Healthcare for the Uninsured: The Education of Postgraduate Physicians

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Dear Colleague,

Dr Atul Gawande, a contemporary medical author, recently compared the uninsured crisis in America to the insidious growth of a malignant tumor that slowly overruns the body.¹ He argues that the collective human psyche is prone to tackle immediate, pressing issues such as terrorist attacks or natural disasters but is less equipped to engage more slow-growing (and potentially more harmful) societal problems that can be left for tomorrow.

His analogy can be applied to the realm of postgraduate medical training. Almost every intern, resident, and fellow is an expert on tackling the "issue of the moment." Whether it is a severely septic patient with kidney disease, a violent drug seeker in the emergency department, or a psychotic patient who is bent on committing suicide?all young physicians are programmed to effectively respond to impending crises. During the course of residency and fellowship, most doctors work at least 80 hours every week, and many learn to thrive in the midst of chaos. Even with the pressures of learning a new specialty, taking care of dozens of acute patients, and satisfying one's superiors, new physicians somehow accomplish these tasks and simultaneously juggle the responsibilities of daily life. It is a rite of passage that has occurred for decades.

Over the course of a few years, as residents and fellows we become skilled at treating our "natural disasters"?the acute patients that we see each day. But what of the "slow-growing tumor" that hovers over our training? What do we learn of broad health policy problems, public health crises, and the increasing number of uninsured Americans? Are these issues important for us to tackle as physicians-in-training? And if so, what difference can a single resident or fellow really make?

You may be surprised to know that the problem of healthcare for the uninsured dramatically affects our training programs (and henceour medical training) every day. This simple fact underlies the reality that we cannot simply wait for our "tumor" to dissolve, but we must collectively realize that each one of us can truly help shape the healthcare system of tomorrow.

The Problem and Its Impact on Residents

It is no secret that the uninsured population of the United States continues to rise. According to the US Census report of 2006, more than 46.6 million Americans are without health insurance.² This is more than a 50% increase in those without access to healthcare compared with 1987, when the uninsured numbered about 30 million.² With little or no insurance, patients are forced to defer doctor visits and to stretch their medications over a longer period. Many conditions that could be easily handled by a routine outpatient appointment worsen, to become persistent emergency department visits and eventual hospital admissions. The Institute of Medicine estimates that uninsured adults have a 25% greater mortality risk compared with those who have health insurance.^3-5

Even those with health coverage are not immune; increased hospital costs are transferred to patients whose insurance companies are able to pay. As a result, insurers are forced to increase premiums on businesses that provide health benefits, which in turn shift these costs to many of their own employees. This is a vicious cycle that affects the providers and US healthcare recipients. As America struggles to curb the quickly escalating costs of our modern health system, an early step may be to begin providing access toall her citizens.

In addition to the millions of patients who live without access to healthcare, the uninsured crisis particularly impacts residents and fellows. Emergency care is refused to no one in this country, and it has been estimated that almost 40% of the nation's uninsured population is treated by postgraduate physicians who are trained in urban hospitals.^6,7 Although treating uninsured patients can be a deeply satisfying experience, these individuals often present with numerous complaints, making it almost impossible for residents to deal with all their significant medical issues in a single visit. As the numbers of the uninsured increase, the care given to this population by residents and fellows also rises, partly because the more senior and board-certified physicians cannot afford to treat new uninsured patients. In the past few years, Medicare support for medical education has declined, forcing many training hospitals to shift resources away from treating uninsured individuals in their facilities.⁶ In addition to denying treatment to patients, this outcome also robs many residents of the crucial educational experiences of helping diverse, underserved populations.

Potential Solutions

During the past half-century, many solutions have been proposed to deal with the problem of the uninsured.

Some of the avenues that have been explored on a national level are (1) employer-based insurance mandates, (2) individual coveragemandates, (3) expansion of public programs (including Medicare, Medicaid, and the State Children's Health Insurance Program), (4) individual tax credits, (5) single-payer models, and (6) nationalized healthcare that combines many of the above components. None of these potential solutions, however, is a simple "cureall" that is without compromise. As the 2008 presidential election cycle becomes more closely watched, many potential solutions will be brought forward. The tough part will be for our nation to discern which sacrifices we are willing to make.

But national solutions are not the only way. During the past 60 years, Presidents Truman, Nixon, and Clinton have had detailed health insurance programs brought before congressional committees. None of these plans ever made it through Congress. States have grown weary of waiting for national proposals and have begun to tackle the issue themselves.

In the past 2 years, Massachusetts and Vermont have passed laws using different mechanisms to achieve universal (or nearly universal) coverage of all state residents. In addition, many states, including Colorado, Illinois, Louisiana, Maine, Maryland, New Mexico, and Washington, have recently created commissions to produce recommendations on how to expand healthcare coverage. Other states, including California, Florida, Indiana, Minnesota, New Jersey, Ohio, Oregon, and Wisconsin, have made healthcare access a political priority and are currently working to develop their own customized plans to assist their respective populations.⁸ Local initiatives, such as the San Francisco Health Plan, are also taking hold around the country, as counties and cities decide to target various populations in their own communities.⁹

How Can You Get Involved?

Every resident and fellow in America can make a difference. Whether it's through participating in policy internships, lobbying local and national politicians, or simply educating yourself, the issue of the uninsured must remain a "hot topic" in our lives. In a 2002 survey, more than 80% of medical students rated the expansion of healthcare coverage as important.¹⁰ But how exactly do we go about doing this? What can one individual do? With time at a premium, these are 3 areas in which you can make an impact.

1. Make "healthcare for the uninsured" a priority of medical education. A significant number of young physicians feel that health policy and public health issues are too often forgotten in their medical education. In the survey mentioned earlier, only 30% of medical students were able to accurately quantify the number of uninsured persons in the United States, with 40% underestimating the actual number.¹¹ To remedy this educational deficiency, every resident and fellow can begin by learning more about the broad issues affecting health policy. The American Medical Association (AMA) Resident and Fellow Section (RFS) has created the HealthPolicy Education Initiative?an up-to-date list of presentations that outline current topics in public health. These can be used for education or can be given at a "noon conference" in any department. It is an easy way to begin to broaden residents' understanding of the issues and can generate new opportunities for involvement.

But simply educating a minority of postgraduate trainees may not be enough. As Dr Rishi Manchanda astutely argued in a recent op-ed article, residency programs must prioritize public health issues (eg, the uninsured) to teach young physicians about how to empower underserved patients to access healthcare.⁷ This innovative change in medical education will come faster if residents and fellows begin to demand it. Talk to your program director, and talk to the leading physicians in your department; they are likely just as concerned about this issue and would be more than willing to integrate new changes into your hospital's postgraduate education. Your initiative will allow you to leave a legacy that may serve to be a model for others around the country.

Many opportunities are available for you to participate in 2- to 4-week programs that can expose you to the intricacies of health policy and how current decisions are being made. Information about national fellowships can be found at the AMS-RFS website,¹² and local opportunities can be created with your state medical society.

2. Lobby our leaders for reforms. Residents are on the front lines of delivering healthcare to the uninsured in urban centers. Often, postgraduate trainees are the first to observe how the lack of healthcare access can have disastrous consequences, such as inoperable cancers, serious complications from sexually transmitted diseases, or long-term psychiatric conditions. The dramatic situations that young physicians witness cannot be underestimated, for these vignettes can mobilize public opinion and thus prioritize the issue in legislative bodies throughout the country. Representatives and Senators place a high value on educated and prepared constituents who are passionate about specific issues.

Many opportunities are available for you to speak to your local, state, and federal leaders, and many of these events are sponsored by the AMA or by your medical specialty society. Do not be deterred by the lack of younger physicians at these meetings; this simply makes your voice that much more important. Residents and fellows provide new perspectives and can bring fresh new ideas to the table. After all, our generation may be dealing with the issue of the uninsured for the duration of our careers.

3. Integrate underserved healthcare into training programs. Some have argued that care for the uninsured can be formally integrated into current training programs. Although such change may be the most arduous, it is likely to have a more immediate and direct impact on underserved populations. Many primary care specialties offer opportunities for their trainees to participate in community-based health clinics that provide free healthcare to hundreds of patients in local underprivileged areas. Allowing residents to spend a portion of their required clinical time in these areas can provide care to hundreds of people, as well as further promote resident education.

Convincing a program director can be easier with help from other local initiatives. Often, major urban centers have free health clinics dispersed throughout the city; cooperating with them to provide one trainee for one evening each week can dramatically increase the number of patients they are able to help over the course of one year. Creating such a program at your own hospital would be yet another way for you to leave a legacy that others will follow.

The time to make a difference is now. Join us in the fight to educate others and to eventually eradicate the problem of the uninsured in this country. Let's start cutting away at the "tumor" before it becomes any worse.

Sunny R. Ramchandani, MD, MPH

Chair, Resident and Fellow Section

American Medical Association

References

1. Gawande A. Can this patient be saved? New York Times. May 5, 2007;sect A:13.
2. DeNavas-Walt C, Proctor B, Lee C. Income, poverty, and health insurance coverage in the United States, 2005. In: Current Population Reports, P60-231. Washington, DC: US Census Bureau; 2006.
3. Institute of Medicine. Coverage Matters: Insurance and Health Care. Washington, DC: National Academies Press; 2001.
4. Institute of Medicine. Care without Coverage. Washington, DC: National Academies Press; 2002.
5. Institute of Medicine. Hidden Costs, Value Lost. Washington, DC: National Academies Press; 2003.
6. Fletcher A. More residents treating uninsured patients. Denver Business Journal. May 6, 2005. Available at www.bizjournals.com/denver/stories/2005/05/09/story5.html.
7. Manchanda R. Teach healthcare, not just medicine. Los Angeles Times. April 9, 2007; sect A:13.
8. National Conference of State Legislatures website. 2007 bills on universal health care coverage. Available at www.ncsl.org/programs/health/universalhealth2007.htm.
9. Cover the Uninsured. Health Care Coverage in America: Understanding the Issues and Proposed Solutions. Alliance for Health Reform. March 2007. Available at www.allhealth.org/publications/Uninsured/Health_Care_Coverage_in_America_2007_54.pdf.
10. Huebner J, Agrawal JR, Sehgal AR, et al. Universal health care and reform of the health care system: views of medical students in the United States. Acad Med. 2006; 81:721-727.
11. Agrawal JR, Huebner J, Hedgecock J, et al. Medical students' knowledge of the US health care system and their preferences for curricular change: a national survey. Acad Med. 2005;80:484-488.
12. American Medical Association?Resident and Fellow Section website. Available at www.amaassn.org/ama/pub/category/15.html.