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The Waiting Room - What Are You Waiting For?

By Dr Pramita Kuruvilla
.

Have you ever had to wonder what happens if you lose health insurance?  Have you ever needed to seek care in an emergency department?  What options exist for those without work-based health benefits?  Can you imagine going to a hospital’s emergency department if you don’t have health insurance? 

Peter Nicks’ thought-provoking documentary “The Waiting Room” sets out to give us a glimpse of that public hospital world, all too familiar and worrisome to certain members of our society and completely foreign to others.  Highland Hospital in Oakland, California, is a safety-net institution with a bustling Level II Emergency/Trauma Center which serves a large and diverse population.  The filming took place over five months in 2010 and was edited to depict events of a “typical” day in the hospital’s emergency department/waiting room.  The real patients who share their experiences are underserved, un/under-insured, vulnerable, and sick.   Many of them are hard workers who are trying to make ends meet, trying to get in to any medical system that will take them, and trying to achieve health or, at the very least, manage their illness to allow a semi-functional life.  They come to the ER from many backgrounds and with needs ranging from true emergencies (gunshot wounds and severe blood infections) to not-trivial-but-not-urgent issues (loss of insurance, chronic pain, and medication refills for long-term disease).   In short, many of the stories were from people needing primary continuity care who had no other options and so they showed up at the hospital of last resort and were forced to wait their turn, often for hours.

With the passage of the Affordable Care Act and the events of the recent elections, we have reduced or removed considerable obstacles faced when obtaining health care.  But, as the film depicts, there are still barriers and they loom high.

Assuming you believe in societal safety nets, social justice, and serving the underserved, the Affordable Care Act is a good thing, but it creates a demand for primary care in a national context of a primary care supply deficit and fails to adequately address the urgent need to bolster the primary care infrastructure.  This means that people will still continue to occupy waiting rooms like the one at Highland.  Patients will be waiting.  And waiting.  And waiting.  There are simply not enough doctors to guarantee available appointments.

What will happen in 2014?   The fight for change isn’t over.  We desperately need to recruit and retain primary care doctors.  Despite the fact that the ACA is here to stay, how will the nation support providing primary care services for all?  Recent studies have shown that Medicaid expansion leads to reductions in mortality.  Yet, that also means that we have to now grow our country’s capacity to enhance existing primary care structures and lure many new physicians to enter (and more importantly, to stay) in primary care.  Otherwise, the waiting room will only become a bigger and slower place.  Several articles that touch on many reasons for the primary care crisis: disparaging attitudes in medical schools, financial burdens from high student loans and low primary care reimbursement, misallocation of resources, the overwhelming expectations in the face of ever-increasing medical knowledge, paperwork paperwork paperwork, and high rates of burnout among front-line clinicians.  Some people can say that doctors are lazy or greedy; others can argue that the burdens of primary care are too demanding as things currently stand.  Regardless of which side clamors the loudest, we need to find a way to have more primary care doctors who can build longitudinal relationships with their patients, not have brand-new patients every 15 minutes due to frequent changes in insurance coverage (and the converse for the patients as well: to not have brand-new physicians at every visit because their last one left due to early retirement or leaving the system).

What options exist for those without work-based health benefits?  The non-reassuring reality is that we are a pink slip away from finding out. 

As a supporter of healthcare reform, as an employee at a safety-net institution, and as a physician committed to global underserved health, this film touched me with its elegant portrayal of the common experiences shared by patients and clinicians at most public hospitals.  The patients are sick, and they are waiting for hours to receive care, and for the most part they are grateful because if the public hospital didn’t exist (and indeed many safety-net institutions are going bankrupt after decades of underfunding), these patients would have no options, not even a last resort. 

For more information, please refer to the following:

The Film and Emergency Room Overcrowding:

“The Waiting Room” Film Website (with links to upcoming film screenings)

Filmmaker Peter Nicks’ Opinion Article in The New York Times: “Waiting for Health Care”

Pauline Chen’s Doctor-Patient Column in The New York Times: “When Hospital Overcrowding Becomes Personal

John Maa’s “The Waits That Matter”

 

Medicaid Expansion:

Jonathan Oberlander’s “The Future of Obamacare” in last week’s New England Journal

Benjamin Sommers’ “Mortality and Access to Care among Adults after State Medicaid Expansions”

 

Primary Care Shortage:

Doctors for America on how the Affordable Care Act is beginning to address primary care shortages

Thomas Bodenheimer and Kevin Grumbach’s Perspective Article in the New England Journal of Medicine: “A Lifeline for Primary Care”

Robert Steinbrook’s “Easing the Shortage in Adult Primary Care — Is It All about Money?”

Pauline Chen’s Doctor-Patient Column in The New York Times: “Primary Care’s Image Problem”

Tait Shanafelt’s recent article in the Archives of Internal Medicine “Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population”

 

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