Reflections, commentary and analysis from Consortium for Science, Policy and Outcomes at Arizona State University.
A middle-aged man with a dialysis catheter to replace his failed kidneys tells the doctor, “I’d rather take this thing out and go on my own…rather die than come here.”
The U.S. healthcare system is notorious for incorporating new technologies to a greater extent than other industrialized nations, with higher costs and worse outcomes. Despite the U.S.’s status as an international leader for new healthcare technology development, many Americans are unable to access these novel therapies – or any therapies at all – due to lack of insurance or access to health care services. Efforts to reform the disparate system are fraught with political fervor, from Lyndon Johnson’s Medicare in 1965, to Hillary Clinton’s failed efforts in the 1990s to achieve universal health care, to today’s ongoing battles over ObamaCare. The system is broken, but cost and outcomes statistics can only convey the brokenness in abstract strokes.
Peter Nicks’ 2012 documentary The Waiting Room takes us inside the Emergency Department at an inner-city public hospital to witness the reality of health care in America, from inside the safety net of this complex broken system. As we follow the experiences of patients, physicians, and staff at Highland Hospital in Oakland, CA, two tracks of the same story emerge. Patients are frustrated as they wait – for hours – to receive medical attention for a variety of ills. Physicians and other staff are frustrated as they try to maneuver through a labyrinth where little moves, and they recognize that sometimes, in order to do good for their patients, they must break the system just a little bit further.
For patients, the Emergency Department is an individual experience – they arrive to get treatment from a doctor. However, for health care providers and staff, the Emergency Department is part of a larger system designed to function at the population level, and not engineered to the level of the individual. Nicks pinpoints the problem with the safety net of American health care system: it is designed for populations, but needed for individuals. As we watch a clerk attempt to explain the triage and bed management system to the family of a patient who has a bullet lodged in his hip, we feel the deep divide between the patient and the system.
Patients and providers alike acknowledge that the public hospital – and this hospital in particular – is a destination of last resort. One physician, talking to a patient who was turned away from a private hospital asks, “You don’t have insurance, so they told you to come here?” A father who brought his sick daughter to be treated lamented that the Emergency Department is for “when you don’t have the means to do it yourself the right way.” Another woman explained that she had been laid off and does not have health insurance. “Other than that, I would’ve went [sic] right to Alameda hospital.”
Nicks takes pains to highlight the efforts of medical staff to care for each patient as an individual, despite the inadequacy of the system. “You do everything so you do not miss a serious or life threatening illness or injury.” But the tools at their disposal – CT scans, intravenous fluids, extensive panels of blood tests – incur even more costs to be absorbed by the segment of the population with the least ability to pay for them. We watch the pained conversation between an underemployed middle-aged carpetlayer who misses the income qualification for free care by $400. He already can’t afford housing and food for his family, and now has multiple bills from visits to the Emergency Department because he cannot secure an appointment in the outpatient clinic. “I don’t know what else to do really. I bought a lotto ticket.”
We get the sense that the unseen clinic – the system’s designated resource to provide chronic and non-emergency care – is faced with the same kinds of problems as the overcrowded Emergency Department, but patients can’t even access the clinics. That is the problem for the man on dialysis. He had a catheter implanted in his chest for receiving dialysis in order to keep him alive since his kidneys have failed. But there is no spot for him in the dialysis clinic. After surgeons implanted the catheter, “they told me to come here for my dialysis.” When he arrives, he joins the throng in the waiting room for hours. By the time he sees the doctor, he is shouting, “This @*&% is very *&%$@!# frustrating for me.” He is literally tethered to the Emergency Department for life support.
As patients accumulate in the waiting room, the already byzantine system must periodically halt its tortured progress to make room for a trauma – a true emergency. One of the doctors explains that when the ambulance arrives “literally twelve to fifteen people stop what they’re doing to focus on the trauma.” In one case, we observe a 15 year-old gunshot victim who is eventually pronounced dead.
But there is no time to mourn. The Emergency Department continues to burst with people who wait for hours and even days. One doctor says, “If I refill his medications, he may not come back to sit in the waiting room next month.” And certainly that is the goal. But, as The Waiting Room shows us, there is no designated waiting room for chronic health care.
Heather Ross is a PhD student in the Human Dimensions of Science and Technology program at ASU. She earned her Doctorate of Nursing Practice from ASU in 2010.