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Growing Up in the Era of Work-Hour Restrictions

Danielle Jones

In 2008, the IOM study on resident work hours came out and in the years that followed the Accreditation Council for Graduate Medical Education (ACGME) subsequently implemented a gamut of “recommendations.”

As a medical student, I remember thinking it was a much needed change – why wouldn’t it be a good idea to improve patient safety and decrease resident fatigue?

Alas, as a newly minted intern growing up in the era of work-hour regulations, it’s become apparent that many of these changes may actually make life harder without achieving their main goal of improving patient care.

The 80-hour work week cap is fine; it’s been in effect on its own since 2003 and overall it seems to have made residency more humane. Most programs have found reasonable ways to limit work hours to this full-time-times-two amount, at least when hours are averaged over four-week periods.

However, the additional bullet point “recommendations” from 2010 seem to play out very differently in real life than they do on paper. Many of them seem to be arbitrary lines drawn in political sands hiding behind a facade of patient safety, but that’s another blog for another time.

So, what do the bullet point regulations look like in the hospital?

They look like: Interns can’t work 24-hour shifts. 

So, what used to be a two-and-a-half shift weekend turns into a four shift weekend. At a four intern/year program like mine, that means instead of two people splitting the weekends and having a post-call day after 24 hours on, one intern is committed to night-float six nights/week for a month while the remaining three interns take the three leftover weekend shifts.

The result: Fewer hours at a time in the hospital, but more working days in a row and more days/month away from your family.

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The Cost of One Wild Night

ticking clock
The clock read 9:30PM and in front of me was dozens of notes, PowerPoint slides, and practice exams to review before 8AM.

The all-too-familiar finals week all-nighter beckoned, and though I’ve had my fair share of experiences with studying until the sun rose, I decided to forgo the typical mug of coffee and take some over-the-counter caffeine pills instead.

My friend proclaimed that they would help more than any energy drink would. I laid out all my exam materials, popped in a couple caffeine pills, and strapped myself in for a wild night of allopatric speciation and coadaptation. A wild night did ensue, but there was no evolutionary biology involved.

Around 11:30PM, what could only be described as the worst headache of my life, detracted me from my desk and led me to the bathroom floor. I decided something needed to be done. Student services at the university health system were closed, so that only left me with the ER as an option.

An ER visit was outside the coverage of my standard student health insurance provided with tuition and I didn’t have a personal health insurance plan. I was wary of any costs that I might incur in the ER.

Instead of an ambulance, my best friend, Eric, drove me to the hospital.

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A Doctor’s Guide to Botched Executions

lockett execution chamber
I give what could be lethal injections for a living.

That’s right. Nearly every day I give someone an injection of midazolam, vecuronium, and an IV solution containing potassium chloride–the three drugs in the “cocktail” that was supposed to kill convicted murderer Clayton Lockett quickly and humanely in Oklahoma.

Here’s the difference between an executioner and me. I use those medications as they are intended to be used, giving anesthesia to my patients, because I’m a physician who specializes in anesthesiology. Midazolam produces sedation and amnesia, vecuronium temporarily paralyzes muscles, and the right amount of potassium chloride is essential for normal heart function. These drugs could be deadly if I didn’t intervene.

My job is to rescue the patient with life support measures, and then to reverse the drugs’ effects when surgery is over. The “rescue” part is critical. When Michael Jackson stopped breathing and Dr. Conrad Murray didn’t rescue him in time, propofol–another anesthesia medication–turned into an inadvertently lethal injection.

When anesthesia medications are used in an execution, of course, no one steps in to rescue the inmate. This gives new meaning to the term “drug abuse”. In my opinion, the whole concept of lethal injection is a perversion of the fundamental ethics of practicing medicine.

Not for amateurs

Though lethal injection is supposed to be more humane than the electric chair or the gas chamber, often it doesn’t work as planned. Mr. Lockett died on April 29 after the injection of midazolam, vecuronium, and potassium chloride into his system. It is unclear from media reports how much of which drug he actually received. Apparently, prison staff had difficulty finding a vein.

The drugs were injected, they thought, into the large femoral vein in Mr. Lockett’s groin, which should have killed him within moments.

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Doctor Paul Revere Fails to Light the Fire

Paul Revere
Writing in the Wall Street Journal (WSJ) Dr. Daniel F. Craviotto Jr. an orthopedist, made a plea to physicians to declare independence from third parties and emancipate themselves from servitude to payers, mandates and electronic health records (EHR).

As rants go, this was a first class rant. But its effect was that of a Charles de Gaulle’s whisper to Vichy France rather than a Churchillian oratory at the finest hour.

The article went viral (it has been tweeted nearly 3000 times), though with little virulence. And it is not WSJ’s paywall to blame.

The author might have assumed that most the healthcare community in general and physicians in particular wish to be free from regulations. I have serious doubts that this assumption is correct in the aggregate. The relationship between regulators and physicians is more complex and symbiotic than it first appears.

Some physicians believe in bureaucracy. Rationalism will march us out of our healthcare wilderness. This belief in scientific managerialism, faith in technocracy, is the new theism. The rationale of the new theists is that regulations fail not because they are inherently useless but because there are so few of them, and even fewer that are actually smart.

Like the first religions started with polytheism, the new believers want more agencies, more alphabet soups, more gods.

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How Community Health Centers are Taking on Accountable Care for the Most Vulnerable

Farzad MostashariLike many participants in the Medicare Shared Savings ACO Program (MSSP), Family Health ACO is sailing in uncharted waters.

All ACOs are facing significant challenges in better understanding patient utilization patterns, identifying high-risk patients, and implementing care coordination strategies.

Even more unique is that Family Health ACO (“Family Health”) is composed entirely of federally qualified health centers (FQHCs).  FQHCs are community based organizations that provide critical primary and preventive care for millions of underserved and uninsured Americans, regardless of their ability to pay.

Nationwide, there are over 1200 FQHCs serving the health care needs of the working poor, the unemployed, the undocumented, and anyone else in need of primary medical care. Family Health provides care to over 200,000 patients and spans nine counties in New York State; from the bustling streets of New York City to the rural landscapes of the Hudson Valley.

Partners in the Family Health ACO include Open Door Family Medical Centers (“Open Door”), The Institute for Family Health (“The Institute”), and Hudson River Health Care (HRHCare).

Collectively the ACO includes 120 physicians, 60 advanced practice nurses and physician assistants, and nearly 100 dental providers.

These organizations have a strong history of collaboration, including their first venture in 2008 to form the Hudson Information Technology for Community Health (HITCH). HITCH enabled the organizations to pool resources and work collaboratively on cancer screening and diabetes management outreach programs.

The ACO partnership is helping to further strengthen the ties between these three community-based health care organizations and their communities.

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A Closer Look at Physician-Hospital Alignment

flying cadeuciiA study by Stanford researchers in the current issue of Health Affairs is likely to intensify growing tension between health insurers and hospitals.

At issue: the impact of physician-hospital consolidation, or vertical integration as some academics prefer to call the trend.

The researchers analyzed 2 million claims submitted to insurers by hospitals from 2001 to 2007, evaluating the impact on hospital prices, volumes (admissions), and spending for privately insured, non-elderly patients. Using data from Truven Analytics MarketScan.

They constructed county-level indices of prices, volumes, and spending and adjusted for enrollees’ age and sex. “We measured hospital-physician integration using information from the American Hospital Association on the types of relationships hospitals have with physicians.”

What they found is not surprising: vertical integration involving physician-hospital consolidation results in better care and higher costs. They found hospital prices increased 2%-3% each time physician-employing hospitals’ market share increased by one standard deviation. And overall spending on services at the hospitals that employed physicians increased while the utilization of services (volume) at those hospitals didn’t change.

They  concluded the following:

“We found that an increase in the market share of hospitals with the tightest vertically integrated relationship with physicians—ownership of physician practices—was associated with higher hospital prices and spending.

We found that an increase in contractual integration reduced the frequency of hospital admissions, but this effect was relatively small. Taken together, our results provide a mixed, although somewhat negative, picture of vertical integration from the perspective of the privately insured.”

What’s the significance of the study?

1-Hospitals and physicians will bolster their position that vertical integration is necessary to improved outcomes. The shift from volume to value via accountable care organizations, bundled payments, medical homes, and value based purchasing require closer collaboration between physicians and hospitals.

“Clinical integration” is central to each, and payers– Medicare and private insurers– are promoting these risk-based contracting efforts energetically while cutting reimbursement rates for services aggressively. So the provider position is this: ‘We get better results. We built what you said you wanted.

It’s costly to make the change, especially while since Medicare and Medicaid don’t cover our costs, demand is soaring and our bad debt from the uninsured increasing. You told us to build it, but you don’t want to cover our costs.’

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Higher Workloads and Fewer Nurses? Not a Recipe for Patient Protection and Affordable Care.

flying cadeuciiIn further celebration of Nurses Week, it’s worth discussing this TIME article about the “Killer Burden on Nurses” under the Affordable Care Act.

The point I’m raising and highlighting here is not meant to be political or partisan, but really one about nursing workloads, management decisions, and what’s right for patients.

We’ve seen recently that American healthcare spending is UP about 10%(the biggest increase in spending since 1980) – mainly due to newly insured patients getting care. The point is to get people care and treatment, but maybe the law should have been called the “More People Getting Healthcare Act?” That’s a noble goal.

From the TIME article, an opinion piece written by a nurse from California:

“… I worry that the switch may compromise the quality of the care our patients receive.”

The nurse talks about patients who are sicker due to not getting good healthcare previously. These patients require more attention and more nursing time.

In any workplace, the staffing levels should be set based on the total workload. Using “number of patients” is not a good basis, since the acuity of patients (and the resulting workloads) aren’t equal. Not every patient is the same.

Hospitals, due to other industries, do a really poor job of “industrial engineering” work that would establish the right staffing levels based on workloads.

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Would a Single Payer System Be Good for America?

Brian-KlepperOn Vox, the vivacious new topical news site, staffed in part by former writers at the Washington Post Wonk Blog, Sarah Kliff writes how Donald Berwick, MD, the recent former Administrator of the Centers for Medicare and Medicaid Services and the Founder of the prestigious Institute for Healthcare Improvement, has concluded that a single payer health system would answer many of the US’ health care woes.

Dr. Berwick is running for Governor of Massachusetts and this is an important plank of his platform. Of course, it is easy to show that single payer systems in other developed nations provide comparable or better quality care at about half the cost that we do in the US.

All else being equal, I might be inclined to agree with Dr. Berwick’s assessment. But the US is special in two ways that make a single payer system unlikely to produce anything but even higher health care costs than we already have.

First, it is very clear that the health care industry dominates our regulatory environment, so that nearlyevery law and rule is spun to the special rather than the common interest. In 2009, the year the ACA was formulated, health care organizations deployed 8 lobbyists for every member of Congress, and contributed an unprecedented $1.2 billion in campaign contributions in exchange for influence over the shape of the law.

This is largely why, while it sets out the path to some important goals, the ACA is so flawed.

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Medicare Advantage: Moving toward a Better Model for American Health Care

Robert PearlDespite the political angst, the doomsday predictions and a very rocky launch, the Affordable Care Act has enabled more than 8 million Americans to acquire insurance coverage through the public exchanges.

Health insurance increases the probability that patients will access the medical care they need. And my colleagues at Kaiser Permanente are already seeing some positive stories emerging as a result.

Beginning in 1978, Medicare beneficiaries had a second option. They could enroll in private Health Maintenance Organizations (HMOs) under a “risk contract” between CMS and the HMOs.

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A Declaration of Independence Is Only the Beginning

flying cadeuciiOn April 29, Dr. Daniel Croviotto published an editorial in the Wall Street Journal, “A Doctor’s Declaration of Independence,” in which he argued that it is time to “defy healthcare mandates issued by bureaucrats not in the healing profession.”

Dr. Croviotto does a good job of articulating his frustration with the increasingly burdensome bureaucracy and regulations placed on care. Many physicians and nurses share his frustration. I once did, until I saw a way out of the cynicism and frustration – a way that can improve the quality and lower the cost of care for all Americans.

No matter how misguided we think the federal government is in its electronic health record mandate or other requirements, simply defying mandates as Dr. Croviotto proposes is not  likely to accomplish much. Those who signed the Declaration of Independence knew it was only an initial step toward ridding the country of tyranny. They had to create a new vision for a better, more effective government.

Similarly, the medical profession needs to move beyond cynicism to create a vision for a better, more effective healthcare system.

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