An interview with Mark S.,* an Emergency Medicine resident, who describes himself as a physician in training to be an emergency medicine doctor. 

We talked in the lounge of a residence hall on his university’s campus, since Mark was the EMS resident on-call and needed to be available on campus if he received a call on his walkie-talkie.  He warned us when he got to the interview that he might be called away in the case of an emergency.  During the interview, we talked about the types of patients he sees and if he believes the ACA will change that, about the shortage of general practitioners and why he believes there is one, and his thoughts about the future of the medical field.

 

Mark said he has not been involved with Enroll Kalamazoo, and really doesn’t know too much about the implementation of the Affordable Care Act in Kalamazoo.  He states that the majority of the patients he sees in the Emergency Room are uninsured, so they could be in the demographic that will be newly insured by the ACA:

“No patient has specifically told me that they were recently insured through the Affordable Care Act, but I assume there are probably some…but I have no idea the numbers.  As the emergency doctors themselves we’re not really involved in kind of taking that information from the patients, but we do know often times which patients are uninsured or Medicaid or things like that.”

He then goes on to explain basic policies of the emergency room, and that by law they are required to stabilize anyone who walks through the door, regardless of if they have insurance:

“Basically whether or not a patient is insured, the emergency room is required by law to see that patient and stabilize that patient, regardless of their ability to pay or provide means of payment.  So if a patient does not have a way to pay, they will still get the same medical care as a patient who can pay but the hospital doesn’t see any money for that. So often times in order to make up for that, that’s kind of what drives up the costs of medicine for every body else who can pay, so that creates a lot of problems.”

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With the growing number of people who will now be able access primary care, there is a concern about a possible shortage of primary care doctors in the medical field.  For many medical students, going into primary care is not an enticing option, especially with the higher anticipated work load resulting from more ACA insured patients:

“Knowing about the shortage in primary care physicians, and the amount of work they are going to have to do in the coming years, especially with the Affordable Care Act coming down the pipeline, was one of the reasons I decided not to do primary care, cause they’re already overwhelmed, but they’re going to be absolutely swamped.  And, they have to see their number of patients throughout the day. Emergency medicine, I do shift work, so I work for 8 hours and I’ll see whatever comes through the door for 8 hours, but I don’t have a set list of patients I have to get through in a day.  And you probably couldn’t pay me enough to do primary care with the amount of work they have to do.  I mean you probably could pay me enough, but that’s part of the problem, is that they don’t get paid well.  They probably won’t get paid much better, and they’ll have to see a lot more patients.”

Mark says that some federal programs help with loan payoffs from medical school for those who go into primary care, but Mark says that many of them require working in a hospital specified by the government for five or six years and could lead to being placed “somewhere in the middle of nowhere.”    He says it is not really easy to decide to take the risk of random placement to receive scholarships for primary care, especially when choosing another specialty may have a higher salary overall:

According to Mark, “You have to pay just as much money to become a primary care doctor… and then end up making a quarter of what a surgeon makes…as much as there is a perception out there that physicians should go into this just because they want to help people, and honestly almost everybody that is why they go into it, but when you get out of medical school, and you’re looking at what you have to pay back and what you have to make in order to pay that back, it is overwhelming. And the primary care specialty itself is one of the lower paid specialties…it’s pretty tough when you are looking at that bill at the end of medical school and you are trying to decide which specialty to do.  Even if you love primary care, it’s pretty tough to make that call.  It’s not like it was 30 years ago when people got out of residency or medical school and your loans, everybody had them, but they were manageable and reasonable amounts of money.  You are basically graduating medical school with a mortgage”

Mark suggests that primary care could be more enticing and possibly help counteract the primary care doctor shortage if they were paid more or had their loans forgiven after medical school.

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While the Family Health Center is an option for health care for those who do not have insurance, many patients still choose to use the ER as their primary place for treatment.  Some of this is due to the fact that many people want their ailment treated right away, instead of having to wait a few weeks for an appointment with their primary care doctor.   As Mark describes it:

“The Family Health Center is overwhelmed.  They have to see hundreds and hundreds of patients a day…and patients don’t want to wait to see their doctor….it’s a two-fold problem…you have patients who don’t have insurance, so that’s a huge  problem, so they come to the emergency department.  And you have patients who do have insurance, or at the very least are plugged in with something like the Family Health Center, but they have a problem that they think needs to be seen very soon, but their doctor doesn’t think it needs to be very soon, so they come to the ER instead of just waiting to go see their doctor.  You hear that all the time, ‘Oh I have an appointment in two weeks but I didn’t want to wait’, so they come to the ER.   And so we become their primary care doctor to help with their chronic medical problems.  That’s an issue…and that’s a mindset issue…I don’t think that’s anything the government can help with.  That’s just people don’t like to wait anymore to see their doctor, they think they need it now.  And that’s going to be one of the problems here with more people insured, is that…more people insured but there’s not more doctors.  So that’s going to make it even harder for people to come in and see their primary care doctors”

Mark believes that prevention is a key to addressing the increase of newly insured patients:

“Prevention is going to be key…and you don’t always need a doctor to be the one to help with prevention, so hopefully that’s something where they can utilize nurses, physician assistants, and things like that to help with too.”

He goes on to emphasize the need for other health care professionals, such as physician assistants or nurse practitioners, to fill in the gaps in primary care, especially since he believes there will not be a surge any time soon in medical students choosing primary care as their specialty:

“There has to be [a higher demand for people like physician assistants and nurse practitioners]…right now that seems to be the only way to fill the gap, cause medical students don’t want to do primary care.  For a lot of reasons…the reasons are financial, I mean you graduate right out of medical with $300,000 in loans, and primary care reimbursement just doesn’t cut it.  There’s prestige issues, like it or not, people want to be the plastic surgeons, they want to be the orthopedic surgeons, they want to be the neurosurgeons cause there’s more prestige to it.  And there’s lifestyle issues.  Primary care, just, it’s a lot of hard work, it’s a grind day in and day out, and a lot of people don’t like that lifestyle.”

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Mark recognizes one problem that may occur with giving more care responsibilities to medical professionals other than doctors: many people prefer seeing a doctor over a physician or a nurse practitioner.  He feels that the mindset of needing a doctor for everything, especially primary care or preventative needs, has to be addressed and changed to meet this growing need:

“We already have that trouble [that people want to see a doctor over a nurse practitioner or physician assistant]…And I think it’s gonna be one of those things where you’re going to have to say, ‘Sorry, oh well, this is what you get’…you’re right they’re not doctors, they think differently than doctors, and they have a different kind of training than doctors, but for primary care issues that are your basic ‘How’s your blood pressure?’, ‘How’s you diabetes?, ‘ How’s your cholesterol?’,  I think despite the fact that people want to see a doctor for that, people are going to have to start getting comfortable with the idea that they are not going to be able to see their doctor for that.  For more complicated issues, [like] cancer, strokes, heart attacks, start seeing doctors for those types of things, but for your primary care type issues, it may not be your doctor any more.  And I think that’s just going to be one of the things that results from the aging population and not many people want to go into primary care…it will be a culture change.”

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While primary care may not be the most enticing specialty in the medical field, Mark emphasizes that there are some great primary care providers in Kalamazoo.  He says there are some that he can call up from the ER when one of their patients come in and, “They know exactly who you are talking about and exactly what’s going on because they have those good relationships and they work hard to make sure that that’s the case”.  But Mark feels that with the number of patients primary care doctors are going to have to start seeing to respond to the higher demand, as well as make a good income, the same level of continuity of care is not necessarily a reasonable feat.

Mark states that he doesn’t see repeat patients very much in the ER setting, and that they don’t have the same doctor-patient relationships and systems like primary care does.  Some of this is because ER medicine does not provide continuity of care.    The ER’s main focus is on stabilization by treating the present issue, and helping the person find resources for long term care or other less pressing or chronic ailments outside of the ER,“We do not have the time in the emergency department to deal with everything in your past medical history.  We have to deal with your presenting complaint.  It is a different type of medicine; it is not primary care medicine.  So for people to try to use it and utilize it in that way…they are not going to get good primary care.  Cause we are not trained to provide primary care”.

Mark said he feels that there is a very small set of patients who come to the ER and don’t seem interested in trying to find insurance that may give them access to more primary care resources or a primary care doctor:

“There are patients that we see for a variety of reasons that are uninsured, and for whatever reason, whether it’s they don’t feel like it, don’t want to, or they honestly don’t know and need help with it, we see those patients” said Mark.  “Often times we try to get a social worker involved to help those patients, but a lot of our repeat visitors just aren’t really interested in signing up or getting help with their ability to pay for medical care.  So they just continue to utilize resources without paying for it…it’s not a huge volume of patients who are like that, but they exist.”

Among  other deterrents to getting insurance, Mark notes that young people may not want to buy something that they feel they will not use very often.  He says it has been hard to convince friends in his age group to buy health insurance.   He feels that unless a person has a trauma or “some wacky unexplained disease” many in the young adult age demographic don’t understand why they need to dole out a lot of cash for health insurance.  This could be due to the fact that the US health care system does not emphasize preventative care and that many young adults may only seek medical care in an emergency or when they are really sick, instead of getting yearly screenings when they are healthy.

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Mark says that for most individual physicians, there is no real explanation or training about how the ACA could impact them: “To be honest with you I have no clue what my responsibilities are [in regards to the ACA] or how they are going to change with the Affordable Care Act.  There might not be any change for me personally, just working in the pit and seeing patients…the only change I may see is a higher patient volume, and maybe a lower patient volume.  No one really knows yet…most doctors are just seeing what they see [about the ACA] on the news, just the same as the rest of the population.  I have hopes that it does good for people, but I agree that we probably need more education about what it means for the individual physician.”

 

Mark ends the interview on a  hopeful note.  He says he feels the future of the medical field is bright and that there are dedicated and talented people coming into the medical field who want to make a change.  He believes that everyone is trying to do the right thing and do the best they can give to give quality care and expand health care access.  He says the difficult part is that politically everyone has different opinions on the right way to lower the cost of care and make it available to more people.   He seems excited for his future in the medical field and curious to see the long term effects of the ACA on patients and providers in the medical field.

 

 

 

*names have been changed to protect confidentiality 

 

photo from fox10tv.com