August, 1978. Dog days in Chicago. The windows overlooking Ogden Avenue were open in a futile attempt to induce a breeze. A kamikaze fly buzzed my head. The air was thick as syrup. My shirt was Saran Wrap plastered to my body. A distant rumble from trucks and cars that barreled past the clinic on Ogden waltzed its way up the four floors to the cubicle where I sat. The room was no larger than a closet. A chair and an examination table wedged in. No sink. A partition, about seven feet high, separated my stall from the next one. A polyester curtain provided a flimsy barrier between the exam room and peeping eyes from the hall outside. A pile of dog-eared manila folders and blank yellow-lined progress notes that passed for patient charts were stacked on the desk in front of me.
During the three years of residency, each internal medicine resident was assigned a half-day every week in the clinic. Interns were thrown in every August, just handed a schedule and told to show up. After a month on the County wards you were deemed ready to tackle outpatient medicine. I was led to my cubicle by a hard-nosed clinic nurse. Part clinician and part traffic cop, these nurses ran the clinics. The waiting area resembled Union Station, with back-to-back, church-pew-like benches, lined end-to-end down the center of the hallway. Stuffed with patients. Their eyes followed me as I passed by.
Technically, we were supervised by an attending physician. Mine was a well-known schmoozer. From my cubicle I could look down the hall to the office where he was ensconced like a night watchman, the door ajar, his legs on the desk and a phone receiver wedged between his shoulder and his ear. A sweet arrangement. We ignored him. He ignored us. Voices carried from cubicle to cubicle. No privacy. I learned outpatient medicine by eavesdropping on the conversations that other young doctors in the stalls around me had with their patients.
In the midst of the politics, the chaos, the poor physical condition of County Hospital, the hard urban rudeness of the clerks and other staff, my clinic cubicle would become a place of refuge for me. I was home. It was my calling to be a primary care doctor. There I discovered my patients and how their lives and illnesses were intertwined. It is where I learned to be a doctor over the next three years. Mostly taught by my patients. When I told people that I worked at Cook County Hospital, their imaginations took off. They conjured up images of the Emergency Room; urban violence; the Saturday night "knife and gun club;" grit and despair; track-marked heroin addicts who shivered and vomited in withdrawal; toothless Skid Row winos who slept off weekend benders. Urban trauma, alcoholism and heroin punctuated the story of Cook County Hospital, but there was much more to the place.
Fantus Clinic was a Soviet-style yellow-brick and cement ambulatory office building appended to the west side of the main hospital by a corridor. Grey city pigeons lined up side by side on the concrete ledges outside the Fantus casement windows that faced Harrison Street as if mimicking the long lines of people inside the building. Across the street was a hamburger joint and Login's Medical Bookstore, where generations of doctors and students bought stethoscopes and medical textbooks. George, a grizzled, homeless schizophrenic, dressed Eskimo-like in layers of clothes and winter coats (even in summer), staked his claim to the Fantus Harrison Street entrance sometime in the late 1970s. All day he stood outside. At night he slept in the hospital. A de-facto doorman, he muttered and gesticulated at his internal tormentors. There was always a gaggle of assorted city people congregated near him puffing cigarettes under clouds of blue smoke. The Harrison street bus rumbled to a stop in front of the Fantus entrance in twenty-minute cycles and let out load after load of passengers, a tide of humanity who surged past George into the Fantus lobby.
The lobby was clogged with patients. Standing. Limping. Shuffling. Sitting. On crutches. Rolling in wooden wheelchairs. Old. Young. Frail. Pregnant. In every nook and corner, they sprawled on benches. Jammed the elevators. They came to County to get outpatient care denied or unavailable elsewhere. Four-hundred-thousand each year. This was the County that did not make the evening news or the TV shows. Regular people who just needed to see a doctor and had nowhere else to go. They waited hours, endured rude clerks and inexperienced doctors like me. Lines ringed the clinic. They snaked down the hallways and around the corners. Lines for registration, for appointments, and even longer lines for the pharmacy. The patients armed themselves with bags filled with food. They were here for the long haul. Everyone knew you had to wait at County.
Most clinics had no set appointment times. The morning patients were told to come at 8:00 a.m. and the afternoon patients at 1:00 p.m. Once they showed up, it was first come first served. The oral surgery clinic had a perverse policy. They would treat only fifty patients daily. No appointments. Fantus' doors opened at 7:00 a.m. Patients with toothaches, loose teeth, oral tumors and mouth abscesses lined up in painful silence during the dark hours of the early morning. When the doors to Fantus were opened, it was like the starting gate at Arlington race track. They're off! The crowd scrambled through the open Fantus gates. Patients, some in wheelchairs, others with canes and crutches, raced to get to the Oral Surgery clinic to win one of the fifty prized slots that guaranteed a dentist would see them. This system had persisted through the years despite its inhumanity. Those who were too slow, too feeble, or too late to get one of those numbers would often leave, resigned to suffer and try again another day.
Why did County patients tolerate these waits and abusive conditions? Our patients declared that they came because County had "the best doctors." This was not true. There is no way we were the best. We were young, uninitiated, and worse, unsupervised. But many of our patients had been turned away from other institutions or had family or friends with the same experience. Maybe it was cognitive dissonance. Were their tributes to our medical prowess born of our lifesaving deeds or had they been conjured out of the cold fact that we were among the only doctors in the city who would see them without judgment? That it was worth the wait because County doctors were the best? Or maybe it was the only way they could justify to themselves the humiliation and abuse they endured. I felt unprepared to live up to my patients' expectations of me.
My first patient experience in clinic was inauspicious. There was no chart. Just a blank piece of yellow-lined paper. I called the patient into my cubicle and he sat in the chair, arms crossed, face gripped in an angry frown. A skinny, thin-haired middle-aged white guy, with bugged eyes. "I just need my phenobarbital, nothing more," he said. Epilepsy medication. He had been waiting for hours. The outpatients at Fantus had to change doctors every three years as a new batch of residents matriculated and the graduating ones departed. The luck of the draw. He scowled at me as if I was the short straw.
Maybe we would not have had the altercation had the chart been there. But it was missing. More often than not the patient charts never appeared. Maybe if the medication he was demanding had not been phenobarbital, a barbiturate and a controlled substance, I would not have challenged him. But with no chart, and no playbook, I was flustered. I felt the tension escalate in the tiny space as the blood rose to my face. He just wanted his script and nothing more. This was my first outpatient experience. I had never written a prescription before and this guy wanted me to take him at his word. For a barbiturate. "Now wait one minute, mister. Not so fast," I thought. I questioned him to be sure that he truly had the disease he claimed. "How do I know you have epilepsy?" I asked.
Purple splotches appeared on his neck and cheeks and rose to his ears with the challenge. His pupils narrowed. I had done it now. He stood up, now fully red-faced, fists clenched and yelled. His voice rebounded across the clinic. "Why would I make up epilepsy?" he screamed. "Give me my phenobarbital." I let loose in return. I might be young and inexperienced but I was not a pushover. I was nose to nose with my first patient — not what I had imagined when I opted for a career in primary care.
My mind raced as I considered my options. Phenobarbital was a controlled substance. What if he was a drug user? I gazed at the pile of charts in front of me. It was hot. The air was muggy. I had patients waiting for me in the hospital when I was done with clinic. Why would anyone fake epilepsy? He had a point. I had no frame of reference. I could not afford to get bogged down. I took a deep breath. "What the fuck?" I mused. I took his word, wrote out a prescription for three months of a medication I had only read about in a pharmacology book. He grabbed the script out of my hand, as soon as I wrote it, eyebrows furrowed.
I was at a crossroads. Ready or not, here I was, "Presenting Dr. Ansell." A "real" doctor. And while I felt like a poseur, a fraud, I decided that despite my insecurity and inexperience, I needed to act as if I knew what the hell I was doing.
One month into my internship, on the West Side of Chicago, in a steamy corner of the fourth floor of Fantus clinic, at the County Hospital. An epiphany. I suppressed a wave of panic and shoved my doubts aside. Oh. I got it. I was a "real" doctor now. The patients expected no less.
Somehow, that experience freed me up to dive in to outpatient medicine. My patients' lives were a window into a slice of American life I had never known — sharecroppers, wooden shacks on dusty backroads, back-breaking cotton picking for pennies a pound. Towns whose names littered civil rights history — Philadelphia, McComb, Indianola, Yahoo City, Little Rock, Montgomery, Birmingham. Life under Jim Crow. "Yes, suh. No, suh." The humiliation of survival in places where being black meant no chance for justice. The Illinois Central ride to Chicago. The promise of jobs. The disappointment of segregation and the urban violence that greeted them.
I learned about the lives of my patients in Chicago every week in that clinic. Hyper-segregated neighborhoods. Unsafe streets. Unemployment or backbreaking jobs in factories and foundries. Women followed when they walked around Loop clothing stores. My black male patients had all been stopped by the police for traffic violations — "Driving while black." They taught me the routine. Something I had never experienced myself. Flashing red lights. A floodlight blasts through the back window illuminating the interior of the car. Every black parent taught his or her children how to respond to a police stop. White kids were taught to trust the police. Black kids were taught to be cautious around the police. There was a routine that black men had learned to follow when stopped by the police. Open the window. Put your hands up. Easy does it. On top of the steering wheel where they could be seen as the cop approached the car. Sit still. The police flashlight aimed at the driver's side and then throughout the interior of the car. Look straight ahead. Don't move your hands unless the cop orders you to. No quick moves. Say "Yes, sir and no sir." Do not argue.
This was just part of the reality of black life in Chicago. The hand of institutional racism was invisible to most white people, including my friends, who tended to avoid institutions or neighborhoods that catered to black people out of fear for their own safety or discomfort. My weekly session with my patients in the General Medicine Clinic heightened my sensitivity to the issues of race in America. In 1906, W.E.B. DuBois said, "The problem of the twentieth century is the problem of the color line." I was a middle-class white man from a small city in upstate New York. I had never been in a position to understand the meaning of these words until I was immersed in the lives of my patients that revealed their truth so powerfully and so tragically.
It did not take long for me to peel back the doctor-patient relationship more and discover other difficulties my patients faced. One of my patients was an elderly black woman, stoic and quiet, her hardscrabble life etched into the deep creases that traversed her face in such a way that her skin, had it been cloth, would have taken days to iron out. She sat quietly, in a button-down cotton dress, threadbare and almost colorless from many washings. Under it, her breasts sagged. Her steel wool wiry hair was iron gray and held in place with a bandana. She arrived in my office for a routine visit. Her blood pressure was through the roof. I leafed through the chart and noted it had been controlled in the past. I began to dig to see if I could identify a cause.
"How do you feel?" I probed.
"All right," she mumbled with her Arkansas accent.
"Are you having any chest pain or problems breathing?"
"No suh."
I tried another line of questioning before moving on. "Have you had any recent stress in your life?"
Jackpot. Her eyes welled. Her voice remained emotionless.
"My gran-chillin, got kilt. On my fron poich," she said.
Two teenage boys. Out of school. On their way to see her. Chased by gang members. They sprinted to her house. Bounded up the porch stairs. Frantic, the gang close behind, guns ablaze. Bullets ricocheted. Knock, knock, knock, they banged on the door. "Mama, mama, mama," they called for their grandma. She heard the shots and the banging, and thought the gang was trying to break in. She cowered in panic on the other side of the door, inches from her grandchildren.
"Ah was a-scared to open it. Ah din know it were them. Ah din know it were them," she repeated.
When she opened the door after the shooting stopped, she discovered the two young boys. Dead. Full of bullets, their blood joined in a pool on the porch. She wailed. "Jesus, Jesus, Jesus." Her blood pressure shot up. And remained high two weeks later.
If I had not asked, she would not have told me. I might have just adjusted her medicine and had her return in three months. I did not learn how to treat this in medical school. There was no medicine for grief, for the inevitability of urban violence. I felt powerless. I mumbled my sympathy and asked her to return in a month to recheck her blood pressure.
I heard similar stories from my other patients. The violent deaths of family members and friends, drugs and imprisonment. Children in gangs. Just about every man had a scar from a knife or bullet wound. Almost every woman had lost a close family member to violence. The names of lost loves and relatives were tattooed onto the arms and in the memories of my patients. Many years later one of my patients lost her high-school-aged son in a drive-by shooting, a block away from home. It happened on a summer night in Chicago when thirty-one children were shot and eight died. He was killed when he pushed a girl out of the way of the bullets. My patient, the mother of the dead boy, climbed into bed with her mother, also my patient, and they held each other and cried together. Her two surviving children struggled at school. She developed diabetes and hypertension and some heart abnormalities. The grandmother's health deteriorated as well. How can these experiences not affect health and accelerate death in our patients? Each story left me, mouth agape, in shock and dismay. My condolences rang hollow.
Many years later, colleagues of mine conducted door-to-door health surveys in Chicago's poorest neighborhoods. More than a third of those surveyed had higher rates of depression, asthma, hypertension and smoking than those in white communities. Racism, poverty and violence took their toll. As an observer to the lives of my patients I could attest to the fact that poverty was as exhausting as it was deadly. I saw the damage it caused in the faces and bodies of my patients. These were painful lessons for me to learn as a twenty-six year old. But I could not imagine being anywhere else.
Sometimes, I got too close to my patients. Mary S. had severe rheumatoid arthritis and lung disease. She had spent her life cleaning white people's houses and raising their children. She moved to Chicago from Mississippi in the 1940s to find work. Now in her sixties, she had to quit work because of her advancing lung disease. She dragged a canister of oxygen with her to my office. In between gasps, she told me she wanted to get better and help raise my newborn son. She expressed no bitterness about her illness or about my inability to cure her. During her last hospitalization, she made one request. She lay in the hospital bed, her chest heaving to get air. We held hands.
"Doctor Ansen?" Her eyes sparkled. "Ah want ta see yo chile. Please, can ah see yo chile?" We hatched a plan. On the next Saturday morning, I brought my son to County Hospital for her to see. She came to the sixth floor window of the Medical A building. I stood outside and held my infant son up over my head like a gift offering to the gods. She smiled and waved at us from the sixth floor window, oxygen tubes dangling from her nose. We waved back. I cried when she died a few days later.
I learned a lot from the patients. I was discovering the tools of medicine from them. Many of my patients and I grew up together. They had seen me become a father for the first time, and they consoled me when my father died. I had seen their children grow up, having children themselves. I had helped them through family crises, tragedies, diseases, and deaths. I had no idea in those first weeks and months of General Medicine Clinic how much I would grow from these relationships. I am on a first-name basis with many of my original patients. From them I gained insight into illness and the dignity with which people can face hardship that has helped me through difficult times in my life. I have taken care of three generations of some families, and have seen the destruction that poverty, poor diet, obesity, diabetes, and hypertension can unleash on a family's tree. I learned that sometimes giving hope or an embrace is as therapeutic as a drug. I sometimes measure my life progress by thinking of the people who have had an impact on my growth as a human being. My parents, my wife, my children, my friends and colleagues. I number my patients among them.
Excerpted from the book County: Life, Death and Politics at Chicago's Public Hospital by David Ansell M.D. Copyright 2011, David Ansell M.D. Published by Academy Chicago Publishers. All Rights Reserved.
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