Saturday, August 6, 2011

Cook County Hospital: Health care for the poor or poor health care?

I am a family doctor, and I did my residency training at Cook County Hospital in Chicago in the late 1970s. After a few years in Arizona, I worked as an attending physician there for another 14 years. When I tell people that, I get a lot of responses like “Oh! That must have been something!” They are thinking, I guess, that it was an endless stream of gunshots, a constant flood of the worst that they can imagine in their Emergency Rooms. It wasn’t, at least not all. Don’t get me wrong – the Emergency Room was incredibly busy, there were lots of gunshots and other traumas, and no matter where you worked there was an endless stream of people. But mostly it was doing medicine, family medicine, with people who were usually poor and usually sick and usually in need and usually not able to access care anywhere else.

David Ansell, MD, captures much of the story of “County” in his recent book of the same name.[1] It starts with his arrival as a new intern in 1978. He was part of a group of medical students from Upstate Medical School, the State University of New York medical school in Syracuse, he and 3 others in internal medicine and one in pediatrics. They had decided that they would train as a group, to support each other, and do it in a setting where they would be able to make a difference in the health care of people in need. Cook County was the place they chose, and it was no coincidence. The need was there and there was a “critical mass” of house staff with similar commitment, including me; I had started two years earlier.
The year before I came as an intern, in 1975, the House Staff Association – our union – had gone on strike. The issues were entirely about patient care, and the Hospital and its Governing Commission refused to negotiate over them. It wasn’t that they had something against unions; the County’s employees were almost all unionized and they probably would have talked about wages and traditional issues of working conditions. But when the residents defined “working conditions” as including EKG machines on the wards and nurses available to start IVs, the County wouldn’t consider negotiating. A dozen of these striking residents ended up in Cook County Jail after the politicos at the County Board got an injunction against the strike. (Ironically, one of these became, several years later, the medical director of the hospital in the Jail.)  A year after Ansell got there (and after I left) in 1980, control of the hospital passed from a quasi-independent Health and Hospitals Governing Commission to become directly under the County Board, eliminating any impediment to the Board members using it as it had always been – a jobs program for their supporters.

Ansell does an excellent job of documenting the challenges facing the hospital in those years, even while telling enough “horror” or “gross out” stories to keep readers and reviewers interested. Abigail Zuger, MD, gives it a pretty good review in the New York Times (“Their zeal changed lives, if not the system”) although she doesn’t like his writing as well as that of Fitzhugh Mullan (“White Coat, Clenched Fist”[2]) or others. On the other hand, my father liked  his writing style a lot.

Rush University Medical CenterAnsell’s story goes beyond the years of his residency, for he became an attending physician at County. He worked there for many years (when I got to know him best), before leaving to become Chair of Medicine at Mount Sinai Hospital in Chicago and then to his current position as Medical Director of Rush University Hospital, back across the street from where he started. He traces the long saga of the hospital. On the downside, political machinations and exploitation of the hospital and the people it served, and, on the up side, the improvements in patient care and hospital quality. For example, when I started the Emergency Room had 2 attendings who worked day shift, and the senior doctor in the ER at night might be a 2nd-year medical resident; 10 years later it was a well-staffed ER with many attending physicians and an ER residency program. There still was and continues to be a very long wait.
The later part of the book describes the regular turmoil creates by politics at County as well as the efforts of Ansell and others to provide the best possible care to their patients, individually and as a group. County physician staff were, for the most part, incredibly dedicated both to the care of their own patients. They did whatever they could to make the hospital a good, or at least, better place for health care for the entire population that depended – and still depends -- on it. Even when that meant going head to head with the County Board and their hand-picked administrators. And that, of course, is the story.

Cook County to ban smoking on all hospital grounds
Was – is – Cook County Hospital (now reconstituted in a new building as John H. Stroger, Jr., Hospital) a “hell-hole”, where patients received substandard care from inadequately trained physicians, in physical disastrous conditions? Or was it the only place in town where the poor, largely minority, people of Chicago could come and receive care after being overtly or covertly turned away from other sources of care? Both, certainly, although the former is much much less true than it was 30 years ago; the latter is a little less true. Not every patient who came to County was personally turned away somewhere else, of course. It was known in the community and in their family that this was the place people could go and get care, and amazingly often, get respect from doctors like Ansell.

From a lot of the doctors and other staff. Yes, some of the staff was callous, but unlike at many university teaching hospitals, the medical staff were usually concerned more about the future of the patients than about their careers; unlike in many community hospitals, they cared for everyone, not just those from a certain background, socioeconomic status or degree of “social acceptability”, or at least ability to pay.

Do I have criticisms of Ansell’s book? Sure; everyone has their own experience, and while David and I overlapped for much of our careers, and certainly, I hope, in our social concerns, I do find some things missing. Reading County one might think that all of the “good guys” and all of the good programs were in Internal Medicine. Certainly many of them were, from Quentin Young, MD, the Internal Medicine Department Chair for many of those years and still a dedicated health activist, to the plethora of committed physicians he describes and many others. But the physicians in department family medicine also played a major role.

Family medicine at Cook County? Under the leadership of Jorge Prieto, MD, Family Medicine was the pioneer for getting County doctors out of the “hulk squatting in faded splendor” on Harrison St. into the community. Dr. Prieto only agreed to take the chair of the department if the hospital agreed to set up a clinic in the Latino community. The South Lawndale Health Center, where I trained, is still there, although expanded into much bigger quarters and known as the Jorge Prieto Health Center. An entire network of community clinics was set up (and later largely dismantled), an effort led by Family Medicine. For many years, training at Cook County in Family Medicine defined urban family medicine, along with a few other programs such as Montefiore in the Bronx and San Francisco General. That is another story. David Ansell has written his book about County, and it stands on its own.

Cook County Hospital, then and now (as Stroger), is a publicly funded hospital that cares for the neediest people in the city. Is it often second class care? Maybe, but that is a step above no care, which is the reality for many people in cities and counties and states without publicly funded health care.

[1] Ansell, DA. County: Life, death and politics at Chicago’s public hospital. Academy Chicago. 2011.
[2] Mullan, F. White Coat, Clenched Fist: The Political Education of an American Physician, Macmillan, 1976.

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