Inspired To Heal
Stories of clinicians, educators, innovators, and researchers who built or led programs of excellence in government health institutions. Each guest has excelled in clinical medicine, program building, or public health. They persevered and succeeded through a clear vision, collaboration, and a passion for the mission of government-run health systems. Their stories will inspire those seeking change in their own organizations.
Inspired To Heal
Cook County Hospital's Past & Present
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With the looming cutbacks to Medicaid, safety net health systems are vital. After three-decades at County, Dr. David Schwartz explores its tumultuous history—one filled with challenge and progress. As a young doctor, he grappled with the frustrations of witnessing sometimes indifferent medical care, which improved under strong leadership and reduced political interference. Join us for stories of clinical care and our nation’s first blood “bank”.
Epilogue provided by Scott Fridkin, former Cook County Hospital fellow and CDC epidemiologist.
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Over more than three decades of patient care they've witnessed significant progress in healthcare at the hospital, particularly in the treatment of HIV infected patients. His commitment was sustained by the arrival of leadership that prioritized accountability and excellence in patient care. Following his recent retirement, he dedicated his energy to researching the history of Cook County Hospital. In this interview, his characteristic candor shines through as he explores the sometimes sordid history of the institution and questions its place in our nation's healthcare system. Dave, welcome to Inspired to Heal.
SPEAKER_01Thank you, Bill. I'm glad to be here.
SPEAKER_03On my block, we have an annual block party. One of my neighbors introduced us to a rapid-fire question and answer game about one of life's enduring questions. Two musical performers would be named. And then you must choose your preference, like Tom Jones or Neil Diamond. As a Marx Brothers of Fiftienato, Dave, Duck Zoo or Horse Feathers.
SPEAKER_01Duck Zoo is, I think, the pinnacle Marx Brothers movie and is especially germane in these political times.
SPEAKER_03A line from that that I think is probably worth repeating. If you think this country's bad off now, just wait till I get through with it.
SPEAKER_01Yeah, well that's and and you have to sing it. Groucho style duck soup is really a a pure triumph.
SPEAKER_03So for a darker version of the game, microbes or humans?
SPEAKER_01Without microbes, we couldn't be who we are, and so we owe them a debt of gratitude, even as we try to keep them at bay.
SPEAKER_03It's spoken like an infectious disease physician.
SPEAKER_01Yeah. It's like if you live in in Minnesota, you gotta embrace the cold. And when you do ID, you have to embrace the bugs to a degree.
SPEAKER_03Dave, you trained in Seattle and then decided to return to Chicago.
SPEAKER_01Yeah.
SPEAKER_03What or who inspired you to come to Chicago and then work at Cook County?
SPEAKER_01When I was finishing my fellowship, I heard from classmates and others that I knew who were working at Cook County Hospital who let me know that there were positions available, and I interviewed there, and it seemed like a good idea. A lot of this was because in Seattle, you train at a lot of hospitals. The hospitals I most enjoyed working at were the VA and Harterview Medical Center, which is the Cook County Hospital Analog in Seattle. The patient populations were more aligned with the sort of people that I enjoyed working with, so that I thought County would be a good fit in that regard.
SPEAKER_03Was there anything between college and medical school that inspired you to go to County?
SPEAKER_01In between college and medical school, I worked at a storefront drop-in center for kind of down and out behavioral health challenge people. I was like a lay counselor to the people who would come and spend their days. And I found that I really enjoyed working with these folks and working in general with people who were trying to sort things out in their lives. But I decided to go to medical school in part because I felt that I needed to have a better idea of what the hell I was doing rather than just trying to improvise everything.
SPEAKER_03It sounds like that experience was an opportunity for you to learn and and particularly learn that you needed more skills.
SPEAKER_01Yeah, for sure. I felt like I I learned about myself that I could work well with people in those circumstances, but I definitely needed to have a better handle on how it could be more helpful.
SPEAKER_03I think that Cook County was your final destination. Did you anticipate working there for the next 30 years?
SPEAKER_01When I started there, of course you're starry-eyed and full of vim and vigor, but it was a very kind of a hard slog. There's definitely an initial phrase of wonderment and really concern that it may be a bad place to stay. It was a very chaotic place. The facilities were unbelievably antiquated. There were lax and sometimes even abusive policies. For example, in the clinics, the patients didn't have time deployments. You were told to arrive at 1 o'clock on January 27th. You arrived at 1 o'clock on January 27th along with the other 50 patients. Patients had to spend hours and hours and hours waiting to get their needs met. Whether you got to look at their old medical records, which were paper then, was maybe a 50-50 proposition, as was the retrieval of x-rays. It was bewildering that many of my colleague physicians, they were drawing a full-time salary at County, but they were also working in their own private practices during normal work hours. When I first interviewed at County the head of medicine, as well as the guy who was just about to leave as the head of ID, both said, Well, you'll want to open a private practice when you come. And I was like, What? I want to work at County. I don't want to do other things. When I was on the ward, some of the events that occurred caused me to hit a wall. I'll offer one anecdote. When I was on a medicine ward service, among our admissions was a 17-year-old who had broken up with his girlfriend, became despondent, and swallowed a bottle of Tylenol pills. He was brought to the emergency room. They began the protocol of treatment by starting every four-hour treatments with Nacetylcysteine, which can be the difference between liver failure and death or survival. He was admitted to the ward to continue this regimen. That was really all he needed. He was a very impulsive act. He wasn't actively suicidal at the time that he got there, but he's mainly there to get these doses of N-acetylcysteine. On our rounds the morning after he arrives, we get to his bed and how are you doing? I'm fine. Have you been getting these medication doses? He said, What medication doses? He hadn't received any doses of the drug once he arrived on the ward that put him at risk of getting a liver failure. He survived fortunately, but it was very upsetting. I went to his nurse and I asked her, well, why didn't he get this drug? She said, Well, it's respiratory therapy who administers it. Well, there was a drug called mucomist, which is a preparation of anacethycysteine that is used to break up patients' uh respiratory secretions. The nurse had assumed that that was what was supposed to be given. I went to a physician leader, I said, What is going on with this? And he just kind of shrugged his shoulders and said, you know, shit happens. Those kinds of episodes were very unsettling. Ultimately, what kept me going was that there were enough, uh actually a a sizable number of superb colleague physicians who, despite these conditions, were able to make a real difference. That helped me to wonder whether I couldn't follow in those footsteps. What they did eventually uh helped to make clear that this is a place where there were many opportunities to make important and meaningful improvements in how it works, and by doing so it could really positively impact uh a large number of people. I will give a shout out to my medical school classmate Kathy Diamond, whom you've already interviewed. She perceived that there really needed to be a systematic program by which patients who had terminal disease could get their needs met more effectively. And so she kind of invented from Whole Cloth the palliative care program that many other institutions in the Chicago area borrowed from. When it was just me interacting with the patients, whether on the hospital wards or in the clinic, I really enjoyed those interactions and enjoyed getting to know patients that I cared for. By the beginning of 1994, it seemed likely that Bob Weinstein was going to move to Cook County. I had met Dr. Weinstein a couple of times before and really admired him and thought that he's the kind of guy who could really offer tremendous leadership to our group, to myself individually. And of course, he did uh begin in the summer of 1994.
SPEAKER_03He's a national or international.
SPEAKER_01He was international. I actually introduced him as his grand round speaker when I was a chief resident in Seattle in 1991. He was a brilliant speaker and very funny. In another life, he would have been a comedian.
SPEAKER_03Marx Brothers level.
SPEAKER_01Um well, you know, he he had the mustache for it, actually, when he first arrived. I never saw him with a big stogie, but there are definitely affinities with Berto Marx. Another huge positive development was Brendan Riley's arrival. Brendan arrived in 1995 as the new chair of medicine. He was every bit as good as anyone hoped for. He got rid of that double dipping that I mentioned among all Department of Medicine docs. He said, look, you've got to leave your uh outside practices or you've got to leave county. He was a terrific teacher and he provided terrific patient care and he modeled how to handle yourself and how to work with patients and with each other in a way that was very positive. And the last thing I'll mention is how HIV care was really revolutionized by Bob and by colleagues at Rush. Importantly, this is one story where the Cook County Hospital administration played an extremely positive role, especially Ruth Rothstein, in creating the core foundation. It consisted of leaders from both Rush and Cook County Hospital, all of whom recognized the way that the AIDS epidemic was shifting into the inner cities to becoming a disease of heterosexuals with issues with substance abuse, and that this was a population that lacked resources, they wouldn't be able to get care effectively elsewhere. The provision of health care for people with HIV AIDS really needed to be stepped up at Cook County Hospital. The Core Foundation was able to construct the Ruth Rossing Core Center. We launched all sorts of innovative programs that were very helpful.
SPEAKER_03The prognosis for HIV is much better now than it was at the beginning of your career and is now managed like a chronic disease. Are there any patients that you took care of during your entire 30-year career?
SPEAKER_01I care for a guy now whom I first met in September of 93. He was in his early 20s at the time. It hasn't been an easy life for him, but he's still around and has a reasonable health status. There's another guy that I first met in the spring of 94. He's doing overall quite well. He's now in his late 60s and contending with the many of the same barnacles, as my dad called them, that we all have to contend with as we get older. They're both illustrative of what HIV care really consists of, managing common problems as the population ages. That's made for a very rewarding career, really, and one that I still enjoy. HIV can be very rewarding because you have so-called Lazarus patients, patients who rise from the dead once you apply appropriate anti-retroviral therapy.
SPEAKER_03Several populations end up colliding with the public safety net health system. Places like Cook County are trauma, and then people who would lose their job, they'd lose their insurance and get sick unexpectedly, and end up in our system, of course, pandemics like HIV-AIDS, where it was the combination of people losing their jobs because of the illness, and then requiring the safety net to step in and provide care. What populations do you think we will need to care for in the future?
SPEAKER_01Historically, the main population for which the county provided care had been largely black and from the part of Chicago that was so terribly segregated, that changed in the late 1960s because of the passage of the Civil Rights Act and the advent of Medicare, which the federal government said, look, if you're going to get Medicare payments, you need to end racial discrimination. After the late 1960s, the the proportion of people of Hispanic ethnicity of county patients rose from less than five percent in 1970 to something like 15 to 20 percent by the the 1980s. Many didn't know how to access health care insurance or other resources unless and or until the country comes up with a mechanism for funding healthcare that is inclusive of all of its populations, there's uh gonna need to be something for people who are excluded. This is among the moral quandaries that I've delved into. A place like Cook County Hospital is a lifeline for many, on the one hand, but on the other hand, it helps to make possible these systems of exclusion. From the perspective of other hospitals in Chicago, they absolutely relied on county to take the patients that they didn't want to take. I'm afraid that that will continue into the foreseeable future, even though the Affordable Care Act has provided insurance to a large segment of that group. There still remain many who are excluded at the front end or who lose that support.
SPEAKER_03You have witnessed an evolution of the care that's been delivered at Cook County from the early 1990s until you retired in 2022.
SPEAKER_01Aaron Powell, yeah.
SPEAKER_03You've mentioned several things that benefited the care and the way people were treated. You did mention the mission-oriented physicians that built programmed the arrival of a department chair who really made an effort to improve the systems of care and also in parallel improved the academics, which I think attracted people who wanted to help make the changes.
SPEAKER_01When the county was allowed to begin enrolling people into county care, the Medicaid Managed Care Plan, that changed the whole purview of the institution because the county care enrollees brought revenue. It also changed the county to a place where one needed to more actively market our wares because we had more or less a captive audience up till that time. Now people who had been coming to county because they didn't have other options suddenly had other options. The Affordable Care Act ushered in an era where the county became more outward-looking in its administration, where it tried to look at itself as a competitor with other healthcare systems. There came into being a more dominant cadre of administrative workers who showed themselves to be less attuned to what clinicians are concerned with. Infectious diseases had made some magnificent gains for the county in terms of the HIV program, which I mentioned, the whole apparatus of which you were an important part, but that Bob Weinstein also helped to stand up. We did a lot of research on antimicrobial resistance and how to uh mitigate it. And so doing provided the institution with important improvements in informatics with the computer system that was set up by you, Peter Kushkowski, and others in the early 2000s. That became a part of the county informatic infrastructure. The Affordable Care Act brought the county more into the mainstream of corporatized medical care, and in the process, I think lost some of its unique attributes.
SPEAKER_03You touch on something that people in other businesses comment on is that an enlarged corporate structure doesn't allow for a lot of grassroots innovation, which can lead to the burnout that I think physicians are experiencing across the country where they've lost control of how patients are cared for. So you've been researching the distant past of Cook County Hospital. Do you have any stories that you'd like to share?
SPEAKER_01I I don't think we adequately recognize what life was like on the wards through the first half of the 20th century, where you had a completely captive patient population that had very little by way of options for care elsewhere. You had management by a body of politicians who knew little about what really is needed to organize large-scale health care and were pretty indifferent to the conditions that the patients had to face. The hospital had many reckonings during those years. For example, in 1927, the hospital was surveyed by the American College of Surgeons, which by agreement with the American Hospital Association had taken over the role of doing hospital surveys. There was a guy named Malcolm McKetchern who did all these surveys, and he visited County, spent some time there in 1927, and he reported that the conditions are miserable, you need to make a lot of investments, and those recommendations were roundly ignored by the commissioners. There's a book called The Old Lady on Harrison Street by a man named John Raffensberger, who was a surgeon. He did his internship at County in 1953 and describes how on a given open ward you could have 60 patients. There would be one intern and one nurse to pass medications during the day. There were no nurses present at night. It wasn't unusual to find patients who had expired during the night the following morning. The conditions were much worse than when I arrived there in 1993. A lot of those things had been fixed. There was this period of tremendous upheaval. Beginning in the late 1960s, Richard Ogilbeat, the president of the Cook County Board of Commissioners, was reform-minded and he really thought the commissioners should not be running Cook County Hospital. And he created a governing commission to take over. Over the next 10 years of this governing commission's existence, it was a major disaster because the governing commission was run by a Dr. Houghton, who was imperious and who was constantly fighting with a group of doctors, mostly house staff, including our friend John Raba, who were much more ideologically attuned to the needs of the patients. The Governing Commission was also up against the commissioners, which by the latter part of the 70s wanted Cook County to be back under their control and more or less starved the institution of resources because they had budgetary control. Governor Townsend gave Cook County Hospital back to the control of the commissioners in 1979. One of the reasons why I did all this is, as you've already alluded to it, what is the role of an institution like this? And if we need an institution like this, how should it work? I think it's important to be aware of the past going forward. We had innovation among our physicians. We were in the first blood bank. What isn't appreciated is how a surgical intern would have to recruit blood donors from among most often family members of patients that they Wanted to operate on, they had their own account. A blood bank was like a bank where you had an account of how much blood was there. If you were running low and you couldn't get family members to donate blood for your surgeries, they would go over to Madison Avenue into the taverns there and find paid donors.
SPEAKER_03Madison Avenue at the time.
SPEAKER_01It was one of the down and out parts of the city. When a patronage system of hiring is allowed to happen, so many personnel believed that providing political support of whoever their political sponsor was was really their primary responsibility. But also many had developed a kind of learned helplessness that comes from working in an overwhelmingly chaotic environment. The patronage has been largely done away with, but the learned helplessness was horribly damaging to the institution and to its its mission. It was in that context that the exceptions to that, of of whom there were many, it made their efforts all the more heroic. It's unfortunate that such heroism was required.
SPEAKER_03How do you think an institution like Harborview in Seattle succeeded, where you have a similar government-run institution?
SPEAKER_01Calendarview began as a poorhouse and it was made into an actual hospital around the Civil War. It was under the control of commissioners who were even more overtly corrupt than later. Harborview opened in the 1930s. It came into being at a time that the University of Washington Medical School was being developed. They knew that they needed to have a good facility for indigent people. So what wound up happening is that the management of Harborview was given over largely to the University of Washington. It was funded by King County, but the University of Washington was responsible for hiring and firing the doctors. Seattle, which went through the same kind of growth in the 20th century that Chicago did in the 19th, had uh a better understanding of how to do this well and had a politics that looked at a facility like Harborview as a real asset to the community. Harborview enjoyed a justified reputation as being a place of excellence.
SPEAKER_03Ruth Rothstein was a CEO during the 1990s. She was one of the forces behind getting the Core Center developed. What can you tell us about her?
SPEAKER_01In the course of my research, you do come to appreciate how important she was because she really took the role very seriously. She viewed herself as being a reformer who could help to make the county into an institution that would be much more responsive to the needs of its patients. And I have a tremendous respect for her.
SPEAKER_03What advice would you give to people considering working in government safety net health institutions such as Cook County?
SPEAKER_01Discuss with your potential future colleagues how the institution is working, both at a clinical level, but also does it have support in the community? It's not impossible to get the kinds of satisfactions that I spoke of exclusively with indigent patients or exclusively working in a place like a county hospital.
SPEAKER_03Who knows what will happen to County if they're really cutting Medicaid?
SPEAKER_01It might it'll be more important than ever. It'll hit the skids financially. There'll be a great hue and cry to maintain it because the loss of Medicaid coverage means that all the other institutions that see Medicaid patients are going to want the county to take them. We're going to be back to where we've been in various cycles uh through the decades.
SPEAKER_03I think so. Dave, you have some celebrity status in my family because when I had a relative sick and hospitalized at Cook County, he had had abdominal surgery and was having fevers, and you came by as the ID consultant. Before you asked about his medical condition, you asked if he was a Cubs or Sox fan.
SPEAKER_01Yeah, that's right. And of course we know the answer to that. I'm sure that it it enlarges my magnanimity to know that I treated a member of the opposition.
SPEAKER_03When he said he was a Cubs fan, you feigned like you were gonna punch him in the stomach.
SPEAKER_01That's an old trick. You know, and people who had their bellies opened up, you know. I provided that kind of treatment to my younger brother, who was a devout Cubs fan. And we we had physical fights over, you know, who which team had the better shortstop and stuff like that. We're very well raised. My my mom's brother thought we would never come to any good at all. We were such knuckleheads.
SPEAKER_03Dave, I have one final closing question. If you could choose one item to put into your doctor's bag, literal or figurative, what would it be?
SPEAKER_01The renewed sense of the the incredible rewards of compassionate and effective patient care. The learning that one engages in is fascinating. You learn all the time if it's done well and effectively. You also engage in relations with patients that is unique. It's a kind of intimacy that comes from close collaboration with another person to address problems of such great import and often of urgency. One literal thing that I thought of that could be useful in a doctor's bag was actually dental floss, because among the many comorbid problems that the patients we care for suffer from, poor dental hygiene and the loss of teeth at an early age, in addition to the big jars of condoms that we have in the clinic rooms at the core center, we would have packs of dental flus.
SPEAKER_03Um I wonder what would be more popular, Dave.
SPEAKER_01Or, you know, you wonder who would imagine ways of using both simultaneously. But anyhow, that was one little tidbit.
SPEAKER_03Many thanks to Dave for sharing the history of Cook County. His experience and insights from over 30 years ago in the old hospital and under the direct oversight by elected commissioners provides valuable context to the transformative changes discussed by prior guests and those featured in upcoming interviews. After this interview, I spoke to a former fellow and colleague, Dr. Scott Fridkin. Scott, what do you know about Dave? What would you like to tell us?
SPEAKER_02I met Dave my first day of ID fellowship after having worked at the CDC for two years, and I was lucky enough to end up at Cook County. My first week I was on service, walked into that building and met Dave, and was terrified because I hadn't walked in a patient's room with a patient in it for two years. He really helped me adapt to this huge transition from public health back to the clinical bedside. And what I think really struck me was his ability to connect with the entire part of the patient's needs and care. As an ID consult, I think helped me understand that our role was more than just which antibiotics to prescribe. Dave really helped us understand some of the more subtle complications that patients would encounter from unnecessary antibiotics, as well as the indirect effects of creating antibiotic-resistant organisms. This bond that I formed with him evolved into a personal relationship. He always remained a really powerful mentor, just like he did during fellowship. That was something I really appreciate about Dave.
