Wednesday, September 9, 2009

Summer of Work Exposes Medical Students to System’s Ills -

This summer, medical students from the University of Washington took a long look under the hood of the health care system they are about to inherit, and many returned to campus last week with their eyes wide open and their idealism tempered.

Jacob R. Opfer shadowed a pediatrician in Gillette, Wyo., who sometimes saw 45 patients a day, allowing little more than five minutes a visit. Amanda I. Messinger worked with a family practitioner in Kodiak, Alaska, who eschewed electronic medical records, leaving staff members to decipher histories from illegible script. Jens N. Olsgaard manned a community health center in Butte, Mont., where four of five patients had no insurance, and treatment was often structured around ability to pay.

The students learned not only to deliver babies and suture wounds, but also to order unnecessary tests as protection against lawsuits, to hector specialists into seeing Medicaid patients, to match patients with prescriptions on Wal-Mart's $4 list. And they saw firsthand what Mr. Olsgaard called "a tidal wave of chronic disease" — diabetes, hypertension, obesity, depression — that left many questioning how much any one physician could really accomplish.

"I often wondered what we were actually doing to help people," Mr. Olsgaard said. 

Not surprisingly, many concluded that it was critical to reorient a reimbursement system that had profoundly devalued primary care and prevention.

"You have to reimburse for primary care," said Ms. Messinger, 24, who grew up in Snohomish, Wash. "You have to reimburse doctors for spending the time to catch things early, to manage chronic things, to be able to offer people treatments they can afford early instead of waiting until there's a catastrophic surgery. It's pretty simple."

For 21 years, the University of Washington School of Medicine has dispatched its rising second-year students across the Northwest to provide primary care in rural or underserved areas. The monthlong program is elective, but a record number of students took part this year — 117 from a class of 216.

The school has a cooperative agreement to train medical students from Alaska, Idaho, Montana and Wyoming, none of which has a medical college of its own. The summer program is one of several vehicles, along with loan forgiveness enticements, designed to lure students back to their home states to practice in areas with a shortage of primary care givers.

This year, the students set out as negotiations were intensifying in Washington over wholesale changes to the health care system they will soon be joining. Whether there will be improvements to the system remains to be seen, but few students returned thinking there was little to fix.

Payment policies that leave primary care providers struggling to cover their costs have pushed family practitioners and internists into early retirement, and discouraged newly minted doctors from replacing them. To make a living, and chip away at immense educational debt, general practitioners often find they must churn patients and work long, unsatisfying hours.

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