Tag: Vipan Nikore

Work Hour Restrictions – A Painful Gift to Medicine

When I completed my overnight shift and left the Medical ICU the morning of July 1, I raised my arms victoriously. I uttered, “Finally, internship is done!” I may have been one of the last to speak such words.

As of July 1, 2011, intern year forever changed. In the world of medicine the first year of residency, or intern year, is when doctors earn their stripes. Traditionally it is the most demanding year in a decade-long quest to become a practicing physician. But this year, the Accreditation Council of Graduate Medical Education (ACGME) mandated that interns can no longer work more than 16 hours straight, and must have 10 hours off between shifts. Second- and third-year residents can still work 28-hour shifts, but no more 30-hour shifts for interns.

To the outsider, this may seem like a common sense change that would only improve patient safety.  Within the medical field, however, this change is arguably the most controversial in the history of medical education.

Advocates believe these duty-hour modifications will decrease medical errors and improve unacceptable working conditions for residents. ACGME officials still believe that residents should be able to handle the vigorous hours and workload, but believe launching the least experienced physicians — new interns — into those demanding conditions just days after medical school is inappropriate and unsafe. As well, the general public generally favors the new changes.

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Defining Quality in the Health Insurance Industry

My patient, whom I’ll call Jane, had a neurologic disorder that prevented her from emptying her bladder properly. She required a permanent urinary foley catheter to help her urinate. Jane landed back at the hospital with yet another urinary tract infection – her third in one month. She had pus draining from her catheter and was infected with a multi-drug resistant strain of the bacteria Proteus. Our lab ran tests (sensitivities) to determine which antibiotics would be required to eradicate the infection, and it turned out the only oral drug that could destroy the infection was fosfomycin. Giving her fosfomycin would allow her to avoid intravenous antibiotics and be treated at home. This would prevent a lengthy expensive hospital stay. Thank goodness for fosfomycin, I thought.

One problem though: The insurance company wouldn’t pay for her 3 day fosfomycin prescription. It took several calls by our case manager and senior resident physician before, finally, the insurance company agreed to pay. And even then the insurance company decided to place a restriction on her purchasing of fosfomycin — they only allowed her to purchase only one dosage at a time. Did I mention that her neurological disorder prevented her from walking? Yes, a lady from a low-income area of Cleveland who cannot walk was required to find her way to the pharmacy three times in order to eradicate a dangerous infection. Was this just cruel, or was I missing something here?

We had to delay discharge two days, which was troublesome for Jane. Plus, the cost for two more nights in the hospital negated any savings that the insurance company gained by refusing to pay for her medicine. The time lost by our team members on the phone arguing with insurance companies easily could have been spent providing care to other patients. I’m struggling to find the winner in this equation!

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Hockey Teams and AED’s Save Lives

I’ve played over a thousand ice hockey games in my life, but I had no idea that last month’s adult men’s league game in Cleveland would be the most memorable. I grew up in Canada, three blocks from Wayne Gretzky, the greatest hockey player ever, but I wouldn’t be surprised if my recent game was more important than any game that my former neighbor played. This game was literally a matter of life or death.

I almost didn’t show up to the game. I had just landed in Cleveland from New York City after attending a close friend’s wedding. I’d landed at 8:15pm, jumped in my car and dialed into a conference call for my organization uFLOW, arriving and finishing my call barely in time for the 9:30pm puck drop. I didn’t plan my schedule around the game; the timing just happened to work out.

It was close to the end of the 2nd period when I heard our captain, Brandon Dynes, yell something and race off the ice. I soon realized he skated off to call 911. I looked down at the end of the bench and saw that our teammate Harley was unresponsive. Harley is 69 years old (though could pass for 50) and as the eldest player in our men’s league has been an inspiration to many of us. I quickly went over to assess him and found he had no pulse, was not breathing, and not responding to verbal or physical stimuli. I was fortunate that the opposing team had a physician playing as well, Dr. John Wood, an orthopedic surgeon. John quickly came over and could not find a pulse either. Knowing end organ damage such a anoxic brain injury can occur quickly, I grabbed Harley and layed him on the bench and started compressions, pressing his chest extra hard knowing I was going through a layer of hockey pads. I later quickly ripped off his pads off to assure better compressions.Continue reading…

Fighting Compassion Fatigue

Six months down. Six to go. I am officially halfway through what people have told me will be one of the most challenging years of my life.  I’ve rotated through Cardiology, Primary Care, Gastroenterology, General Medicine, Psychiatry, Palliative Medicine, the Medical Intensive Care Unit (MICU), and Rheumatology. Finally I have reached every resident’s favorite rotation – vacation.

Intern year has been hard work, but I’ve enjoyed it and am extremely pleased with the experience my Internal Medicine program has provided. Each rotation has taught me a tremendous amount and helped me grow as a physician, but the most profound impact occurred during my back-to-back rotation in Palliative Medicine and the MICU. Last August, Atul Gawande wrote an insightful essay titled “Letting Go” in The New Yorker. He vividly illustrates the different mindsets for treating patients in palliative medicine compared with doing so in the ICU. He discusses the lost art of dying and how palliative medicine can help us regain that art. I was fortunate to have witnessed this sharp contrast by working in palliative medicine immediately followed by working in the MICU for a month.

The sights and sounds while walking through the halls of our Palliative Medicine floor are unique. One moment, I might walk past the “Caring K-9” dog, and the next moment I might hear peaceful sounds from a talented violinist as I walk by a patient’s room. As Gawande mentioned, the goal in palliative medicine is comfort, and any measure that may enhance comfort is fair game. Contrast that experience to the ICU, where I might arrive to work at 5 a.m. and by 5:01 a.m. might be doing compressions in attempt to restart a stopped heart. No morning coffee to settle in, no dogs roaming the hall, no violinists. It is intense and unpredictable in the ICU.  Generally the goal is the keep the patient alive at all costs.

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The Measurement Question

I sat at home with a sense of relief. I had just finished my first month of residency – a grueling inpatient hospital month where I was pushed to new limits.  I now finally had my first “golden weekend” (meaning I had both Saturday and Sunday off). More importantly, I had survived my first month without any patient deaths on my service. Given how sick people are when they come to the hospital, I felt pretty good about this result.

That feeling lasted less than 24 hours. As I logged in from home onto the electronic medical record to finish some documentation, I realized one of my patients was in coma due to a sudden stroke. This patient had few clinical symptoms and appeared the healthiest amongst all the patients I managed the entire month. A heavy knot quickly developed in my stomach, as I could not shed the feeling that perhaps I did something wrong. I scoured the medical records, retracing my management. Over the next couple of days I discussed the case with other colleagues and experts in the field, and read in depth on the management of this condition.  To my relief it was clear that I did not nor did anyone involved in the patient’s care make an error in management. Unfortunately, however, this patient eventually passed away.

As I reflect on the experience, an important point stands out in my mind. This patient exhibited few signs of being “sick” and was managed very well by all the physicians during the course of the hospital stay, but died. On the other end of the spectrum are patients who appear incredibly sick, and despite a poor prognosis survive against odds. One of the goals of residency is to learn to assess a patient and quickly identify who is in imminent danger and may need immediate attention. Unfortunately, however, physicians cannot predict everything, as situations similar to the one above are not uncommon scenarios. Given this fact it makes the discussion about measuring healthcare and pay for performance very cloudy.

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