With my two-year term as Section chair coming to an end this November, I am feeling a strong sense of transition with so much undone and more to do. With both my tenure at Cook County Hospital and as Medical Care Section chair coming to an end that month, November represents a major change in my professional career and personal life.
Before coming to Medical Care issues (capital M C), I want to talk about what is happening personally with my own medical care work (small m c). Mardge Cohen (my wife) and I will be retiring from work as general internists from Cook County Hospital (now called Stroger Hospital-more on this below) after 31 years of service at Chicago’s only public hospital. The move was precipitated both by my being offered a wonderful opportunity to work at Harvard’s Brigham, as well as a profound crisis — both fiscal and leadership — at our beloved Cook County. The job at Harvard will offer great opportunities to further the work that has brought me into the Medical Care Section of APHA including research, practice and teaching in quality improvement, medication safety and policy, and medical informatics. I will be working in the section of General Internal Medicine at Partners Brigham hospital under David Bates, who is a true national treasure and who heads their Center for Patient Safety Research and Practice for which I will become the associate director. Also exciting for many of my APHA interests will be the opportunity to help teach the annual summer course on clinical effectiveness in the Harvard School of Public Health.
The cutbacks and undermining of services at Cook County are important to share with members of our Section and are receiving insufficient attention from the local and national media. John H. Stroger Jr., [the father who renamed the new hospital that we fought so hard for (and that he initially opposed!) after himself], after being advised by many not to run for re-election as president of the County Board in 2006, did so anyway. However, a few days before the March primary election, he suffered a stroke. He nonetheless narrowly won the primary election, in part because the public was misled about the seriousness of his medical condition and the hospital’s growing fiscal crisis. After not being seen or heard from for months after the primary, his Republican opponent declared “let him show his face at the window to show he is still alive.” The family refused, arguing that this would interfere with his recovery. Instead, at literally the 11th hour in July (in the final hours a replacement candidate could be slated by the Democrats), Todd Stroger (the son, referred to by some as “the toddler”) was picked to replace his father on the November ballot. He won in the election that coincided with the November 2006 APHA meeting.
Many despair that there is no mechanism for impeachment or recall. My patients, unprompted and almost unanimously, enter my exam room voicing their protest. “Why did I ever vote for that man; look what he is doing to the hospital and the clinics.” One of my cancer patients stated, “Cook County is no longer for the patients.” In reality, the problems at County run much deeper than our current misguided and poor leadership. Todd Stroger inherited a $500 million deficit and many of the problems, which have become so much worse in the past half year and have plagued County for decades. What the current leaders are failing to provide are the right diagnosis and solutions for the problems.
The appointment of Robert Simon as head of the hospital and clinics has furthered the undermining of care at the institution. In implementing budget cuts, he argued that County needed to retreat to its “core mission” of treating strokes rather than hypertension, and that some community and public health services represented luxuries we could no longer afford.
Simon and Stroger proposed slashing hundreds of staff positions at the hospital and clinics (the majority of which were doctors and nurses, who lack any union protections), with the most drastic proposed cuts being the closing of more than a third of County’s community clinics. Not only what was being cut, but how the cuts were being made, added to the chaos and demoralization. For example, in one week hundreds of people received pink slips “in error” only to have them rescinded, and another group of hundreds more received pink slips during the following weeks. Physicians with 20 plus years of seniority were fired. The Occupational Medicine Division was eliminated. Those of us remaining asked ourselves who was worse off, the ones laid off or those left behind to care for the patients who had lost their physicians. Of course the answer is that the ones worse off are the patients -- who face more access barriers, discontinuities, longer waits, and most dangerously, a renewed mania to bill patients and turn over unpaid bills to collection agencies.
While space does not permit a detailed discussion of the financial aspects of this fiscal and billing crisis, it is important to note the obvious. County’s financial crisis does not exist, nor can it be solved, because of failure to send or by sending bills to our poor patients. In fact, it could be argued that the entire $75 million 2005 health care budget shortfall (which set into motion the deficit and cuts for 2006) can be traced to a roughly $75 million cut in federal funding (the so called “intergovernmental transfer” program). Todd Stroger refused to consider tax increases to cover this shortfall. He also burned up the political capital needed to support such an increase by a series of continuing patronage blunders, leading the public to question whether additional funding to support a poorly run operation was worthwhile.
At the three public hearings in February 2007, each attended by more than 1,000 people, the staff and the community mobilized to describe the impact and mistaken logic in these drastic cutbacks. I felt enormous pride in being a County employee as I watched the solidarity and testimony of sheriffs, public defenders, prosecutors, and jail employees (whose jobs and services were also being slashed) raise their voices along with those from the health care community and describe the work they do and how it would be adversely impacted by the proposed cuts.
While some of the cutbacks have been beaten back and Stroger has now inexplicably reversed his position and is calling for a tax increase, uncertainty, chaos, and demoralization are the dominant features of everyday life at County. Worse yet, the leaders appear determined to ignore the experienced and committed voices of those of us who are advocating for our patient and have ideas of how to make County work better. A number of the best physicians and nurses have left or are looking to leave. It is in this context that leaving County at this time of crisis hardly feels like the right decision. But (to paraphrase what Quentin Young said when he left County 25 years ago), County has probably had a maximal dose of what medicine Mardge and I have to offer, with likely diminishing returns on our investments of efforts to make it better. And perhaps (following Quentin’s lead) we can do more for County and the patients in other ways, as we continue our commitment to what County stood for in the past – for accessible high quality services to patients regardless of ability to pay.
The Medical Care Section is one obvious expression of this commitment. My hope is that during the summer and fall we can complete some of the initiatives that I have written about in my earlier newsletter columns. Most important is the continuing effort to improve Section involvement, outreach and communication. There are several initiatives that I hope can advance these aims, and that can be successfully moved towards completion during my remaining months as Section chair. The first is the renewal of our work with the Medical Care journal and its new editors. We have been helping to plan a special issue on the financing and organization of medical care in the United States, and the “call for papers” will appear in the September issue of Medical Care.
But the major initiative I hope to move forward with the help of our summer intern Stacy Liker (first-year student at UIC College of Medicine) is the revamping of our electronic communication structure and processes (hopefully leading to enhanced outcomes during the two-year term of our next chair, Gail Bellamy).
We plan to redesign our communication approach. Many members say they rarely hear from the Section, while others complain of receiving too many e-mails of Section discussion. We will be reaching out to each and every member to solicit your preferences and interests, thereby creating a “profile” of your desired level of communication and topic areas. Your response to the e-mail inquiry you will receive by the end of the summer will populate this profile and allow us to more effectively tailor and target communication to you. It will also permit the option for you to create a personal Web “space” on our Section Web site, where you can post your contact/demographic information, areas of special interest or recommendations for reading, and other desired links.
We will be undertaking this profiling survey effort in conjunction with a retrospective review of Medical Care Section presentations over the past decade, which we hope to cross reference with topics from the Medical Care journal for the same period, thereby creating a taxonomy of Medical Care. While this “taxonomy” project ideally should precede the survey to allow members to then identify interests based on this more rigorous representation of our Section and its areas of interest and influence, for practical reasons (wanted to get the survey going), it will have to proceed in parallel.
I urge each of you reading this newsletter column to thoughtfully respond to the initiative, so we can better know who each of us is in the Section and allow us to better communicate with each other.
In conclusion, and in the spirit of what we will be requesting from you (recommended readings for fellow Section members), I’d like to make my own recommendation of a book worth checking out. It is a remarkable book entitled The Political Economy of Health Care by Julian Tudor Hart (2006, Policy Press). In it, one of my heroes reflects on what is happening in health care in the United Kingdom (and worldwide), which helps put into perspective what we are facing at Cook County, in the United States, and what I suspect each of you faces every day in your own work. It is a book that attempts to provide students of health and caring sciences with a “big picture” of our work — a picture that shatters conventional assumptions: “Though this may entail swimming upstream against the tide of fashion….it follows the prevailing winds and currents of history.”
Hart presents an extremely optimistic picture of what was the basis and early achievements of the much maligned British National Health Service. The NHS is now succumbing to costly privatization efforts ideologically driven by “those without personal responsibility for giving health care or substantial personal experience of receiving it." He shows how we can, via imaginative efforts based on shared understandings, confidently make a better world by “thoughtful human decision rather than the tidal waves of avarice released by market forces,” convincingly arguing for a “world that is planned and shared rather than plotted and grabbed.” In such a world, decisions will be made not on where life and labor are the cheapest but will be based on identified needs, knowledge and learning.
I look forward to working with you through Medical Care to help promote such a world and ensure that the organization and practice of medicine reflect these values and opportunities.
Gordy Schiff
Gdschiff@aol.com