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Family Practice 

As a med student Brian Hertz wanted to treat whole familites and he wanted to work among the poor. At the South Lawndale Health Center he got what he wanted.

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She has been having labor pains since early last evening. They are not hard pains, close together; nevertheless, she is agitated. Her first baby was cut out of her, but her doctor has promised to give this one a chance at a natural birth. Maria Cortez (all the patients' names have been changed) knows that she is nowhere near delivering, but she is very jittery. At noon, she calls her doctor, Brian Hertz. He has been seeing her a couple of times a week for several weeks, and he has told her to call whenever she feels a need to. He wants, as much as she does, to avoid the surgery. When she calls, he questions her in detail, in Spanish, and then reassures her that there is no need to go to the hospital yet. "Have lunch and walk," he advises her.

At 4:30 in the afternoon, Maria calls again. Fairly sure that she is still a long way from delivery, Dr. Hertz nevertheless agrees to examine her at the hospital.

At seven, he takes Maria into the obstetrical emergency room at Cook County Hospital. She clenches her teeth in pain as he probes, discovering that her cervix has dilated only about two centimeters, slightly wider than his forefinger. She's a long way from delivery. "Go home, have something to eat, relax," he tells her.

He understands her worry, is patient and reassuring. When he first examined her, weeks ago now, and saw the long vertical scar from her pelvis to her navel, he asked where she had given birth. Was this the classical uterine incision that must be repeated in subsequent deliveries, out of fear of a rupture? Or was her cesarean a low, transverse incision? A little town in Mexico, she told him.

An average doctor operating out of an average office would have been daunted. But Hertz is not an average doctor. He is a member of a health-care team working in a family-practice clinic at 26th and Lawndale. The South Lawndale Health Center goes the extra mile. Hertz located that little town and wrote to the hospital there for Maria's records. They showed that with a little luck, she could deliver her next baby normally.

She would have to be watched carefully. The delivery would demand her doctor's constant attention, which is not the kind of treatment most pregnant women receive at Cook County Hospital, of which South Lawndale is an outpost, or at most hospitals for that matter. But Maria would get it.

At midnight she calls again. She is sure she is ready. Just as Dr. Hertz is going out the door she calls back to say it was a false alarm. She is just so nervous, she says.

Now it is 4 AM and Maria is positive this time. "This is the real thing, I think," says Hertz. We meet Maria in the emergency room at County, and Hertz takes Maria and her husband Juan up to the fifth floor, to the "labor line," the name its workers give the factorylike labor room there. Hertz steers Maria to a bed in the corner and draws the curtain around her. She puts on a hospital gown and climbs onto the bed. He does a physical examination, takes a blood sample, and hooks her up to an IV. He then arranges for a nurse to shave her vaginal area in case he has to do an episiotomy, a surgical expansion of the vagina.

Suddenly, Maria is nauseated. She calls for Hertz but he is off making preparations for the delivery, and the nurses that oversee the labor line, which now has eight patients on it, are busy. Maria is sick. Hertz returns and cleans her up, changes her gown and sheets, which isn't the kind of service doctors usually perform.

Finally, all is ready in room nine, the private delivery room reserved for the nurse-midwives and family-practice doctors on staff at County. Hertz wheels Maria into room nine and he and a nurse help her onto the delivery bed. The other women on the labor line will stay in the large ward room until they are ready to deliver. Maria, because she is Hertz's patient at South Lawndale, will go through labor and delivery in this private room, attended throughout by her own doctor.

Because Maria and her husband have taken the prenatal classes offered free at the clinic, Juan Cortez is entitled to stay at his wife's side. A year ago, after a heated battle with the obstetrical department, the family-practice doctors and the nurse-midwives won this right for their patients. For 16 hours, clad in surgical whites, Juan will stand beside Maria in her labor.

Hertz inserts a wire through Maria's vagina and connects a monitoring machine to the head of the fetus. He will permit her labor to proceed naturally so long as the baby is all right. If the machine indicates that the baby is having trouble, he will call in an obstetrician and discuss surgery.

At ten in the morning--Maria has been here six hours--Hertz stretches out his long frame on one of the armchairs in this bright, pleasantly decorated room and closes his eyes. He sleeps for a few minutes and then is up again, checking the monitor, examining Maria, comforting her, reminding her to take short breaths to counter the pain. At 10:30, he warns the Cortezes that if the baby does not arrive in two hours, he will have to call in an obstetrician and discuss doing the dreaded C-section. Maria's pelvis is very narrow. She may simply be unable to deliver normally.

Two hours later, almost to the minute, Maria gives birth to an eight-pound, nine-ounce girl. Hertz is jubilant. "I didn't even have to do an episiotomy," he says gleefully. His blue eyes sparkle despite his fatigue. He's delivered Maria's baby right into her lap, Juan cutting the umbilical cord. "This is the kind of delivery doctors love," he says.

Maria's first pregnancy had ended in a C-section, her second in a miscarriage. Grinning gaily, proud of himself for having managed this pregnancy so well, Hertz congratulates the mother and father and takes them off to the obstetrical ward, where Maria and the baby will sleep for a few hours. Juan's on his way home to sleep. The next day, Hertz examines both Maria and the baby--two procedures normally done by two doctors--pronounces them healthy, and sends them home with an admonishment to see him in two weeks so he can check them again.

This was Hertz's hundredth delivery in his two and a half years so far as a family-practice intern and resident at Cook County Hospital. Having delivered Maria's baby, he will now oversee the infant's growth, as he also treats Maria, Juan, and their other child for colds, sore throats, and whatever else comes along. But only until this July. Then he completes his residency. Then he must say good-bye to the Cortezes and his other patients. It is something he dreads. "They are like my family," he says.

They are old men, young women, children, mostly Hispanic, some undocumented, mostly poor, mostly illiterate in English, some retarded, some crippled. "I hate to leave now," he says. "They've all been my guinea pigs to learn from, and now that I really know something I have to turn them over to someone else who's just starting out like I was. I am grateful to this clinic, which is recognized as a model health-care facility, for the opportunity it gives me to work in this community where I might otherwise be viewed with suspicion and distrust. The clinic gives the community access to decent medical care, but it has also allowed me to learn in a way I couldn't otherwise--in this team approach and in a community normally isolated from the rest of the city."

Brian Hertz is earnest and self-effacing. He volunteers little. Asked about the politics of his parents, he replies only, "They believe in justice." He rarely raises his voice.

Perhaps Hertz is more spontaneous making music, although since he came to Chicago he has had little time to play the trumpet that once tempted him to leave medicine. In New Jersey, where he lived until he enrolled in the medical school of the University of Michigan, and during his school years there, he performed with small groups. Recently, he talked wistfully about finding a group to play with in Chicago. But he added, "Of course, I don't have time to practice, so it's just wishful thinking."

But another side to Hertz's reticent personality is a powerful ambition. Self-effacing though he is, he sees himself one day as an international leader in the field of public health.

Hertz's patients have heart disease, diabetes, back pains, herpes, colitis, arthritis. His year as an intern and two years as a resident at Cook County are teaching him how to treat almost every medical problem. He is particularly experienced in the illnesses common in the inner city--tuberculosis, stress-related conditions of all kinds, alcoholism, drug abuse, and physical abuse resulting from domestic violence.

Hertz came to County because he wanted to see these things. He decided early on that he would practice medicine among the inner-city poor. And he would treat whole families. "I came to County because it offered what seemed to be the best family-practice training program for an inner-city career in medicine," he says. The clinic in South Lawndale fulfilled all his requirements for his training.

Juan Cortez, unlike many Hispanics, has a decent job, speaks English quite well, and owns medical insurance. He and Maria could have had any obstetrical care they wanted. But they chose South Lawndale Health Center because in their neighborhood the clinic enjoys a reputation for good medical care and a sympathetic attitude. Almost everyone who works there is bilingual, and while Maria and Juan speak English, it is comforting to them, in times of stress, to speak their native language. Furthermore, Juan's insurance doesn't pay for every visit to the doctor a family tends to make, and Juan earns a modest wage. Fees at South Lawndale are $7 for the first visit and $5 thereafter. About 11 percent of the patients are treated without cost.

In 1974, the clinic's first year of operation, it treated 4,000 patients. In 1986, the clinic treated close to 28,000. Every day, the clinic sends people it has no time to handle on to County. South Lawndale is small and busy; space is used as efficiently as space in a submarine. On any given day, there will be two to four residents and a couple of attending physicians from County at the clinic. Hertz is there two half days a week.

Like many of his colleagues, Hertz sees himself as a medical emissary. He wants to bring the poor relief from the indignities of assembly-line medicine. He wants to reach out and help the uneducated poor, who all too often don't seek medical help because they have no money and no insurance and fear the gigantism of the public hospital.

The Ramirez family, for instance, stirs Hertz's blood. He first met them several months ago when Rosa and Cruz, both in their 70s, brought their daughter Sophia to the clinic. Sophia is under five feet tall, overweight, severely retarded, blind, and partially deaf. Sophia is suffering the symptoms of old age at 34, a natural consequence of Down's syndrome. Hertz tried to examine her, but she became so agitated that he could do no more than take her pulse and her blood pressure. She is used to the privacy of her bedroom at home. Since that first clinic visit, Hertz has periodically visited the Ramirezes in their little apartment down the street from the clinic. But there is little that he can do for Sophia medically. He did prescribe a drug to calm her--her parents had said she had trouble sleeping, and sometimes she banged her head against the wall.

Now he stands in her room, watching as she lies on her bed and plays with a rolled-up newspaper. He listens carefully as her mother reports her complaints. He examines her puffy feet--they aren't swollen; she is simply very much overweight. A torrent of Spanish flows from the mother, then the father. Hertz listens sympathetically, saying little. Sophia is so docile during his visits that he can get no sense of the parents' complaints. He wonders if they are just too old to handle her, or are misunderstanding her requests, causing her to grow frustrated and angry. He cuts her drug dose. Sophia's agitation, Hertz says, may be the result of terrible frustration. He tells the parents to call him the next time she is so agitated. "My role," he says, "is to try to help these unfortunate people understand and deal with their problem."

In their tiny, immaculate kitchen, Hertz calmly explains to these two elderly people what he believes is the trouble. "You must expect that Sophia will get harder to handle. As she gets older, her condition is degenerating," he explains in Spanish. He is gentle, sympathetic, but firm. James Donahue, the clinic's social worker, is trying to find a place for Sophia, but there are no Spanish-speaking homes for the disabled. Hertz worries about what will happen to the Ramirez family. Will the resident physician who takes over his patients be as willing to listen to their complaints, to visit and comfort them?

Hertz is among a dwindling minority of doctors who choose to work in the inner city, but he is one of a growing number who choose family practice over the confines of specialization. Hertz tells the story of Joe Downs to illustrate the difference between his practice and that of the specialist. Joe Downs is an alcoholic and a diabetic, and because of his diabetes has lost a leg. He is seen at County by five different specialists. Hertz oversees his health care and refers him to the specialists as they're needed.

"The difference between the specialists and the family practitioners," says Hertz, "is that when Joe gets sick he calls me. The specialist treats his problems. I treat him."

More and more young doctors are being attracted to family practice, but most of them are in the suburbs, small towns, rural areas. John McPhee's book Heirs of General Practice, published in 1984, describes five idealistic young family practitioners who settled in rural Maine. But the turmoil and cultural diversity of the city are what attracted Hertz. He thrives on the smells and sounds of the Hispanic community where he works, and on the incredible range of sights in Uptown, where he lives. Hertz's powers of observation serve him well on the streets of Chicago. Very little goes unnoticed by this quiet man.

He smiles easily, but there is little room in his life for humor. He does everything with a terrible intensity. At the moment he is full of anger. He had spent what he describes as "many hours" preparing a revised schedule of prenatal care for Cook County's family-practice department, and he just presented it at a meeting of resident doctors. But his project was discussed only at the end of the meeting, after several people had left. "We have a chance to do good work, but it is always getting messed up," he complains bitterly, smacking one hand into the other in frustration.

Now he's in the women's section of Cook County Jail, where he moonlights. The angel food cake that one of his patients baked for him today and that he shares with the jail staff only mildly comforts him. The attention from the two inmates waiting for him is slightly more calming. A handsome, 28-year-old male is a novelty in the women's jail. "Hey, doc," he's enjoyed hearing more than once. "I need mouth-to-mouth resuscitation."

The next morning, Hertz is one of the first staff doctors to arrive at South Lawndale, but as usual he has been preceded by a group of patients who sit patiently in the tiny waiting room waiting for the clinic to open officially at nine o'clock. They do not have appointments; they know that if they are to be seen by a doctor they have to get there early. At nine, Lily Gage, a physician's assistant, will determine in what order, depending on their complaints, these people will be examined. There are often as many as 30 or 40 of them waiting.

Hertz joins his colleagues in the conference room--it also serves as the staff lounge--for the morning seminar. Dr. Manthani Reddy, the clinic's medical director, who has been in County's family-practice department since 1974, lectures the group on the irregularly beating heart, symptoms and alternative treatments, a lecture that Hertz later describes as "very high-level, brilliant." After the lecture, there are questions. Hertz probes Reddy for more details, confronts him with alternative ideas. He asks more questions than anyone else. At one o'clock, Dr. Howard Ehrman, an attending physician at County off and on since '74, will conduct a seminar on recent developments in gynecological care. These sessions occur every day at the clinic and throughout the hospital.

After the lecture, Hertz goes to his examining room. While it is attractively decorated, this clinic, housed in an 1890s funeral parlor, was not designed for comfort. The second-floor waiting room is a narrow corridor with examining rooms along it. The last one is Hertz's. It is about five feet by four.

For the next four hours, Hertz moves back and forth between his examining room and the kitchen where medical supplies are kept along with a sterilizer, a microwave oven, a coffee maker, and a refrigerator. This is where he writes up his case records after seeing patients. This morning most of his patients are children and pregnant women.

"Where is Dr. Hertz? I want Dr. Hertz!" Four-year-old Lupe Reales runs up and down the narrow corridor calling for her doctor. Her mother tries to restrain her but with little effect. Her brilliant black eyes flashing, Lupe is loving all the attention she is getting from the staff, who cannot resist her aggressive charm. At last, Hertz calls Lupe and her mother into the examining room. He treats the child as a friend, pats her on the head, and speaks softly, familiarly. But as soon as he closes the door, Lupe changes her mind. Now she is afraid of Dr. Hertz. She clings to her mother, and when he comes near her she cries out.

Slowly, patiently, he reassures the child that he will not hurt her. He explains what he needs to do and slowly examines her eyes, throat, ears, nose, and chest while she sits on her mother's lap. Finally, she permits him to put her on the examining table to test her reflexes. Lupe has an unusual reflex reaction in her right foot. Hertz's brow wrinkles. He calls Dr. Reddy on the intercom. Lupe's reaction might be a sign of a nerve disorder that usually is a result of a troublesome pregnancy, which Lupe's mother had.

Reddy agrees that a series of tests should be done on Lupe, and Hertz explains this to the mother, who sits impassively throughout. She has, Hertz will explain later, "serious psychological problems." He urges her to bring Lupe in for the tests when she comes in for her own checkup in a couple of months. There is no hurry. The child is obviously developing normally at this time. The important thing, Hertz tells the mother, is to give her every opportunity to grow normally--proper food, exercise, school. "Don't try to restrict her," he warns.

Afterward, Hertz says, "I believe in telling patients everything that might affect their health and well-being. I don't approve of withholding information from a patient."

The next patient is a woman whose baby Hertz recently delivered. She speaks no English, so, in Spanish, with laughter throughout, she and Hertz discuss her condition, her baby, her husband. She has a complaint. Her knee hurts her when she crosses her leg. Hertz explains that the pain is caused by her excessive weight. If she would lose weight, she would lose the pain. He lectures her, gently and softly but firmly, about frying in heavy oil, about foods lighter than the traditional Hispanic diet; he gives her a list of diet foods. She hugs him as she leaves.

Carlos and Anna Gallitea and the three youngest of their six children, neatly and fashionably dressed, crowd into Hertz's little examining room. The children have come for their checkup. The youngest is a year old, a happy little boy. Anna is 24, Carlos 28, and she will deliver another baby in September. The Galliteas smile happily at each other and at everyone else. They speak no English and had a hard time when they first arrived in the States a year ago. They had to leave their three eldest children in Mexico until Carlos could find a job and they could find an apartment. Now Carlos is working as a butcher in a meat-packing plant and the family is reunited.

Hertz has a mission: he wants to persuade Anna to have a tubal ligation after the birth of the next baby. He examines the youngest, who doesn't object and who cries for only a moment when Hertz gives him a shot. Next comes an examination of Anna. She climbs up on the examining table and Hertz lowers her maternity pants and underpants to reveal her protruding belly. It is just a quick look-see, as long as she is here, to make sure things are going well. As he examines her, the children and Carlos crowd into a corner, watching, while the baby wanders around investigating the room.

After he dresses her, she sits up and listens attentively as he talks. Then Hertz goes to his desk to get the papers that Anna must sign at least 30 days before the tubal ligation can be performed. She will deliver in September, and the surgery will be done at the same time. He explains slowly that her signature does not obligate her, it only makes the surgery possible. Smiling, she agrees to sign. She prints her name on the three forms. Anna had only a third-grade education, but, Hertz says, she is bright and understands him. Whether, in September, she will agree to have her tubes tied, he doesn't dare guess.

Hertz learned to speak Spanish from his patients and the clerical staff at the clinic. He carries a thick Spanish dictionary with him, but seems to have no trouble, after more than two years in this setting, communicating with anyone about anything.

Most of his colleagues have also had to learn Spanish on the job. Some have taken lessons. They have a clear-cut mandate to speak the language of their patients. It is one of the things this clinic is famous for in the community. The clinic was started in 1974 by a Mexican doctor, Jorge Prieto, who had been a general practitioner in the neighborhood for 20 years. When the administration at County decided to open a family-practice department, they invited Prieto to be its first chairman. He agreed on the condition that the hospital open a family-practice clinic in his neighborhood. He had two motives: to bring decent, affordable medical care to the community and to create a setting in which young doctors would learn the rewards of practicing in the inner city.

A free community clinic with neighborhood doctors had been operating out of a neighborhood storefront. Under the agreement that Prieto made with the board of this clinic, its community base was retained while the County Board took over the funding and created a teaching institution. It was important to Prieto and remains a primary concern of the staff that South Lawndale be a community-operated clinic. The clinic's community board owns the building that houses the clinic and makes the nonmedical decisions regarding its operation.

Prieto left County in 1985 after serving as chairman of the family-practice department for 11 years to become chairman of the Chicago Board of Health. Hertz and his colleagues at South Lawndale greatly respect Prieto. Though he is no longer among them, his presence is always felt. The physicians often wear embroidered Mexican guayaveras that he gave them instead of the traditional white coats.

Prieto's dream has come true. Of the 111 residents who have come through the clinic, about half are now working among the inner-city poor. Another part of his plan was to recruit women to the program. Nearly half of the physicians who've trained at the clinic over the past 12 years have been women and, Prieto says, "They make very excellent family doctors and many of them are now working with the poor."

Last year, the Center for Urban Research at the University of Chicago, in collaboration with the Metropolitan Planning Council, issued a report, Poverty, Illness, and the Future of County Hospital, recommending that neighborhood clinics modeled on South Lawndale be established throughout the poor areas of the city.

County was already extending the clinic idea. It has been creating alliances with the Chicago Board of Health clinics and with privately owned clinics in the inner city, giving physicians at these clinics privileges at County, and, in turn, referring its patients to these neighborhood clinics. The plan is being implemented by Dr. Patrick Dowling, chief of ambulatory care at County and an attending physician in family practice. He explains that County's patients often travel as long as two hours to get to County because they cannot afford medical care in their own neighborhoods. Eventually there will be ten of these clinics. There are now three.

Before he chose County, Hertz investigated the dozen or so other family-practice programs in the country. He looked, he says, "at the way the staff interacted, the quality of the teaching staff, and the learning experiences I could expect." But the overarching question was whether he'd have a chance to work with the inner-city poor. While Prieto was trying to attract young doctors who could be persuaded to work in the inner city, Hertz didn't need to be persuaded.

Hertz was the last of the 39 doctors in the family-practice program to sign a contract for his second year of residency. About a quarter of his class left County. Exhausted, Hertz considered joining them, but the challenge held him. The terrible overcrowding, understaffing, and constant scraping for the resources to do the job that characterize all big-city public hospitals today defeated some of the residents, Hertz explains, "especially those who came because of the learning experience it offers rather than the opportunity to practice among the underserved." For Hertz, though he got discouraged last year, these conditions are mostly a challenge.

Hertz will refer patients to specialists when his own knowledge is insufficient, but he is determined to learn enough about modern medicine to handle all but the most difficult diagnoses. He is spending as much as 120 hours a week at work, practicing medicine, attending lectures and seminars, consulting with specialists, and reading. In addition to his regular work load, he moonlights in the pediatric emergency room, the psychiatric emergency room, and County Jail, and donates time to a shelter for the homeless. He is paid for the moonlighting but, he says, "the money is a minor factor. The important thing is that I couldn't get this kind of training anywhere else."

When he finishes his residency at County in July, Hertz will join the staff of Claretian Medical Center, a hospital located in severely depressed South Chicago. It's a job that promises more backbreakingly long hours treating the poor and sick.

Art accompanying story in printed newspaper (not available in this archive): photos/Mike Tappin.

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