This piece is part of our first-annual Health Care Heroes series, where we spotlight people doing amazing things in the health care and medical fields. Read the rest of the stories here.
Justin Fiala, MD, is a pulmonary, critical care, and sleep medicine specialist at the Northwestern Medicine Canning Thoracic Institute who splits his time between the ICU and the rehabilitation hospital. But perhaps the work he finds most fulfilling is the free sleep clinic he launched in 2021 that “fills a really blaring gap in the health care system.” Below, in his own words, he shares how the program originated, what it entails, and why he believes sleep is a human right.
IWAS IN the final year of my pulmonary critical care training as the pandemic kicked up. We would see whole families admitted to the ICU at the same time and most of those families would be from historically marginalized groups. The disparities weighed really heavily on a lot of us. And there was so much loss with the pandemic. I remember it put me in such a bad headspace and I was lamenting to my husband at the time. I was like, “I just can't get out of this funk.” And he said to me, "Yeah, but what are you doing about it?" Once I got out of my feelings, I was like, it’s probably not a bad question to ask.
I reached out to CommunityHealth, the largest volunteer-run free clinic in the country. It's been in existence since the ‘90s, and I volunteered there as a medical student. I remembered thinking how impressed I was by the way that they maintained dignity in a free clinic space and how they really centered on the patient. Their whole goal was to have patients see the same provider each time whenever possible. And then what they try to do as well is bring specialty care to the patients to whatever extent possible.
I said, "Hey, I can do pulmonary and I can do sleep. What do you need?" And they said, "Oh, 110 percent we need sleep." They initially probably thought that I was going to be a conduit into my academic facility’s sleep lab. And I said, "Yeah, that's great. We can work on pathways to get referrals in through Northwestern. But also we should dream bigger because 90-plus percent of our sleep studies are now done at home." I said, "We should figure out a way to do home sleep testing for these people. "
There's also so much waste in the sleep system. People come in and they get re-upped for a new machine after a few years if they have good insurance, and then they don't know what to do with their old machine and they get too many mask refills or mask pieces and whatnot. I said, “I bet we can get donated devices and supplies.” All of this turned into a program called CommunityHealth Initiative for Patient-Centered Apnea Protocols (CHI-PAP).
I took some money from some overnight ICU shifts that I would do occasionally just for some pocket cash, went on eBay, and found lightly-used home testing devices then started building a fleet. And then we dispense those to patients. We ask, "Hey, can you do your test and bring it back to us?" I look at those results, interpret them, and upload them into the patient chart. If they have sleep apnea, I get them a donated CPAP device that I clean, make sure it’s functional, run it through a little battery of tests, and then re-up it for a patient in need at the clinic along with unused supplies like tubing, masks, mask pieces, and filters.
The way that the clinic currently operates is that it’s exclusively for patients at CommunityHealth. And that’s because CommunityHealth really served as a preexisting organization that had patients who clearly demonstrated a need. And beyond that, they had all of the overhead taken care of for us. So they do the scheduling, they do the actual rooming and everything. They have multiple locations as well throughout the city of Chicago. And so we're working on expanding from the main location to the satellites. In order to be a patient at CommunityHealth, they have to demonstrate that they live at a level three times below the the federal poverty line. So truly a very, very much in need patient population.
My whole goal has been to demonstrate that this group of people will use these devices to the same extent that the average patient does and to show that we can provide a standard of care to this group of patients. If we're ever going to address this at a societal level, we need that proof of concept and that data to get the people that make the decisions to actually enact change from a legislative standpoint.
Sleep apnea is very common and many sleep disorders will actually end up having a component of sleep apnea contributing to them. You always start by screening to make sure that if it's not present, then you're like, okay, this is primary insomnia and then you treat the insomnia. But many of our patients that come in with a complaint of insomnia still get that sleep study. And then we do have a smattering of patients with things like narcolepsy. Shift work disorder is actually quite common because we have patients who are working multiple jobs and have difficulty adjusting their schedules. The nice thing is that we really do see the spectrum of sleep disorders that are out there and we do our best to provide standard of care across the board.
We're not looking to cure sleep apnea per se. It’s a chronic condition where we're managing it. This is an issue where the back of the throat blocks off multiple times overnight, especially during the deepest sleep when we dream, because when we dream during this rapid-eye movement (REM) sleep, we think that the brain is trying to protect the body from acting out our dreams. So most of the muscles in the body actually go into paralysis during REM sleep, but that includes the muscles in the back of the throat and the tongue. And so everything can just pancake down and block off.
What we're doing with CPAP machines, for instance, is providing pressurized air into the throat and back of the mouth so that we can open everything up and allow people to breathe easily throughout the entire night, regardless of what phase of sleep they're in. And when that happens, then they don't get woken up by surges of adrenaline. We think that it's the reduction in surges of adrenaline that actually protect against heart attacks and stroke in the long term and help with blood pressure control. We see this as a critical piece of the puzzle for overall health.
Some of the patients we started on CPAP for their sleep apnea initially were telling us that they were falling asleep behind the wheel. We bring them back, we hook up their machine, and they're using it nine hours a night and they're no longer sleepy and they haven't had any more bouts of near misses on the road. And that's kind of the idea. It's protecting people long-term because we've fixed this. We've actually addressed the root cause behind their sleep issues.
We always do this assessment of sleepiness called the Epworth Sleepiness Scale, and it's just these questions of different scenarios like, what are the chances that you would start to doze off and feel your eyelids getting heavy? And one of them is if you're sitting and talking to someone. People always scoff at that. If it's never happened to you, you're like, oh, how would that ever happen? But it absolutely is a thing. And so the most severe cases, they will be falling asleep in front of you. I had a gentleman come in, a middle-aged guy, and he answered yes to all of these questions—high chance of falling asleep while I'm talking to you, high chance of falling asleep while I'm driving. And literally in front of me he’s nodding off as I'm talking to him.
So I said, "Hey, we're going to get you set up for your sleep study." I actually expedited his study because I was so worried. He did the study, I looked at it, and it was really profound in terms of the level of severity. His oxygen would drop from 100 percent down to the 60s. Below 88 percent is abnormal. And for the vast majority of the night, he was just up and down, up and down, up and down, and it just looked incredibly severe. So I tried to get him back and I scheduled him for a return visit the following Saturday, and he no-shows. I asked the clinic coordinator, "Hey, can you call him? I'm worried I really want to get him in.”
They called him and he said, "Hey, I've been out of work recently, so I wasn't able to come this Saturday because I just found work again, and it's an odd job, but it's on Saturdays." I said, "Okay, when can you get there? When would you be able to come to the clinic?" The clinic has different specialties that are coming on different days, so they had availability on other days if I needed to flex somebody into another clinic slot. So he said, "Oh, I can come on a Monday afternoon." So I said, "Okay, that's great. I will meet you there." I rearranged whatever I had on my schedule that day, got over to the clinic, which is across the city., and I see him. I actually started him on BiPAP because of the degree of severity that he had.
I put it on him. I'll never forget, he's sitting in the office chair and I see him lean back against the wall as I turn on the pressure and he just melts into the seat. I gently wake him up and I say, "Hey, how are you feeling? Does this feel good? Is it synching with you?" And he says, "Oh yeah, my chest." He makes a fist against his chest, which in medicine you learn is something called the Levine’s sign. It's basically the sign that you're having heart attack or chest tightness, chest pressure, chest pain. He makes that sign, and then he opens up his fist. He says, "It just feels like my chest is lighter." And I was like, "You're going to do great. You are literally the reason why we started this clinic."
I’m in the ICU Saturday through Friday. So sometimes I'm ending Friday and I've scheduled the clinic the next day, that Saturday, and I'll be on my way and I'm just like, "Oh my God, why did I do this? I'm just tired." But I get there and it always fills my cup and it's because of things like this. It's the patients. It's the colleagues that I see at the clinic, whether it's the other sleep providers or the other people who are just dedicating their time to doing primary care or dermatology. Just similarly-minded people. That community has really been incredibly rewarding.
Since we’ve opened the sleep clinic, we've had 281 unique visits, we’ve started 64 people on CPAP, and we've done 136 sleep studies. The numbers aren't huge from a population standpoint, but when you see them in front of you and you see benefits, that's where the impact resonates. Everybody deserves a restful night of sleep. Unfortunately, our society makes that disproportionately difficult for some people. We want to level the playing field and try to meet people where they're at and accommodate them so that they have as many restful nights of sleep as possible.
Describe your job in three words.
Chaos into order.
Favorite medical show to watch?
ER.
Best career advice you've ever received?
“Block out what you think others are going to say you should do because of prestige.”
Robotic surgery: Yay or nay?
Yay in the right circumstances.
Describe the future of AI in health care in three words.
Proceed with caution.
What’s the strangest question a patient has asked you?
Can I touch your mustache?
Morning shift or night shift?
I'm definitely a morning person, but I actually really love the night shift. The ICU night shift is just a different vibe and I love night ICU nurses.
Guilty pleasure after a long shift?
Ramen and YouTube.
Rachel Epstein is the features director at Men's Health and Women's Health, where she leads the brands' most ambitious storytelling across platforms from reported narratives, profiles, and investigations to buzzy, expert-backed service packages. Her work has been nominated for two National Magazine Awards. Offline, she's likely watching a Heat game or finding a new coffee shop.
