American Medical Student Association

By: Farheen Qurashi, AMSA Jack Rutledge Legislative Director

Eyes are on the nation's capitol, as Americans were able yesterday to see, in its entirety, a Congressman to Congressman, Democrat to Republican, President to Legislator discussion on the future of health care reform. The President's Bipartisan Summit on Health Care Reform at the Blair House in Washington, D.C. was the most exclusive party in the city.

This was a highly-anticipated all-public bipartisan meeting, as opposed to much of the process we've seen thus far. Also significant is the fact that this is the President's meeting at all. President Obama has taken a "hands-off" approach throughout this process of reform, likely as a lesson from the last generation attempt at health care reform in the Clinton Administration. Now, however, amid long calls for a more active Presidential presence, a repeated failing to meet deadlines, and ever-growing amounts of obstacles--from public opinion to vote numbers—President Obama has finally taken a very large step in not only participating, but leading the way forward with his health care bill.

Unfortunately, hopes were not high going in for a substantive discussion of the issues--and appropriately so, it seems. The discussion devolved quickly. Though it remained just short of snide partisan remarks, the rhetoric of the past year remained, the ideas and positions seemed to hardly move, and the tension was palpable.

Though there were glimmers of bipartisanship -- Obama admitting there is promise in the idea of selling insurance across state lines, a real discussion of high-risk pools and mandates. A movement forward from the President's recent proposal was in his mention of national exchanges (his proposal assumes state-based, which arguably provide for less access). At times, there was even the frank admittance of idealogies being simply, to a point, incompatible.

But at the end of the day, when the real issue was brought forward--coverage--the injustices against the uninsured became apparent. Senator Barrasso of Wyoming daringly posed that "those [people] with catastrophic insurance are the best consumers...", arguing that the first question when considering a medical test should be about cost. "Would you want everyone in Congress to have catastrophic coverage?" asked Mr. Obama. "Yes..." says Senator Barrasso. "Now how about if you made $40,000 a year?" continued Mr. Obama. Silence.

When our leaders in Washington dare to charge that our first questions when we are sick should be about cost, it's annoying at best. When that leader is in fact a physician himself, it is a sad reflection not only on our leadership, but our medical system. As a future physician, I will never wish upon my patients the concern of finances before their health, or that of their loved ones. I do not want to be asked about the cost of a test that I recommend as medically necessary.

I am in medical school to be a healer, not a salesman.
Health care is a right, not a privilege.

But that was clearly not the adopted basis for yesterday’s summit, at least not for everyone at that select table. And it is clear that none the bills presented – by the House, the Senate, the President and the Republican plan—stay true to that statement enough to provide for truly universal coverage. And whether we are able to accomplish even these first steps forward, in the form of a health care bill this year, is yet to be seen.

Was the summit a success? Depends on where you sit.
Will healthcare be a success? We’ll just have to wait and see.

Wonder what it's like to live and work in a country where health care is a right not a privilege? Wonder how every other industrialized nation achieves better, cheaper, fairer health care? AMSA's National Book Discussion is hosting T.R. Reid on February 25, 2010. He has traveled the world observing different health care models.

When the World Health Organization rated the national health care systems of 191 countries in terms of 'fairness,' the United States ranked fifty-fourth. That put us slightly ahead of Chad and Rwanda but just behind Bangladesh and the Maldives. How is it that all the other industrialized democracies provide health care for everyone at a reasonable cost, something the United States has never managed to do? In The Healing of America (The Penguin Press 2009), New York Times bestselling author T.R. Reid shows how they do it, bringing to bear his talent for explaining complex issues in a clear, engaging way.

Reid has become one of the nation’s best-known correspondents through his coverage of global affairs for The Washington Post, his books and documentary films, and his light-hearted commentaries on National Public Radio. Reid majored in Classics at Princeton University, and served as a naval officer, a teacher, and various other jobs. At the Washington Post, he covered Congress and four presidential campaigns. He also served as the paper’s bureau chief in Tokyo and in London.

Read Chapter One “A Quest for Two Cures” at http://bit.ly/cdQR8e

By Dan Henderson

If long shifts and weeks harm doctors and their patients, why keep them? Why does the ACGME need to be pushed in the first place? I think it’s instructive to look at the culture of medical education, and at what we as trainees are taught to value. Medical education is deeply rooted in tradition and hierarchy. We’re taught to do as was done before us, and to do what we’re told.

Reflecting on my own experience long hours, I was at first enthusiastic for the chance to sacrifice for my patients, to prove my mettle, to distinguish myself. Third year students are commonly told to “show up first and leave last” as a way to shine on their rotations. I used to be proud of the long hours I put in. Now, I’m ashamed. I’m embarrassed to have embraced such an out-of-date notion, one that could have harmed my patients. It’s time to recognize that when we set the bar for commitment to patients impossibly high, we lose sight of our larger purpose – healing them. The belief that each patient should have only one doctor is as anachronistic as bloodletting, and those who cling to long hours as the hallmark of professionalism are, to me, just like those on the wrong side of the debates over germ theory and antisepsis.

By Dan Henderson

You arrive at 5 am, perhaps hoping to show up before some of your classmates or your resident. You power through the morning’s rounds, cases, and notes, slowing, perhaps slightly, during the afternoon low around 2 or 3, before the pressure is on to finish up before your teammates sign-out their patients to you and return to the world outside. A handful of lists and well wishes later, you’re officially on call.

Things quiet as the din of a busy hospital gives way to a wave of shift changes throughout the building. To me, this calm was noticeable, and almost unnerving to me. It’s like standing next to a snow-covered hill in utter silence, knowing that the next small break in the quiet could mean the start of an avalanche.

Classically, that avalanche hits you while sitting in the residents’ lounge, scarfing down cafeteria food before a small TV showing Seinfeld reruns. Then, inevitably, the calm is pierced by the cry of a pager. Then, “Damn. Emergency department.” Then another, “Right behind you.” And so on.

Depending on the hospital, service, weather, day of the week, and lunar calendar, what follows is a deluge of pages, tests, admissions, consults, and notes that either ends somewhere around 2 AM, or when you leave the hospital the next day. Though an established tradition, nearly every trainee who’s worked an overnight shift has wondered, “Why do we do this?”

We might assume it helps train better doctors – it doesn’t. Staying up all night means not having time to study, to read up on the pathology we observe on the wards. It’s also clearly bad for doctors’ health – linked to depression, medical illness, and especially, pregnancy complications. On top of that, drowsy doctors, the evidence and anecdotes agree, have a much greater risk of needle stick injuries (and accompanying risks of exposure to HIV and Hepatitis C) as well as deadly car crashes. Add some real tragedies – the car crash death of a cardiology fellow, an experienced resident, in 1999 in Boston, and the permanent incapacitation of pregnant woman hit by a sleepy resident in Chicago in 2000 (see here for more)– and it becomes clear that long hours are bad for doctors.

By Dan Henderson

The long hours worked by residents are somewhat unique, but their vulnerability to fatigue is perfectly common. In fact, because of this propensity of people to defy the limits of sleep-deprivation, I was almost never born.

Many years ago, my father (then just a twenty-something North Carolinian named David) was at the wheel of his family’s Skymist Blue 1962 Ford Falcon headed for Elkins, West Virginia. He had worked a 14-hour shift at a hardware store the evening before, and then endured a white-knuckle drive through the mountains of West Virginia. Around two or three in the morning, he was driving along at 55 mph, and realized he was drowsy.
The next thing he knew, the car was stopped in the shoulder of. The engine was off, and for some reason, the clutch wouldn’t budge. The dash was completely lit up, and an acrid scent filled the cabin. What had happened?

He got out, and only then noticed that all of the cars windows were shattered. The roof over the back seat was crushed down to the seatback, and all four fenders were deeply mashed inward. As he described it to me, “The only way to get the damage to the car would have been a flip landing on the roof and a cartwheel. It must have been very dramatic.”

Amazingly, my father was unscathed, except a headache and an otherwise unintimidating dab of blood on his forehead. No doubt, the small splotch conveyed a powerful message: “Consider yourself lucky - and get some sleep!”

Recently, I was asked to offer a medical student’s view on the impact of fatigue caused by long hours worked by residents. Even after a move to regulate hours in 2003, residents still work 30 hour continuous shifts, and 80 weeks. Often, evidence shows, they work much more, but simply report it to be within these limits. AMSA and its allies, such as the Committee of Interns and Residents (CIR) want to change this, but it seems it’s not just us who care about this issue. Last week, over 40 consumer safety and patient advocacy groups came together to push for better policies to promote safe schedules. Among them was Helen Haskell, who founded Mothers Against Medical Error after a tired resident’s mistakes led to the death of her 15-year old son in 2000.

Led by the famed consumer watchdog, Public Citizen these groups gathered to announce the launch of a new campaign, and a new website, www.wakeupdoctor.org, to send a message to the Accreditation Council on Graduate Medical Education (ACGME), the group that oversees America’s residency programs.

It was exciting to see the energy and support mobilized by these groups. Consumers and patients are two powerful constituencies, publicly and politically.

Work Hours: Part 2 will be posted soon!