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By Root 641 0

There are lots of things to make you think, Gee, it’s his heart. But then, after evaluating the patient, you find out his ECG is normal. What do you do? Well, you probably say to yourself, This is an old guy with a lot of risk factors who’s having chest pain. I’m not going to trust the ECG.” In recent years, the problem has gotten worse because the medical community has done such a good job of educating people about heart attacks that patients come running to the hospital at the first sign of chest pain. At the same time, the threat of malpractice has made doctors less and less willing to take a chance on a patient, with the result that these days only about 10 percent of those admitted to a hospital on suspicion of having a heart attack actually have a heart attack.

This, then, was Reilly’s problem. He wasn’t back at Dartmouth or over in one of the plush private hospitals on Chicago’s north side, where money wasn’t an issue. He was at Cook County. He was running the Department of Medicine on a shoestring. Yet every year, the hospital found itself spending more and more time and money on people who were not actually having a heart attack. A single bed in Cook County’s coronary care unit, for instance, cost roughly $2,000 a night — and a typical chest pain patient might stay for three days — yet the typical chest pain patient might have nothing, at that moment, wrong with him. Is this, the doctors at Cook County asked themselves, any way to run a hospital?

“The whole sequence began in 1996,” Reilly says. “We just didn’t have the number of beds we needed to deal with patients with chest pain. We were constantly fighting about which patient needs what.” Cook County at that time had eight beds in its coronary care unit, and another twelve beds in what’s called intermediate coronary care, which is a ward that’s a little less intensive and cheaper to run (about $1,000 a night instead of $2,000) and staffed by nurses instead of cardiologists. But that wasn’t enough beds. So they opened another section, called the observation unit, where they could put a patient for half a day or so under the most basic care. “We created a third, lower-level option and said, ‘Let’s watch this. Let’s see if it helps.’ But pretty soon what happened is that we started fighting about who gets into the observation unit,” Reilly went on. “I’d be getting phone calls all through the night. It was obvious that there was no standardized, rational way of making this decision.”

Reilly is a tall man with a runner’s slender build. He was raised in New York City, the product of a classical Jesuit education: Regis for high school, where he had four years of Latin and Greek, and Fordham University for college, where he read everything from the ancients to Wittgenstein and Heidegger and thought about an academic career in philosophy before settling on medicine. Once, as an assistant professor at Dartmouth, Reilly grew frustrated with the lack of any sort of systematic textbook on the everyday problems that doctors encounter in the outpatient setting — things like dizziness, headaches, and abdominal pain. So he sat down and, in his free evenings and weekends, wrote an eight-hundred-page textbook on the subject, painstakingly reviewing the available evidence for the most common problems a general practitioner might encounter. “He’s always exploring different topics, whether it’s philosophy or Scottish poetry or the history of medicine,” says his friend and colleague Arthur Evans, who worked with Reilly on the chest pain project. “He’s usually reading five books at once, and when he took a sabbatical leave when he was at Dartmouth, he spent the time writing a novel.”

No doubt Reilly could have stayed on the East Coast, writing one paper after another in air-conditioned comfort on this or that particular problem. But he was drawn to Cook County. The thing about a hospital that serves only the poorest and the neediest is that it attracts the kinds of nurses and doctors who want to serve the poorest and neediest — and Reilly was one of those. The other thing about