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.
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.
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.