of health care.
Kevin Pho: The book is 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. Thanks again for coming on the show.
Dean David Schillinger: Thank you, Kevin, for having me. It’s been a pleasure.
