This week is a vacation week for me. A year ago I started my medical residency in internal medicine-pediatrics and since then it continues to be a whirlwind. In my program at Indiana University, we switch between working within the pediatrics department and internal medicine department every 4 months. This year I did 8 months of pediatrics, divided by a 4 month block of internal medicine. Since I am doing a program that actually combines two residencies, my "year" is 16 months long; I will complete 8 months on internal medicine and 8 months on pediatrics before I am officially an upper level resident.
This recent article in the L.A. Times blog highlights the current problem facing the U.S. healthcare system: spending. In most circles, the problem is usually blamed upon doctors and specialists, in a private setting, pushing expensive, sometimes unnecessary tests and procedures upon patients where they are not needed. It's portrayed as a pharmaceutical industry that spends way too much on drugs and then even more on physicians to prescribe those drugs. It is far less, if ever, portrayed as patients who abuse the system and the cost they afford the healthcare system. In the last month I have rotated through the ER of a very large private care hospital. I have seen some patients more than once in that same month. Sometimes I have seen patients who are supposed to have an upcoming appointment and can't wait any longer. Most of the time patients fail to have a primary doctor, and so come to the ER for any ill. This is despite the fact that my city, Indianapolis, has a multitude of safety net clinics that specialize to the care of uninsured (Wishard Advantage is by far an incredible, comprehensive health insurance program for the indigent in Marion County, where Indianapolis resides).
Many of the visits in the ER are non-acute, that is not life-threatening. Many could be managed in a clinic setting or local urgent care center. ER costs far exceed the costs of a clinic or urgent care visit, however, and when that patient is uninsured the cost must be absorbed by the hospital. Hospitals then need to compensate with charges elsewhere, to patients who can pay, in order to continue to act as a safety net. If there were no surplus in profits, then uninsured would never be able to find an ER to care for them.
How could this be fixed? Many patients I have seen in the ER come to the ER because of an inability to see their doctor on the day they are sick due to the clinic schedule. I can vouch for that in that I seldom see a patient who feels acutely ill in the clinic. Urgent care centers are few, and those that exist in places like Walgreens or CVS are not always run by physicians but nurse practitioners. Most are lacking in the ability to run basic labs or do x-rays in their facility (such as my own clinic, who sends all blood work out for analysis). One thought I have had regarding acute illness care is that clinics adopt a rotating urgent care schedule. A practice could have a section of patient rooms that would operate as walk-in or same-day appointments only, and physicians could rotate through staffing the same-day clinic instead of seeing scheduled patients. With the presence of a basic lab and perhaps ultrasound and x-ray machines with appropriate technician, a large majority of acute illness visits could be handled.
If you go to an ER, you can expect to be there on average a few hours, depending on how busy the ER is and how many patients there are sicker than you (ER's work via triage, or the practice of treating the sickest patients ahead of less ill patients, and secondly in the order in which patients arrive). If primary care clinics operated with an urgent care service as well, higher volumes could be seen by the clinic and with costs less than that of a full capability ER.
Just some initial thoughts on the health-care system and potential areas of reform. This would in fact require there to be higher numbers of primary care physicians. The always avoided 21% cut in Medicare payments still looms, and so long as it does primary care will likely see difficulties as more new doctors pursue specialties that will ensure they can pay off their student loans.