"The Emergency Department is the canary for the rest of the healthcare system."
An interview with Dr. Graham Walker about working as an Emergency Medicine Physician in the United States of America today | by Kimberly J. Soenen March 23, 2025
Dr. Graham Walker is an Emergency Physician, writer, and a developer. He graduated from the Stanford University School of Medicine in 2008, then did his residency in Emergency Medicine at St. Luke’s-Roosevelt Hospital from 2008 to 2011. He earned a BS in Social Policy from Northwestern University. His academic interests include medical education, medical simulation, and clinical informatics. He lives in San Francisco with his husband AJ and speaks fluent Spanish and French. I met Dr. Walker 23 years ago in Chicago while working on Single Payer Universal Healthcare policy together. I reached out to him a few weeks ago to catch up and see how Emergency Medicine professionals and our Emergency Departments were doing in the current political climate.
Soenen: Why did you become a physician?
Walker: I became a physician because I liked the idea of helping people and mixing science with the art of medical practice. I considered other fields in technology and policy where I am also passionate, but figured I could do those as hobbies, but medicine could not be a hobby.
Soenen: Where do you work now?
Walker: I work at Kaiser Permanente San Francisco Medical Center as an emergency physician. I work for The Permanente Medical Group, which is the physician arm of Kaiser Permanente for Northern California. We are the largest physician-owned and run medical group in the United States!
Soenen: Moral Injury, Moral Harm and burn out are sweeping the medical professional field and Healthcare-adjacent jobs. What prevents burn out for you and what keeps you motivated, engaged and loving your work?
Walker: The people. It’s always the people. Whether it’s a kind, appreciative patient or an incredible colleague or a dedicated nurse, it’s the incredible other human beings that I get to interact with.
Soenen: What is the aspect of your job that keeps you going through the incessant political and policy whiplash the American system of government imposes on medical care professionals?
Walker: In the context of legislation, one helpful law is the Emergency Medical Treatment and Labor Act (EMTALA). It ensures public access to emergency services regardless of patients’ ability to pay. The law transformed Emergency Care when it was passed in 1986, but is desperately in need of an update.
Soenen: What is the best part of your job?
Walker: There’s a ton of great parts of my job. One of the least known outside of emergency medicine is fixing a nursemaid’s elbow. The elbow is a really loose joint, especially in toddlers. Parents often come in panicked, “my daughter won’t move her arm.” One small simple maneuver later, they’re magically using their arm again like nothing happened. Makes you feel like a magician, parents are extremely thankful, and they’re out the door in 15 minutes.
Soenen: What are you seeing now in your hospital Emergency Department that you did not see eight years ago, and why?
Walker: I would say the two biggest differences are the normalization of Emergency Department boarding and the extreme elderly population growth. I’m sure the two are related.
Nonagenarians and centenarians used to be very rare, to the point that I would ask every single patient with their secret was to longevity. Not anymore. I now routinely see several patients over the age of 90 years old during every shift, and I would not at all be surprised to see more than a third of our Emergency Department filled with patients over the age of 90 on some shifts. They are, of course, in various stages of health or illness, especially by nature of them being in the Emergency Department.
The cause of boarding is certainly multifactorial, but my understanding is that it’s fundamentally due to problems with flow through the healthcare system:
· You’ve got more patients seeking Emergency Department care due to the flaws of the rest of the healthcare system, and more patients getting outpatient tests, treatments, and procedures, meaning that those with side effects and complications will be routed to the Emergency Department as well;
· You’ve got more and more restrictions and denials from (Commercial Health Insurance industry) insurers making it harder and harder to admit patients because they don’t meet strict “criteria” which minimize and overlook the complexity of human biology and individual factors; this leads to patients who can’t go home, but can’t get admitted, so they sit in an Emergency Department;
· You’ve got frailer and sicker patients who are admitted to the hospital, so even after their acute medical or surgical problem is normalized, fixed or addressed, they are more likely to need rehabilitation services like Skilled Nursing Facilities (SNFs) and Nursing Homes, and cannot go directly back to their home after the hospital;
· You’ve got fewer (or at least not more) SNF beds to deal with these increased needs… so these patients back up in the hospital, which means they back up in the Emergency Departments. But the Emergency Departments aren’t allowed to say “sorry, we’re full” to anyone, nor are we allowed to tell people estimated waiting times… so it’s a vicious cycle.
This is not even to mention the fact that many ER doctors retired in the past six years and many ER nurses also retired or found less stressful work that paid the same amount of money. Decreased supply and increased demand should cause prices to go up according to Macroeconomics 101, but that’s not allowed in healthcare.
“Right now, I’m not convinced we actually know what our values are, nor do we follow them.”
—Dr. Graham Walker
Soenen: Do ER docs have to deal with Denial of Care by Commercial Health Insurance industry companies, or are you buffered from that denial conversation because you are in triage mode?
Walker: We don’t have to deal with denials or prior authorizations the way that outpatient medicine does because it’s illegal to do prior authorization on emergency care. But, that certainly doesn’t mean we lack administrative headaches.
Emergency physicians often get pushback that a patient “doesn’t meet criteria” for admission to the hospital; we may have trouble arranging follow-up for our patients. We can treat, stabilize, and diagnose many things, but much of what we diagnose requires outpatient follow-up. We can put you in a splint for your broken leg, but that needs to be checked out by an orthopedist to make sure it’s healing well. That requires follow-up, and if a patient is uninsured, while the Emergency Department has to see them because of EMTALA law, the outpatient specialist does not.
Finally, the other “financial” challenge for emergency physicians and Emergency Departments is that some portion of our care is completely unfunded—as in, no one pays—or underfunded. The exact numbers of course vary from ED to ED and statistic to statistic, but I’ve seen numbers anywhere between 10-50%, and that every ER doc in the United States provides $100,000-200,000 of uncompensated care, on average, per year.
Soenen: What, of the many ongoing Public Health crises in the United States, is front of mind for you? Addiction? Diabetes drug toxicity? Mental Health? Housing? Chronic Illness? Sexual Violence? Health Literacy?
Walker: All of the above?
The Emergency Department is the canary for the rest of the healthcare system. We will always see whatever’s going on in society before anyone else. We are the place where patients go for help for literally anything. We’re a microcosm of every Public Health, medical, social, and societal problem in the United States.
During COVID, all of us could predict when the next wave or surge or variant had hit our communities because we’d see the cases rising before the official statistics got collected and reported. Like clockwork. “Hey, I haven’t seen any COVID in awhile, have you?” to “Wow! Three patients with COVID in the same shift, must be a new variant.”
Same with Monkeypox which is now called “Mpox.” I saw the surge happen before my very eyes in San Francisco, and also saw it go away, as well.
You know how there’s the “Waffle House Index” for natural disasters? We’re that, but for everything else in society besides the weather.
Soenen: Can you share with us one of your most fulfilling experiences with a patient in the Emergency Department where you were elated to learn what you thought was insurmountable became a success story because of trouble shooting, talent or will on your part?
Walker: I’ll keep it simple because emergency medicine isn’t always about incredible “life saving” — sometimes it’s just being able to help someone.
I had a young woman who’d been in Maui the prior week, then Tahoe (I know, what a life!) and had been having foot pain and swelling, to the point she had to stop snowboarding. I looked at the bottom of her foot and saw nothing there besides some redness. She limped in to see me. She had the faintest little red dot in the heel of her foot, and recalled that she thought she’d stepped on a pebble while on the beach in Maui. I grabbed my ultrasound and saw there was a foreign body in her foot. I numbed her up--the heel is a very hard area to get numbed!-- and made a small incision. I took me about ten minutes but I ended up pulling out a three-to-four-inch Kiawe tree thorn from her foot like I was removing Excalibur itself. Neither of us could believe it. We high-fived, I put her on some antibiotics after washing it out very aggressively, and sent her on her way. She felt a ton better.
Soenen: Can you share with us one of the roughest days in the Emergency Department when you did everything you could and the outcome was not successful?
Graham: I have to pass on that for now.
Soenen: Do you have advice to offer to medical residents?
Walker: Residency is the time to ask questions. The more the better. Why are we doing it this way? Why not that way? And, it’s the time for you to figure out what kind of doctor you want to be.
Borrow wording, phrases, and approaches from your favorite attending. See how one person handled a situation, and then see how another does. You get to shape yourself during residency — that’s the opportunity and the challenge, because after that, you’re the attending and will have to decide how to handle those same situations yourself.
Soenen: What are the qualities that make an exceptional Emergency Medicine physician and what are your strongest talents in this field? Innate or learned?
Walker: Flexibility, adaptability, and the ability to rapidly connect with patients— gaining trust and rapport. A lot of that comes from communication and being able to read the room quickly. Making a joke can make one patient feel a ton better by releasing some tension and anxiety, but can make another patient very upset that you’re not taking their concerns seriously.
I think you also have to be okay with uncertainty in medicine. Some of this is nature, some of it is nurture.
“I see more energy and activism from healthcare professionals around calling out the problems in the healthcare system than I’ve ever seen before. More engagement from those of us doing the work and seeing the patients will always be better than rules or policies or laws made in corporate conference rooms or bureaucrats who’ve never sat in our seats for a day.”
—Dr. Graham Walker
Soenen: We both worked together for the late great physician and human rights activist Dr. Quentin Young in Chicago. What is the best advice Quentin gave you when you were a young man?
Walker: I remember two.
The first is: “Medical training is the best behavior modification program the world has ever created.” I think he was warning me that I’d be forever changed. He was right. I can’t un-see or un-understand certain things in life anymore. They’re burned into my brain.
The second is: “Even the most heavenly program — underfunded — is hell.” You can take something perfect and decimate it very easily by not giving it the resources it needs. True of all sorts of systems — biological and man-made!
Soenen: Ready to be humanized?
Walker: All about it, yeah.
Soenen: Traditional scrubs or colored?
Walker: Some shade of blue. No black. Black is bad luck.
Soenen: Clogs or sneakers?
Walker: Worn-out gym shoes have become my new Emergency Department shoes.
Soenen: Haste, Harm-for-Profit, speed and greed? Or Single-Payer reform?
Walker: I’m not sure anymore what the fix is. I’m not sure it’s just Single-Payer. It might be — but we’re seeing challenges with health systems across the world, including Single-Payer systems.
Soenen: Artificial Intelligence and Health Tech or Hands-on-Body and good ole’ Primary Care?
Walker: I’m all for tools that augment the clinician. You always need the history and the physical exam. But let’s help make it easier for our doctors to make great diagnoses and get through their days with technology copilots.
Soenen: Thoughts on Senate Bill 1655 / The National (Improved) Medicare for All Act?
Walker: I think Senator Bernie Sanders (VT-D) is drawing crowds because he understands what people are facing. That’s the biggest boon for SB 1655.
Soenen: Favorite bands to exercise to?
Walker: Right now, Doechii.
Soenen: Jogging to blow off steam or…?
Walker: Walks in Golden Gate Park with my dog, or hikes in Mount Sutro Open Space Preserve.
Soenen: Favorite Sunday afternoon meal?
Walker: Maybe Burmese food or dim sum.
Soenen: Best medical film or hospital series of all time?
Walker: The Pitt, Scrubs, and Getting On.
Soenen: Hobbies that have nothing to do with medicine?
Walker: Video games, traveling, music theory and foreign languages.
Soenen: If you could submit three solutions to better our approach to, and model of, healthcare in the United States to Congress, what would they be?
Walker: Oof. I struggle with this a lot.
I think we could learn a lot from systems like Singapore, Australia, and France in terms of financing and how payments flow. Ultimately, I think we need to come to some agreement about what values we want from our healthcare system. If we want to focus on an ounce of prevention instead of a pound of cure, then let’s do that. Let’s pay for insulin. Pay for cheap generic drugs instead of expensive hospitalizations.
Right now, I’m not convinced we actually know what our values are, nor do we follow them.
Soenen: What are you hopeful about now?
Walker: I see more energy and activism from healthcare professionals around calling out the problems in the healthcare system than I’ve ever seen before. More engagement from those of us doing the work and seeing the patients will always be better than rules or policies or laws made in corporate conference rooms or bureaucrats who’ve never sat in our seats for a day.
ADDITIONAL RESOURCES
LISTEN
Once Upon a Time in an Emergency Room – Radio Lab
WATCH
The First Wave by director Matthew Heineman
READ
From Columbine to Corona: The Virus of Poor Public Health Policy in the United States by Kimberly J. Soenen - Tarbell
Viruses Have Historically United the World in Health Solidarity – In the Era of Misinformation and Divisiveness, Where Do We Go from Here? by Kimberly J. Soenen - Tarbell
What Does It Mean to Photograph the Pandemic? Colin Edgington on how images of COVID-19 attempted to capture the invisible
MENTAL HEALTH SUPPORT FOR MEDICAL PROFESSIONALS
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National Suicide Prevention Lifeline: 800-273-8255 (TALK)
Trevor Project Lifeline (confidential suicide hotline for LGBTQ+ youth): 866-488-7386
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