Future in the balance

Seth Harrer is spending a month in Omaha, completing a rotation in his orthopedics residency for the University of South Dakota School of Medicine.

But the Sioux Falls native is also keeping a sharp eye on Washington.

For Harrer and other students in the medical field, the health reform issue represents far more than a political debate. Whatever does – or doesn't – come out of Congress will have a profound impact on the careers of health care professionals who aren't even out of school yet.Harrer has been selected as a student delegate to the American Medical Association (AMA). He began his work as a delegate at his first AMA meeting in June, which featured extensive debate about health reform.

Harrer quickly learned the complexity surrounding the issue."Reform means different things to different people," he said.

Two delegates and two alternates are elected in each of the seven AMA regions of the country. Harrer will help represent medical students in 14 states, primarily in the Great Plains, Rocky Mountains and West Coast, along with Alaska and Hawaii.

"I hope I can assist with positive changes in the health care field," he said. "Our top priority must always be to do what's best for the patient."Harrer said working with medical students from around the country has given him valuable perspective on health care.

"One of the reasons why I got involved with the AMA (is that) it's one of the larger groups of physicians," he said. "They are really active with health reform. They are in on the big discussions and trying to guide this reform."

Harrer thinks some sort of legislation will come out of Washington, possibly this year."From hearing (President) Obama speak, he sounded pretty eager to get something through," he said. "I could see something in the near future."

The time seems right for reform, but the process needs a great deal of input, Harrer said."I believe there will be something much sooner than later," he said. "The more people you have involved to guide that reform, the better off it will be."

For now, medical professionals are waiting for a clearer picture of proposals coming out of Washington, Harrer said."I think a lot of the questions have to do with the small details," he said. "We will know a lot more after the AMA national meeting in Chicago."

Medical students, and others in the field, are concerned about patients falling through the cracks, Harrer said."A lot of the people would love to see access to health care and access to health insurance," he said. "But the pathway to get there is fuzzy and difficult."

A number of the AMA delegates are wary of the government's role in health care, Harrer said.He described the so-called public option as "fairly vague."

"At our last annual meeting, when we brought up the public option, nobody knew what that meant," he said. "Some people were afraid of the entire thing."

Harrer said he's not surprised the nation has between 47 million and 50 million uninsured people."Sometimes, they don't get the care that they need," he said. "That's why health reform will hopefully change that, so you aren't losing loved ones because they don't have the money or insurance to get the health care that they need."

The AMA also strongly supports tort reform for malpractice, which contributes to soaring medical costs, Harrer said.While insurance coverage has dominated debate, Harrer said he's concerned that another major area – the lack of physicians in rural areas – has gone unaddressed.

"There is a need for physicians, not only in South Dakota," he said. "From what I have seen from attending meetings, a lot of states have shortages."

The shortage promises to worsen as more doctors retire, baby boomers age and the population grows, Harrer said. And that's not counting the millions of uninsured who would join the patient rolls under health reform, he said.

"If you open the floodgates (under reform), it can clog up the health care system," he said. "The fear in my mind is that there won't be enough of us physicians to get done what needs to be done."

Medical students find a number of huge obstacles in beginning their careers, and health reform provides another challenge, said USD Medical School professor Evelyn Schlenker.

"I think some medical students have $140,000 in debt when they finish school. They're thinking, 'I have got to make that up,'" she said. "They are starting up their medical practice in debt, then they have medical malpractice insurance. And they have to set up and keep track of insurance policies and billing. It's an expensive proposition."

While many medical students go to urban areas for higher-paying careers, the number who opt for rural living remains strong, she said."I think the proportion of medical students who come back to South Dakota is not bad. It's something like 40 percent," she said. "Then you have some of them go to surrounding states so they can stay in the area. They like the quality of life in the Midwest."

South Dakota is taking the right steps toward keeping medical school graduates in the state, Harrer said."Getting the four-year medical school was big. Next, we need to increase the size of the medical school's classes," he said. "One of the big issues is getting more residencies in the state, and they are moving toward it. Those students who do a residency in an area tend to stay there."

USD has added a new residency in pediatrics, which has already become an excellent program, Schlenker said. The residency should help keep doctors in the state, she said.Rural areas often lose young doctors, or fail to attract them, because of the long hours, heavy workload and isolation, Schlenker said.South Dakota's rural facilities have received additional personnel and resources with the growth of the Sanford and Avera health systems, Schlenker said.

"You have the advantage and the scale of changing how they practice medicine," she said. "If they want to get into major IT (information technology), electronic records or telemedicine, they have got some of the capabilities of doing it."

New doctors and other health professionals could also see changes in the way they are compensated, said USD law professor Mike Meyers.He pointed to the fixed income for physicians at Mayo Clinic in Rochester, MN. The arrangement is a move away from the "fee for service" system found in most medical practices.

The fixed-income arrangement depends on the health care system, Schlenker said."A number of health organizations do that besides Mayo. And Mayo is not just Rochester. They have clinics in Arizona and a branch in Florida," she said.

"I guess it depends, first, on what the salary is, and two, what kind of benefits they get and the things they don't have to pay for. It also depends on what kind of medicine they want to practice."Health reform could also bring about greater use of electronic medical records, said USD business professor Greg Huckabee.

The military has used electronic medical records since 1990, he said. The Department of Defense has offered its software free to health facilities since 2000."The private sector has turned down free software that is used for 24 million veterans and 2.1 million in uniform. (Health facilities) want the free market to figure it out," he said.

"Medical staff still do charting, where they take down blood pressure and weight, by hand. It's still going on in this day of automation, in this incredible day of palm pilots."As he begins his medical career, Harrer sees the need for a greater emphasis on patients taking personal responsibility for their wellness with good health habits.

"Only about 8 to 10 percent of the health of our nation is based on wellness in terms of information and personal habits," he said.Medical students are not the only ones struggling with the health reform issue, Schlenker said. She has taught a course entitled, "Is there a health care crisis?" focusing on changes to the system that would improve patients' health.

Such changes include more emphasis on better medical record keeping and greater communication between doctor and patient. Areas with doctor shortages will increasingly turn to physician assistants and nurse practitioners, she said.

She also sees an emphasis on wellness, alternative medicine and healthier lifestyles."You don't need health care for healthy people," she said. "If people remain well, it decreases your health care costs."Schlenker said she started the course so students understand the complexity of health reform and other issues.

"One of the major reasons I came here (to USD) was that I like to teach students," she said. "They are the leaders of the future, and I want them to be great leaders of the future."As for the national debate on health reform, Schlenker sees a need to move beyond partisanship.

"I think the center of this whole debate should be the patient," she said. "Now, it's the dollars and how much people are going to win or lose. It's scary."While the future remains uncertain, Harrer said he would consider spending his career in South Dakota.

"I think it's always an exciting time when you are starting a career in medicine," he said.

"I have no firm plans, but I would love to stay in the Midwest. A smaller community would be fine."Mount Marty College officials in Yankton declined to participate in this story, citing a decision not to comment on the health reform issue at this time.

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