Category Archives: Business of Medicine

Why Sleep Center Accreditation is Important

Long time no see, everyone!  This past week has been very full, limiting my abilities to write until now.  One important event of this week was an American Academy of Sleep Medicine (AASM) re-accreditation site visit for a sleep center that I medically direct.  I am pleased to report that the facility remains a fully AASM-accredited sleep center.

To most, medical facility accreditation may not mean much, or anything at all.  AASM accreditation does mean a lot, however, to clinicians and staff for whom it is important to maintain a distinction for utilizing accepted medical and procedural standards of care regarding the diagnosis and management of patients with sleep disorders.  The AASM is the primary governing body that develops and maintains national standards of care in sleep medicine, establishing benchmarks for quality of work done by physicians and in sleep centers based on sound, published scientific data.  As such, AASM accreditation should be important for patients as well:  though there are certainly plenty of excellent sleep centers that are not accredited, it is reasonable to presume that one’s care in an AASM-accredited sleep center is generally more likely to be in keeping with established and accepted national standards of care as compared to in an unaccredited facility, particularly one that’s been around for many years without any intention to obtain accreditation.

AASM accreditation requires adherence to specific standards and guidelines for clinical work and management, diagnostic testing, and operational procedures.  It is a rigorous process, one that involves a detailed application, demonstration of maintenance of education and certification, ongoing adherence to AASM practice parameters, and site visits and inspections.  Plus, rules and standards change all the time in medicine, so accreditation forces us to keep up, stay current, and continue to do our best caring for patients in this ever-changing modern world.  Finally, and importantly, accreditation also means that a sleep center’s physicians are able to deal with all sleep-related problems, not just the easy stuff.

Many years ago I participated in the accreditation process as an AASM site inspector.  It was a great experience; it gave me opportunities to travel and to see how other centers did things.  One of the medical directors I met during my visit told me that he looked forward to our inspection because he considered it a learning opportunity.  That remark has stuck with me ever since:  the idea that a visit from the AASM should be something not to be dreaded, like an audit or an investigation, but instead something very positive, something that allows for further growth and mastery in the field of sleep medicine.  In my career I have seen sleep centers through their own accreditation as medical director many times, and in many ways the process is fun.  I find it interesting to hear the perspective of the site inspector, pick his or her brain a little, understand how physicians around the country are handling certain complex situations, and learn how others are dealing with all the changes constantly thrust upon us in American health care.

To those who ask me how to choose where to go for their sleep medicine care, I do recommend considering exploring which area sleep centers are accredited by the American Academy of Sleep Medicine as they make their choices.  Some insurance plans and other administrative bodies require patients to get their care at accredited facilities.  I recognize that some underserved parts of the country may not have accredited centers yet, and it also always takes time for a new sleep center to obtain its accreditation, but the pathway to accreditation is quite accessible now for those sleep specialists willing to step up.

And no, the American Academy of Sleep Medicine didn’t pay me to write any of this!  Have a great evening, everyone.  Cheers!

What a Young Billy Joel Fan Can Teach Us

I was the tender age of 12 when Billy Joel released his groundbreaking album, 52nd Street, in 1978. His songs were all over the radio, and I fell in love with them. When his tour stopover in Wichita, Kansas was announced, I begged my parents to go. After some inter-parental discussion and to my great disappointment, it was determined that I was too young to attend the show. As consolation, Mom took me to Musicland in Towne East Square and picked up the 52nd Street LP for me to take home and enjoy. And boy did I enjoy it. I played both sides over and over, memorizing every word. “Zanzibar” remains one of my favorite songs of all time. Imagine my surprise and delight when, upon finally seeing a live Billy Joel concert several years ago here in Seattle, he performed that obscure but wonderful piece from 52nd Street; it felt like he played it just for me.

(In the unlikely event that you’re interested, I eventually wore my parents down, and my very first rock concert ended up being Kiss in 1979, a year after 52nd Street was released.)

I am but one of many millions who have loved Billy Joel’s songs over the years. Recently, during a Q and A with Joel at Vanderbilt University, a freshman named Michael Pollack stood up and asked if he would be willing to be accompanied by him on piano on “New York State of Mind,” his favorite song. Joel granted him his wish, much to everyone’s delight, and the musical result was . . . well . . . incredible. Inspiring. Please click on the video above to witness the performance.

There’s a lesson or two to be learned from this brief event, one which I’m sure Michael will never forget. This world is getting smaller, but the number of people inhabiting it is getting bigger. How are today’s young people to survive and succeed with so much competition surrounding them? It’s no longer sufficient to be good at what you do. You have to have guts now. Billy Joel, in his typical east coast nonchalance, said of Michael, “guy’s got chops!” No disagreement there; he killed it on the piano, as you can see. But another quality Michael possesses is just as crucial, if not more so: guy’s got cajónes too. Big ones.

The favor Michael asked of Joel was asked for honestly and audaciously. No one outside his friends, family, and teachers would know who Michael is today if it weren’t for that moment of boldness and risk. It paid off.

We are at a societal turning point here in the United States. Health care is in a major crisis. Regulations, ever-declining reimbursements, minimal autonomy, increasing overhead and malpractice premium costs, mounting paperwork and administrative hassles: it’s becoming more and more difficult for doctors to find success and happiness in their work. This isn’t a whine or a call for sympathy; it’s just factual. My concern is, in a time in which doctors are retiring early or just plain quitting, who of our young citizens will choose medicine as a career in the future? Why should they go through the hassle and put in all that money, time and effort for so little in return?

I’ve been asked recently by high school and college students if I would recommend medicine as a career. My answer was that it really depended on who they are, based on honest self-assessment. There’s a definite analogy I see between the qualities of a successful and happy future doctor and those of Michael Pollack, the Vanderbilt freshman pianist:

1. You have to have passion. You have to really want it, and for the right reasons.

2. You have to be good.

3. You have to have the audacity to work aggressively to get what you need or want, because in today’s way of the world it’s no longer given to you or made easy.

Seems to me that a young man or woman possessing these three elements should be able to weather the current health care storm and carve out a satisfying, fulfilling career in medicine. If any of the three are missing, however, the happiness factor will plummet, I can promise you. A missing link or two may be why there is so much unhappiness and dissatisfaction among doctors right now.

I want people to go into medicine in part, admittedly, for selfish reasons. I want a quality physician to be willing to care for me when I am old. Doesn’t everybody?

So to those kids and teens considering becoming a doctor: do it if you really want it. If you really want it, and if you know it, and if you know what you’re getting into, then go for it. And go for it hard. Not obnoxiously or unethically, but boldly. It takes audacity now to make it in this world. If you ever want a reminder of what that quality looks and sounds like, click on the video again.

Have a great weekend, everyone!

A St. Patrick’s Day Anecdote

 

Long ago during my training years, a man in his early sixties—I’ll call him Karl—was admitted to our hospital service one day in mid-March. Karl had metastatic cancer, and he was dying. We on the in-service team liked him very much, remarking quietly to each other how it so often seemed to be the good ones that die early of such tragedies. Despite his terrible prognosis and physical discomfort he was pleasant–jovial, even–during morning rounds, putting everyone at ease with his polite disposition.

One day we walked into his hospital room, and he was having a tough morning, though not for physical reasons. He was really down, uncharacteristically so. We asked him what was troubling him. A little embarrassed at first, he shared that it was St. Patrick’s Day, and true to his Irish roots he normally celebrated that day with a glass (or two) of green beer. Doing so was a custom of his and his family’s for decades. He told us how unfortunate it was that he wouldn’t be able to celebrate this way this time ‘round.

Upon examining him and talking with him further, we took our leave and somberly continued morning rounds. Afterwards I stood at the nurses’ counter with my chief resident. I was post-call and yearning for sleep, so I wasn’t paying much attention to what he was doing; I was hanging around until his exit off the floor, which was tacit permission for me to go home and go to bed. He made a couple brief phone calls and wrote something in a patient chart. He slammed the chart shut, startling me, and grinning widely he proclaimed, “That oughta do it!” And he walked off, swinging his stethoscope in his hand as he disappeared down the hall.

I looked down: it was Karl’s chart. I couldn’t help it, of course. I opened it, flipped to the “orders” section, and read the following in my chief resident’s barely legible scribble:

“Administer 1 glass beer p.o. x 1. Apply green food color prior to ingestion.”

I smiled as I left the hospital that morning.

After awakening from my post-call nap I called the floor and spoke with Karl’s nurse. He had enjoyed his green ale. Several days later he went to hospice a happier man.

That was a couple decades ago. I hear that beer is still available in some hospitals. But I wonder how difficult it would be for a dying person to get it these days. The process of health care is so burdened now with endless complexities—regulations, statutes, administrations, commissions, regulations, third party payers, boards, committees, and did I mention regulations?—it seems hard to believe that underneath all of that still exists the original idea that I went into medicine for in the first place: to actually care for people, to make what is miserable less miserable, to heal, to help make life a little better, maybe lengthen it too. All this sounds so quaint and clichéic now, things one might say in a medical school interview. But isn’t it still true, what we’re all still supposed to be doing in health care? If so, does the administration of health care now really have to be such a struggle, such a fight all the damn time?

To some of those non-clinicians who have their hands in the business of health care, I would ask what they would do if charged directly with the task of making a person’s life better. What rules that they themselves created would they try to bend to grant a dying man a green beer? Or would they? A green beer would be difficult to pre-authorize.

As my life continues on, I am increasingly grateful for what I have, who I have it with, and what I am allowed to do every day for work. I think of Karl every St. Patrick’s Day. To my readers, if you choose to celebrate a little tonight, I’d appreciate your lifting one up to Karl and cheering the greatness of life. We’re lucky to have each day we have.

Happy St. Patrick’s Day, and Happy Selection Sunday!  Lá Fhéile Pádraig Sona Daoibh!

 

Sleepy Residents: The Tricky Business of Medical Education

 

This morning one of my patients was telling me about her recent sleep deprivation; recently retired, she has been going to bed late and getting about 5 hours of sleep most nights.  I mentioned to her my own experiences in sleep deprivation, specifically when I was a resident in neurology years ago.  I explained how my frequent long work days and on-call nights resulted in frequent sleepiness and fatigue, sometimes to the point in which I dozed during lectures and grand rounds.  Her reply was, “How is that allowed, for new doctors to work such long hours? Isn’t that dangerous?”

How much and how long a resident should be allowed to work have long been a challenging issue in the realm of medical postgraduate education, and one not without controversy.  Certainly when I was training, there was a pervasive sense of machismo associated with working your white-coated tail off, as if spending every waking moment in the hospital made you superhuman, worthy of admiration and respect.  In addition, a certain culture has developed over the centuries regarding the “coming of age” of the young American doctor, “paying your dues.”  As academic institutions go, it is often difficult to break such deeply entrenched, longstanding traditions, particularly when the professors have long ago paid their dues.  The medical school where I completed my residency was built in 1797, so as one may imagine there were many time-tested, conservative traditions we were expected to follow.  Me, I found the training process and the hallowed traditions associated with it absolutely fascinating, and sometimes even thrilling, but there were times (usually around 2 a.m.) in which I really questioned why things had to be the way they were, such as being up all night every third night for months on end.

There’s another oft-overlooked reason why interns and residents have been so overworked, and it is purely economic.  In reality, a postgraduate trainee and a training hospital enter into a business partnership agreement of sorts the July following the trainee’s graduation from medical school.  The trainee needs the postgraduate education in order to become board-certified in a selected medical or surgical specialty and to practice medicine independently someday in that specialty.  The hospital system needs the trainee’s hard work, without having to pay that trainee the salary that an attending physician would command–the polite way of saying cheap labor.  There needs to be a consistent, large stable of doctors to make everything run properly at a large tertiary care center, and without interns and residents to do much the work, such large, complex institutions would simply grind to a halt, go bankrupt, or both.  And with the steadily declining margins of hospitals in recent years (and undoubtedly more to come), how much a hospital must pay for a doctor’s work becomes an increasingly important consideration.

Understand:  I don’t write any of this in a pejorative way.  Both trainee and hospital have legitimate needs and they need each other, so the relationship is forged on “Match Day” and it continues until the end of the training.  When I first found out my first-year salary as a newly minted intern–$28,500–I was overjoyed, frankly; it was better than paying to be there, like I had been in medical school.  With each subsequent year of training my salary jumped by $1000-2000 per year.  And through it all I spent countless hours in the hospital, often well over 80-90 hours per week, making my income less than minimum wage.  There was no questioning it, no raging against it; it just had to be so.  So what gets sacrificed most easily and most commonly in such a system?  The trainee’s sleep.

Certainly there is the argument that the trainee’s education would be enhanced by allowing proper amounts of sleep and off-work time, and there is clearly truth to that.  However, it takes more than that to change a longstanding, proud institution like American postgraduate medical training; there is much more to consider than the trainee’s education.  I recall a general surgery resident friend telling me once that he had fallen asleep, standing, earlier that day in the middle of a case; he just shrugged, knowing there was nothing that could be done about that until he finished his training.  I remember myself often struggling to stay awake in the middle of the night sitting in the ER writing up a history and physical, looking at the unoccupied ER bed in front of me and literally lusting for it, wishing I could curl up and get some much-needed sleep before our morning rounds.

In 2003, Accreditation Council for Graduate Medical Education (ACGME) limited work duty hours went into effect, reducing the maximum amount of time allowable for postgraduate training work.  Among the policies was a call for an “80-hour weekly limit, averaged over 4 weeks, inclusive of all in-house call activities.”  I trained in the early- to mid-nineties, so this change came too late to benefit me and my brethren.  I deeply appreciate all of my postgraduate medical training, and I remain very grateful for having had it.  I do believe strongly, however, that I would have learned more, and would have been happier, had I been allowed more sleep per night on average.

I lead a very busy life; it’s hard, in fact, to find someone with a crazier life than me.  However, I get my 7-8 hours most of the time (I’d be a hypocrite if I didn’t, right?).  I find that proper sleep allows me to maintain my very busy life and to enjoy it.  And, importantly, I know that most everybody can get their 8 hours if they allow it.  Unless, perhaps, you happen to be a young doctor in training.