In 1988 Robert Simon accepted the position of chairman of the department of emergency medicine at Cook County Hospital and took on the task of cleaning up its once-notorious ER. "We've set up a good model program. We built a brand-new ER. Our ER is excellent in terms of its morbidity and mortality rate--it's probably the best in the county. All of our physicians are board certified or are board eligible. We have the second-largest residency in the country, the largest faculty in the country at any one hospital in emergency medicine, and we have a huge amount of grant support for research. So we've really done exactly what we wanted to do."
But the 45-year-old Simon, who's also the founder of an organization that sets up medical clinics in war zones around the world, had an even larger mission when he took on the job. "What struck me is how many people in our country there are that work for a living but have very poor access to health care because they have no health insurance," he says passionately, rocking back and forth quickly in his chair. "I remember reading an article in the New York Times that said that 25 percent of America goes uninsured. These are the people that work as grocers, in small stores, as barmaids or clerks--jobs that are not with the big companies that offer insurance.
"What I wanted to do was, in my specialty, develop a top-notch program for those people; to do that I'd have to be at a public hospital. I wanted to help build a great residency in emergency medicine. And I wanted to assist in research that would reduce the cost of health care. That's the area where we've probably had the most significant effect. We've found things that could save this country hundreds of billions of dollars in health-care costs--with exactly the same quality. We've done the research on it, here at Cook County, over the last six years."
He believes that everyone in the country ought to have some kind of medical coverage, either through a managed-care facility or a public hospital. He also believes that the only way this country can ever afford that is to cut costs--which is why he's now pushing to have his ideas tested in emergency medical centers around the country.
Simon, who says he's "probably the only Republican at Cook County Hospital," may have compassion for the working poor, but he's quick to note where he draws the line. And he doesn't care who's offended. "I did not come here to help the bum on the street--the alcoholic or drug addict who comes to the ER 40 times a year just to get a place to sleep. I didn't come here for 'the homeless,' because I've worked for 18 years in emergency medicine--I know what 'the homeless' really are. I'm not a liberal. Die-hard liberals talk about 'the homeless.' If they actually saw what they're defending I don't think they'd be so die-hard. Most of the homeless really don't care about themselves or are psychiatrically impaired. You can give them any opportunity in the world, and they would not take advantage of it. They could do things for themselves, but they won't. So who the hell cares about them? To me, society wastes enormous energy, money, and resources on them. I can say this, as I come from a family of 16 children whose income was less than one-third of the official poverty level."
Simon was the 13th child of 16 in a family of Lebanese immigrants. He grew up in Detroit in a Lebanese-Italian neighborhood, near Gate 12 of the Ford Motor Company. His father's name was originally Abdul-Jalil, but some anonymous official at Ellis Island dubbed him Simon when he immigrated near the turn of the century. When his father's first wife died after the birth of her 12th child he returned to Lebanon to find a second mate. Bob Simon was the oldest of her four children.
"My father was a common laborer, a complete illiterate. He worked at Ford Motor Company and was an unpaid union organizer for the United Auto Workers. He worked with Walter Reuther, and he was at the 'Gate 12 massacre' when other union organizers were killed. In those days auto workers were treated like slaves. But he died condemning the unions of today. 'Now they spend 95 percent of their time defending the 5 percent of workers who are derelicts and don't deserve their jobs.' That's not what he made those sacrifices for."
The family depended on a nearby Salvation Army thrift shop to clothe themselves. Simon remembers a 25-cent overcoat that got him through the Michigan winters during high school.
He won full scholarships to college and medical school, entering Wayne State University in 1968. His intensity and single-mindedness got him through the college premed courses in just two years, even though he was also working washing trucks and busing tables. "I used to average about four hours of sleep a night, then every ten days or so I'd sleep for eight or ten hours. I didn't know what the scholarship situation would be, and I wanted to get done with it." From 1970 to 1974 he attended medical school at Wayne State and worked nights as a janitor.
After doing his internship at Detroit General Hospital, he spent three years in Michigan's upper peninsula working in an emergency room and spending a couple of days a week working with an orthopedist or a plastic surgeon. In 1978 he did his residency in emergency medicine at the University of Chicago, then went to UCLA, where he practiced and taught and wrote. He's the author of five books, two of them classics in the field of emergency medicine, and about 50 journal articles.
In 1983 Simon made a radical change in his life. He sold his house in Malibu and went to Afghanistan, where he set up his first war-zone medical clinic, an experience that would help shape his later thinking about emergency-room medicine. Why go to a war zone? "I guess because that was the critical need then. At that time I was not married, I didn't have any kids, and I felt that if something were to happen to me it would not be a big loss for anyone. So I could do it. Other people who had obligations to their families couldn't.
"I went to Afghanistan after hearing about the atrocities that were being committed. As we hear about Bosnia's atrocities today, those were in the American newspapers then--poison gas being used on civilians, butterfly bombs designed to attract and kill and maim children, and all the rest of the horrible things that the Soviet Union was doing in its invasion of Afghanistan. I contacted the Union of Afghan Doctors--a group of doctors who had fled the country and were based in Pakistan--and asked if I could help them, if I could go into Afghanistan and provide some medical assistance. They agreed. So I went in, and I surveyed the country, and I came out very committed to these people."
Simon applied to various organizations for funding for the clinic he'd set up and was turned down. "I still have a letter from the World Health Organization. I asked them if they would support the clinic, and they refused. It wasn't that they were against the clinic. It was that their charter forbids them to go into a country unless the government in charge of that country permits them to do so. The same with the Red Cross. So the Red Cross could go into Hitler's Germany only if Hitler said that it was OK to go and only where Hitler told them they could go. Same with the Soviet Union's Afghanistan situation. Same with Cambodia. If they wanted to go where the Khmer Rouge controlled the area they had to get the permission of the people who controlled that piece of earth. The Red Cross has that in their charter, the WHO has that in their charter, the UN has it in their charter--everybody." He also found that lots of groups were happy to work with refugees. "Refugee camps are easy to access. If there was an attack on America and we all went to Canada, then [refugee organizations] would go to Canada and set up tents and feed people. They're basically welfare camps."
Simon saw the need for an organization that could set up clinics in places where other organizations couldn't or wouldn't go, so he founded the International Medical Corps, which has saved lives on battlefields in Cambodia, Nicaragua, Lebanon, Angola, Sudan, Somalia, Rwanda, and Bosnia. "All of our programs have two things in common: we only go to the most difficult places--almost always the war zones--and while we may start with direct relief inside the war zone, we never end with direct relief. We always end with self-help. We train people to take care of their own. I'm strongly antiwelfare--strongly antiwelfare. That's why I set up the organization to be self-help. We set up training programs in Afghanistan, we trained Afghan natives to be medics, we've retrained the Afghan doctors, we've trained administrators, laboratory workers, nurses, and medics. At this point there's not a single American running any of our hospitals or clinics in Afghanistan. All 28 of them [at the height of the war there were 52] are run and administered by Afghanis, and they're virtually self-sufficient--the community now supports them."
According to spokesman Ken Ferber, the IMC, whose annual report contains glowing quotes from such disparate politicians as senators Bob Dole and Paul Simon, now has 75 American and "hundreds of local" employees. Since 1984 they've trained "tens of thousands" of people to do various medical and administrative jobs. There are now programs in seven foreign countries and several American cities, and their budget is $13 million a year, coming from the U.S. government, other governments, foundations, corporations, and private donors. "Interestingly enough," says Simon, "four years after we set up IMC the WHO gave us grants, and now we've gotten over a million dollars in grants from them. Last year we passed the $50 million mark in grants that we've received from different donors."
Phyllis Oakley, assistant secretary of state for population, refugees, and migration, was the State Department's Afghanistan desk officer when Simon founded the IMC. "We did not always see eye to eye," she says. "We had a few rough patches because he wanted to go into Afghanistan, into the war zones, and at the time we had a firm policy against that. But what he did was terrific. He set out to ease the pain and suffering of the people there. He didn't entirely succeed--nobody could--but he went a long way toward establishing health care there for people who needed a lot of it."
When asked why he did it Simon says, "It's not an issue of religion. I am not a religious man. I have no doubt that there is a God, no doubt at all. Something has to organize the world, and it has to be an intelligent force. Human beings can make things as complex as cars and computers, but an eyeball is much more intricate than a computer or a Mercedes. So there's no doubt that there's a creator. But it's a creator that plays with a Lionel train set on the table and enjoys watching it crash.
"So I'm not into this to go to heaven, number one. Number two, I'm not into it because I feel like I have this great debt to society. I do it purely for one reason: it makes me feel good about myself. The reason that I live an ethical life and the reason I make these sacrifices is purely because it makes me sleep at night feeling very good. It's like the Ayn Rand concept of the virtue of selfishness, if you will.
"To set up IMC and support those clinics I had to raise $100,000. I had to sell a Malibu house. Then I was able to raise more money and hire staff. Selling my home received enormous publicity, and everybody thought, "What a sacrifice!' But that's not a sacrifice. You're selling three bedrooms, two baths that really belong to a bank, and what do you get? I got 52 clinics, taking care of 1.1 million people a year. What a great return on my investment! I don't look at it as selling my house to help humanity. I look at it as selling my house to get a phenomenal investment. Instead of getting me a beautiful car, it got me a great feeling, which is far more important to me."
Yet after five years Simon was ready to move on. "I think the major drive for me was simply that I always organize my life in five-year plans. It just works for me, whether it's for medical school or any other goal." This time he took the job as head of the department of emergency medicine at Cook County Hospital.
It's a "moderately slow" time in Cook County's emergency room, located on the first floor of that enormous beige brick pile. Only about 35 miserable-looking patients are sitting in the waiting room, and there's no air of panic in the treatment areas.
"This is a new unit, about three years old," says Tom Scaletta, a young MD with a stethoscope slung around his neck. "We're focusing on security these days, and that's real new." It used to be that anyone could wander in off the street, which led to everything from petty theft to necronapping--gang members swiping the bodies of their deceased victims. Violent patients remain a problem; offenders have their sins added to their records, a process known as coding, and will be watched the next time they appear. "That's prevalent not because it's Cook County Hospital, but because they're on drugs, or alcohol, or they're involved with gang violence," explains Scaletta. "Violent patients are prevalent in all ERs." Trauma patients are now quickly undressed, to reveal their wounds--and to check them for weapons. Some people get upset when they have to wait too long and become another source of disruption. Security guards are much in evidence, and all visitors must wear ID tags. Patients have bright orange bands around their wrists, and they must wait alone, except for those who require translators.
Once a huge, open, grimy room, the new ER has been subdivided into clean, specialized areas. Triage is practiced at the entry points: those under 16 are directed to the adjacent children's hospital, trauma patients go to one side, and regular emergency patients--with chest pains, asthma, dizziness--go to the other. On the side where regular emergency patients go is a special bay for gynecological problems and another for asthmatics, as well as "fast track" examining rooms that are like mini doctors' offices. The asthma area is empty on this relatively cool, clear day, but, says Scaletta, "under certain weather conditions--when there's a lot of pollution, when there's pollen--it really fills up."
In an adjoining building is a small ward that's at the heart of one of Simon's reforms: an observation unit for patients who need to be watched but don't need to be admitted to the hospital. "This is no-frills medicine," says Scaletta. "You get what you need, not what you want. That's a thing of the past."
The observation area is an open ward with a nursing station in the center. It's unisex--curtains can be pulled to provide privacy--and patients are assigned beds according to their afflictions: the more ambulatory closest to the washroom, the sickest next to the nursing station, and sickle cell anemia patients away from the side with the clock.
"Sickle-cell-anemia patients are in pain," explains Scaletta, "and the system makes them addicts because of the narcotics they're given for their pain. That makes them very difficult patients." Because of their addiction, they tend to watch the clock and drive nurses nuts with their demands for drugs. Scaletta believes Cook County sees more "sicklers" than any other hospital in the country--and that they get better treatment here. "Other emergency rooms force them out in two hours. We put them in observation for 23 hours and help them."
Rufina Rafi, a registered nurse, recollects a night when Simon was on duty in the observation unit and woke up a patient to send him home. "He said he was in too much pain to go home, but Dr. Simon said, 'You couldn't be in that much pain or you wouldn't be asleep.' So he said, 'I want to see your boss,' and Dr. Simon said, 'I am the boss!' 'No, I want to see the man above you' 'The road ends here. I run this emergency room!'" The patient finally left, chastened.
"Let's take asthma," says Simon. "Almost every family has somebody in it that suffers from asthma. It's the number-one pulmonary disease in our country. Traditionally when people come to the emergency room with asthma you give them several inhalation treatments, and then you either admit them, if after two or three hours they're not better, or you discharge them. We surveyed 54 other hospitals and found that they were admitting 75 percent of their asthma patients. If they're admitted, they're usually admitted for one to four days and discharged.
"What we've done is revise the treatment, giving them a shorter stay with more intense management. We keep them for 12 hours in an observation area attached to the emergency room instead of putting them in a regular ward. And we give them two treatment modalities rather than one: we've added prednisone--a drug that reduces airway inflammation--much earlier than is usually done. While they're there they're learning how to use an inhaler and how to prevent recurrent problems. The bottom line is this: we've reduced regular admissions by 30 percent, saving the hospital $1.2 million. If applied nationally that would save half of a billion dollars a year.
"I can give you the same story with chest pain. Of the 1.5 million people admitted every year in this country to coronary-care units, half of them don't have an MI--a myocardial infarction. They're admitted because they have the right symptoms, even though their EKGs are negative. Coronary units have one-on-one nurses--that's very expensive. We've devised new protocols so that within 12 to 23 hours we can recognize the ones that don't need admission. We give them three EKGs in one day instead of one a day for three days, we give them cardiac enzymes every eight hours instead of once a day. That alone would save one-third of a billion dollars annually if applied nationally.
"All this work has been done primarily by our research faculty: Dr. Rob Zalenski, Dr. Rebecca Roberts, and Dr. Michael McDermott. Dr. Zalenski's research in this area shows that approximately one third of all ER patients could benefit from this approach."
Simon believes the nation, which is now spending 12 percent of its gross domestic product or nearly $700 billion on health care, could save billions if ideas like his observation unit were instituted nationally for the 25 most common problems that show up in emergency rooms. He'd like to see the government set up eight to ten emergency medicine centers across the country to study those ideas. "It would be nice to have 10,000 patients from multiple centers. That way we will know that the data is accurate, that it's been replicated in different centers. In those centers, study the diseases from the perspective of what we can change in both the therapies and the way we treat them to reduce costs. That alone would save probably $20 billion nationally."
Administrative costs are another thing Simon believes the centers could study. "Right now hospitals--HMOs and non-HMOs--are spending 25 to 30 percent of their entire budgets on administration costs," he asserts, adding that the average HMO spends 30 to 40 percent, more than in any other country. "A large part of that expense is the cost of implementing government regulatory-agency edicts to the hospitals, but most of those edicts have been put into effect without any studies being done on them. Why is it that a hallway has to be eight feet wide? Has anybody looked at why this regulation is there? Does it change anything about how medicine is practiced, other than to increase costs? A lot of the regulations that are required of hospitals are illogical. A lot of them have never been tested. What I propose is that these eight or ten centers be deregulated in order to test all these regulations, to see if they're needed."
He thinks the centers should also be allowed to test the effects of a cap on malpractice awards. "A huge number of the unnecessary X rays and lab tests would be reduced if we simply capped awards. And instead of having a jury decide things they don't understand--I certainly could not decide as a jury member whether a bridge was engineered well; I would go based on who was the best actor of the two lawyers--I'd have a review panel of experts."
David Dorris, who was elected president of the Illinois Trial Lawyers Association in June, is contemptuous of Simon's proposals to cap malpractice awards and substitute panels of experts for juries in malpractice cases. "How much and how soon does he think giving up substantial rights would affect the cost of medical care? Doctors are wonderful businessmen, and they know how to make a good living. But the Government Accounting Office made a study of the malpractice issue. They found that less than one cent of every health-care dollar goes to malpractice. It's a fraud. Doctors have a problem--they charge outrageous costs and live like the royalty of this country. And when people question their ability to live that life they blame lawyers and horribly injured people. They complain about extra tests, but they only do those extra tests because they own the machines."
What about capping the costs for doctors practicing at low salaries in public hospitals? "Do the people they injure suffer any less than people earning more money? We have a system in this country to pass costs along through insurance." In any case, he doesn't believe a cap would save money.
And the expert panel? "If I were a criminal I would love to have a system of mass murderers to judge whether I was guilty or not. Juries adjudicate against everyone in our society, and it's offensive that doctors want to be special. They did not drop from heaven, and this godlike persona that doctors want to have placed on them should offend everyone."
Simon scoffs at most of Dorris's statements but says one of them needs refuting. "That 'less than one percent of the cost of health care' figure is BS. The people responsible for that study are lawyers, and the results are bogus. That figure looks at malpractice settlements. It doesn't look at the bigger costs, like unneeded tests. There are a lot of them, and we aren't ordering any because we own the machines. Studies have shown that 81 percent of all CBCs--complete blood counts--and ankle X rays are unnecessary. They are done solely because of the fear of lawsuits."
But Simon does agree that most doctors--himself included--are paid too much, another reason medical care is so expensive. "It certainly doesn't take a huge amount of skill to do an appendectomy. Physicians who do surgical procedures are really overpaid for those procedures--really overpaid. Emergency physicians, my specialty, are overpaid. People think we have to make a lot of instantaneous judgments, the same thing they think about nurses and the same thing they think about surgeons. In reality that's not the case. There's some of it, sure. But what really should happen is that a lot of the cases that are coming into emergency rooms should be screened and be seen by people who are at a much lower level of training. A huge number of the sore throats, of the back pains don't need to be seen by doctors. We could reduce the costs dramatically by having physician assistants, who would refer patients with complicated diseases. I've done time-task studies: every five minutes I watch what a nurse does and record what she's doing. What I've found is that 82 percent of what a nurse does in the emergency room could be done by a medic or a guy with a high school diploma with just a few months of training--at a markedly reduced cost. That would eliminate a huge number of registered-nurse jobs in this country. Most of them are overpaid for what they're doing.
"The true emergency physicians should be reduced in numbers--and should only be concentrated in certain centers." He believes this country needs far fewer emergency rooms. "What's best for America is not that you have eight hospitals in one square mile, like we do in the city of Chicago, each with its own emergency room and ER docs. What's best for our country is that we designate emergency centers, like we've designated it trauma centers.
"Nobody wants listen to this, because I'm threatening too many livelihoods--including my own. I'm very willing to reduce salary along with everybody else's."
Yet he does think that pediatric and family physicians are grossly underpaid. "Any idiot could know everything there is about an eyeball, Anybody could know every disease kidneys are prone to and keep up with the journals. That's easy. The hardest thing is to be a competent family practitioner or a competent generalist. To know 80 or 85 percent of everything you need to keep up with on that eyeball and on that kidney and everything else is very, very hard--yet they're the least paid."
Ruth Rothstein runs Cook County Hospital and is Simon's boss "Here is a physician who understands not only what is quality of care, but also understands economy of care. Worrying about economy is not he way we--doctors, nurses, administrators--were brought up, and it can be hard to make the transition to that way of thinking. But the world has changed. Bob Simon was already there when everybody else was trying to figure it out. The guy is not a softie, and he doesn't necessarily want people to love him. But I think everyone who's dealt with him respects him."
Yet Simon is frustrated that he doesn't seem able to get a serious public hearing in the media or in Congress. "[60 Minutes} did a piece on IMC, but they couldn't find enough conflict in this story to make it fit into a 60 Minutes format. I can easily go to Washington when it comes to IMC issues and be heard by a congressional committee. I can't get them to listen to me on this, because my ideas propose too much radical change. You can see why the politicians wouldn't take it on. The biggest enemies of my plan are going to be the American Medical Association, the American Nurses' Association, the American Hospital Association, all of the companies that make the beds and special equipment. The trial lawyers are obviously going to be a major, major group against it. The regulatory agencies in the federal and state governments--with all these tens of thousands of jobs at stake--they're all going to be against it.
"Is this a nut talking? Well, if this is a nut why is it he's been able to have probably the most cost-effective, efficient organization in the world in a war zone? It's easy to be cost-efficient in a refugee camp, but in a war zone it's very hard. So this is not a nut talking. This is a guy who has a track record. Why not just listen to what his ideas are and see if you can implement them, see whether they'll really work or not?"
At least one congressman, North Shore Republican John Porter, does take some of Simon's proposals seriously. "While the government went through a lot of threats last year regarding changes in the health-care system," says Porter, "every corporation, large and small, is taking a very hard look at the bottom line, and they're reorganizing health care for cost reductions. That fits perfectly with Dr. Simon's models on how to save money on basic procedures. I think his ideas are going to be very much brought into play. This is the kind of thing I'll look for in legislation and try to get into the mix."
"I don't know it I have the right answers," says Simon. "All I know is that for 20 years, since I've been a kid, everybody has been talking about changing the health-care system and listening to these Ivy League economic experts. And what have we gained? We've gained a 15 percent increase in health-care costs every year.
"We have to stop listening to these phonies. They aren't experts. If you have a problem with crime you go to a street cop. You don't go to a guy with a criminal-justice degree. If you have a problem with the medical system, go to a guy like Bob Simon, who has a track record, who's a regular worker in the emergency room--the equivalent of a simple street cop--and give him an opportunity to be heard and to be tested. For 20 years I've been trying to revise the health-care systems. Anyone who doesn't have a track record in actually reducing costs--not shifting costs and playing these goddamned games-shouldn't even be considered."
Art accompanying story in printed newspaper (not available in this archive): Photos/Mike Tappin.