PART III: OPERATING ON EMPTY

Tired, hungry and making life-or-death decisions

Workplace stress is not unique to the medical profession, but the profound physical and emotional demands inherent to its training raise questions about its consequences. Dr. James Knutson reflects on the intense life of a first-year medical resident.

By Jessica Scarpati, Enterprise staff writer

   It was the first time in days that sunlight, not florescent lighting, had shone into Dr. James Knutson’s bloodshot eyes.
   He shuffled past the morning landscape of the hospital in Brockton — hurried nurses, families talking in hushed tones on cell phones and staff members on smoke breaks — as the automatic doors parted for him.
   Knutson had turned off his pager after finishing his overnight shift, but he continued to feel its vibration pulse through his fingertips.
   Sleep had become a foreign concept. He had been jolted awake several times to respond to pages from nurses who wanted him to attend to a patient, verify a medication or authorize some other order because he was the only resident on call.
   The half-dozen surgeries he had assisted on the previous morning were a distant memory. His day had started at 6 a.m., greeting patients in the pre-operative room — an hour after his alarm had roused him.
   He had spent the morning clamping arteries and navigating organs with leftover Halloween candy as his only nourishment.
   By the time his red sneakers touched the pavement outside Signature Healthcare Brockton Hospital, Knutson’s body had begun to rebel against his neglect.
   He felt woozy. Everything ached. His stomach gnawed at his insides.
   It was the day after the presidential election. He entered the hospital before polls opened and left after the country had picked a new president.
   Knutson, 30, one of eight residents completing his intern year at Signature, had wanted to vote.
   Someone was supposed to cover for him so he could go to the polls — but, well, now that he thought about it, Knutson wasn’t sure what happened to that person.
   Voting had become another part of life that he just didn’t have time for anymore. And at this point, he was too tired to be upset.
   Workplace stress is not unique to the medical profession, but the profound physical and emotional demands inherent to its training years — residency — raise questions about its consequences.
   How could someone underfed, overworked and exhausted be allowed to make life-or-death decisions? And moreover, who would want to?
   “I think we live lives of denial,” Knutson said. “It’s hard to know personally if your concentration or decision-making is waning.”
   Nerves frayed and eyes bloodshot, Knutson slunk behind the wheel of his Volkswagen and headed toward his South Boston condo — he could almost feel the soft give of the pillow against his cheek.
   He called his wife, Katie, to unload about his workday, only to find out that after hours of surgery and two days in the hospital, he had one more task to complete: buy furniture.
   Then he remembered e-mails he had to write. A friend he had been ignoring insisted on meeting for dinner.
   After working 30 hours, Knutson came home and only napped 30 minutes.
   “What (was), ‘I’ll just go home and go to sleep,’ turned into reinvigorating my relationship with my wife, going shopping and getting extra points there, tending to a neglected friendship, and by the time I got home, it was 10:30 (at night),” Knutson said. “I was like, ‘Whoa, this is way past my bedtime.’”
   The power went out that night. His alarm clock didn’t go off. His body jolted awake at 5:30 a.m.
   In a few hours, he would be repairing a carotid artery.
   By Thursday, he said, he felt “manic.” He had lost track of the day by mid-afternoon, despite having to write down the time on every piece of paperwork he signed.
   Breakfast had been a bag of Skittles. Lunch, a bite-sized Snickers bar.

Dr. James Knutson writes a note on his pants as he answers a page. Knutson often uses his pants as a notepad when he is on call and doesn't have a notebook handy. (Tim Correira/The Enterprise)
   When answering pages from nurses, Knutson no longer has time to look for paper. He takes notes on the leg of his pants, often upending a laundry basket to find old notes.
   At one point, he stops answering pages by phone and instead sends text messages.
   “I can’t talk fast enough, I can’t walk fast enough,” Knutson said. “On a service like this, you never do more with less — more action with less sleep, less food.”
   Residency and its demands don’t last forever, and surgery is known as one of the most taxing of rotations.
   The title “resident” is not coincidental. Before the 1980s, most states and specialties did not adopt any limit on work hours, making 100-hour work weeks common, according to the industry’s national accreditation program.
   It wasn’t until 2003 that the Accreditation Council for Graduate Medical Education, which oversees residency programs nationwide, instituted an 80-hour weekly limit in an attempt to balance education criteria with patient safety.
   Critics of the changes have suggested residents may not be able to learn all they need to with such restrictions, but there is some evidence that the standards may be worthwhile.
   A New England Journal of Medicine study following interns at Brigham and Women’s Hospital in Boston from 2002 to 2003 found they made more serious medical errors on a “traditional” schedule of 24-hour shifts every third day, as opposed to a schedule with shorter hours.
   In the study, interns on the traditional schedule made 36 percent more serious errors than those on the reduced schedule.
   But the intensity of the job may also jeopardize the health and well-being of the interns themselves.
   Numerous studies over the years have established higher suicide rates among physicians when compared to the general population.
   Because the interns at Signature are not surgical residents year-round, 80-hour work weeks are not routine, said Dr. Dale Ellenberg, medical education director at Signature. He estimated they work 40 to 60 hours per week on average for the year.
   If an intern appears severely distressed, he or she may be recommended to see a counselor or psychiatrist at the hospital, he said.
   “These are like our kids for the year, and we take that very seriously,” Ellenberg said.
   Knutson, who aspires to be a radiologist, hasn’t reached his breaking point, and said he doesn’t expect to. “There’s not a lot of quit in people that go into medicine,” he said.
Dr. Leah Palifka holds her newborn son, Zachary Michael Palifka, shortly after he was born in September at Signature Healthcare Brockton Hospital. (Tim Correira/The Enterprise)
By Jessica Scarpati, Enterprise staff writer
   It has been a tough month for Dr. Leah Palifka.
   Not that her month in ambulatory care — working in the hospital’s outpatient clinics — was unusually demanding.
   But it has been four weeks since the Brockton mom has been attached to her newborn son, Zachary Michael, who was born Sept. 24.
   “It’s hard to leave him in the morning,” said Palifka, 34, who returned from a seven-week maternity leave to Signature on Nov. 12.
   Because of the time requirements and contractual obligations of her internship at Signature, and next year at a hospital in Utah, taking any more time would’ve disrupted her path to becoming a doctor.
   Palifka said her husband, Bob, has been able to get more time off to care for the baby during the day, and the couple has gotten help from her parents, Joe and Millie Platenik.
   As for Zack, he is growing happy, healthy and chubby. Yet the new parents haven’t quite caught up on sleep yet.
   “He’s smiling, interacting and crying less — but not sleeping through the night,” Palifka said.
By Jessica Scarpati, Enterprise staff writer
   Dr. Justin Routhier already had few doubts he would become a radiologist.
   It’s unclear, however, why he is surer than ever.
   Was it that grueling summer in surgery, shortly followed by working the graveyard shift in September on the “night float” rotation?
   Or did his enthusiasm renew halfway through his intern year at Signature Healthcare Brockton Hospital because he spent October training in his preferred specialty?
   Probably a little of both, Routhier conceded.
   Though one thing is clear — his month with working with staff radiologists at Tufts Medical Center “absolutely” confirmed his aspirations.
   “One hundred times, yes. I am so glad I am doing radiology,” Routhier, 26, said with a laugh.
   After spending Thanksgiving with his family in Rhode Island, Routhier got one last chance to dip into his professional interest in early December, when he was part of a presentation at a radiology conference in Chicago.
   “It’s actually based on original research done by myself and one of my mentors at Brown” University’s medical school, Routhier said.
   The pair studied how to effectively evaluate and treat women who show abnormal results from breast MRI scans, and presented their findings to an audience Dec. 2.
   The scans often pick up anomalies missed by mammograms, Routhier said, but noted that those images could be false alarms — leading to unnecessary biopsies.
   Routhier felt a little out of place presenting the research as an intern to “radiology bigwigs,” but said he was relieved that the audience didn’t “rip them apart,” as he had seen happen with other speakers.
   As has been the theme for most of his intern year — particularly during his rotations on the medical wards — the demands of the program crimped how much time Routhier could spend at the conference.
   “The whole conference is a week long, and obviously I can’t stay,” he said the week before he flew out.
   The presentation was scheduled for a Tuesday.
   He spent Sunday overnight at the hospital on call, left work Monday morning, flew to Chicago that afternoon, presented the research Tuesday and was back at work Wednesday.
   “Internship and the medical wards in general are not conducive for time off,” Routhier said.
By Jessica Scarpati, Enterprise staff writer
   Is there a chance of a James Knutson, Jr., coming into the world any time soon?
   Not likely, says Knutson, 30, despite some goading from his wife.
   “It seems like it’s enough work to just take of myself, much less a spouse, much less friends or family, and then to have a little life that you’re solely responsible for — oh, it’s scary enough to be responsible for some of the lives here,” he said. “I’m happy to wait.”
By Jessica Scarpati, Enterprise staff writer
   While Dr. James Knutson was on the frenetic and draining surgical rotation, breakfast could be a bag of candy. Lunch? A chocolate bar.
   But throughout the rest of his intern year, he has tried to squeeze in three actual meals each day.
   Here’s the fuel this doctor runs on:
   Breakfast: Yogurt and nuts
   “They make good omelets here, and I was telling my wife about the good omelets,” Knutson began, referring to the hospital cafeteria.
   “She’s a bit of a health freak, and so she warned me about what an omelet a day would do for my cholesterol,” he added. “After being reminded of that, now I shun the omelets, sadly.”
   Lunch: Greek salad, Coke Zero and an oversized chocolate chip cookie
   “Despite the fact that we’re up all the time and we’re kind of almost always in motion, supposedly people put on a ton of weight in intern year and during residency,” Knutson said.
   “The Coke Zero and the salads are an effort into fooling my body, I guess, that I’m full,” he added. “But I’m pretty sure the cookie is what I’m running on for the rest of the day.”
   Dinner: On nights off, eat in or go out
   “If I’m here and I’m on call, then all the rules are out the window — it’s always chicken fingers and french fries,” Knutson said.