In the last few hours of his Sunday morning shift, an alert Dr. Ben Papoi strolls at a trotter’s pace through the quiet corridors of a hospital, quick, determined.
Sunday morning usually doesn’t draw the crowd the third-year resident physician sees during the week.
After 24 hours of being on call at the hospital, he weaves through the halls knowing exactly which room on which floor he is going to.
At 9 a.m. this Sunday, he makes his first stop to see a patient in the neuro-intensive care unit on the sixth floor of Lansing’s Sparrow Hospital.
As the female patient lies in her bed, alone in a dark room looking out into gray abyss of the capital city, the silence is broken by the rhythmic pulse of the heart monitor.
Papoi checks in.
“Do you know where you are right now?” he asks. “Which hospital are you in? Can you tell what day it is? You’re close. It’s the third.”
He whips out an electronic organizer and free hands the letters a, b and e.
“Can you read that?” he asks. “It was a trick question.
“Do you know who the president is? Which one?”
She passes the test. The patient is recovering from a fall in which she landed on her head, causing subdural hematoma, a collection of blood on the surface of the brain.
After he recorded his observations, it’s back to the stairs to do what he calls the best exercise he gets at work.
This routine occurs every four days for intern resident physicians at Sparrow.
One day earlier, Papoi started a shift day at the hospital - again working a 24-hour shift - where he delivered a baby.
“You’ve got a pager going off every five minutes over a 30-hour period. It’s mentally taxing and it’s physically taxing.”
Papoi, a graduate of MSU’s College of Osteopathic Medicine, said he is used to it through a routine of preparedness.
Papoi has learned a few tricks during the years to keep his sanity. He said he plans for being up all night and prepares for the level of work he has to do that day.
“If you come in expecting to work, and you are going to do a 30-hour shift, and you are going to be awake for all of it, you probably start preparing a day out,” he said. “You eat well, you get a lot of sleep the night before. You don’t stay up and watch Jay Leno or David Letterman. You go to bed and you get some sleep.”
Papoi also spends an extra 15 hours per week as a private physician in the community.
The length of shifts is just one issue being pushed through the U.S. House of Representatives. Across the country, a massive overhaul of the health care industry may change the way hospital employees work.
If U.S. Rep. John Conyers Jr., D-Detroit, gets his way, MSU medical students can look forward to less stress and fewer hours during their residencies.
MSU’s chapter of the American Medical Student Association welcomed the congressman to speak to the university in January.
Conyers introduced the Patient and Physician Safety and Protection Act on Nov. 6 before the House. The bill would limit the number of hours resident physicians can work to 80 per week. It also proposes a 24-hour work-shift limit, one day off per week and to provide funds for additional hospital staff.
AMSA, the nation’s largest medical student organization, asked for Conyers’ help less than a year before the bill’s introduction.
“This is like asking somebody ‘Do you think it’s a good idea to stop beating my wife?’” Conyers said. “This is not a highly controversial issue. This is a piece of cake, it’s simple, it’s not rocket science. Long hours are bad medicine.”
Conyers expects the bill to pass by November.
AMSA says a lack of enforcement still forces residents to work up to 120 hours per week - 17-hour days. An AMSA study reports after 24 hours without sleep, doctors have the cognitive ability of having a 0.1 percent blood alcohol level.
“We don’t let people drive, but we do let residents work on patients,” said Stacey Wiles, a second-year medical student at MSU.
Wiles said this bill is aimed at protecting residents and patients.
Robert Levy, legislative affairs director of the American Medical Student Association, said the reason residents are working long hours is economic, and hospitals are cutting labor and aid from the nursing staff.
“In the last 20 years, there has been a shift in purpose from focusing on patient care and residence education to the service to patients and service to the hospitals,” Levy said. “When you’ve been up for 36 hours straight, and you are working 120 hours per week, things are going to happen, medical errors are going to occur and their attitudes toward patient care is going to suffer.”
Dr. Kenneth H. Musson, president of the Michigan State Medical Society, said the medical community constantly finds itself overworked.
“There are probably situations where resident physicians are working longer than they should,” he said. “That is not a healthy situation.”
Musson doesn’t think doctors working 80 hours a week is excessive.
“Some people are better equipped than others. It depends on the individual,” he said. “If you say physicians should work 40 hours per week, you will have physician shortage.”
Dr. Wendy King, a third-year internal medicine resident at Sparrow, said she isn’t allowed to work more than 80 hours per week.
“That is very strictly enforced,” King said. “We work nowhere near those hours.”
King said she is required to fill out a form answering whether she works more than 80 hours after every rotation.
Dr. Michael Zaroukian, director of MSU’s Internal Medicine Residency Program, oversees 31 residents.
Since Zaroukian was a resident in the early 1980s, he said several changes have occurred.
“There has been a lot of progress I’ve seen since I started my residency, in patient safety and avoiding resident fatigue. Some people think nothing has changed. There were no limits on the number of patients a resident could see,” he said. “There were no requirements for an attending physician to be there to supervise the residents. It is more humane now than it was.”
He said it is necessary to work more than 40 hours per week to get the amount of training done in a specified amount of time.
“One of the benefits of the bill, if it is written correctly, is it would require rest at a certain point of time,” he said. “They must then turn over their care to another resident with more rest. If there is a need to protect against excessive fatigue, any bill should allow for flexibility to make sure residents get enough rest and get the education experience they need.”
Second-year medical student Ryan Burri said he is looking forward to seeing this bill pass in the interest of patients and personal safety, though.
“I don’t think anybody wants a doctor who has been up for 24 hours trying to figure out what’s wrong with them,” he said.
Papoi not only knows the effects of sleep deprivation, but he is aware this issue isn’t so simple. Papoi said if the legislation passes, he would spend more time in the hospital working shorter stints.
“The opposite side of all of this, that most residents have figured out by the time they get to the end of their residencies, is that if we were to change the call schedule so that you never had to work more than x hours per day, it would mean we would have more calls,” he said. “I don’t think there is a doctor in America that would dispute that sleep deprivation causes some level of impairment of your judgment.
“If we came up with a new plan, I would end up doing four or five or six calls in a two-week period,” he said. “I wouldn’t mind ruining one night a week, but I sure would hate to ruin three or four. That’s lost time with my family. I believe their goal is to make health care better and safer for the patient. But to go in and revamp the system legislatively and say this is how things have to be and this will make things better for the patient - this may have some long-term ramifications that they are probably not aware of.”
Patient face-time
For the amount of time Papoi spends with patients, he said he typically spends more time getting lab reports and reviewing charts.
Papoi said his alertness depends on how much sleep he gets the night before. On a typical call night, he probably gets two hours of sleep, and that depends on where he is in the hospital.
“If you’re on intensive care, you probably won’t get any sleep at all. If you’re on the baby-delivering service, like I was, you could get eight hours. Typically, if I am on call Saturday and going to be up all night, I’m going to take it easy Friday night. The hours are fine. A lot of people work 100-hour work weeks. There are some residents that would complain about the number of hours, but very few.
“It is difficult for the typical person who wants to go to med school who wants to understand what they are subjecting themselves to.
“They get a taste of it and in their third and fourth years of med school, but the internship, you are facing one of those tortuous 30-hour calls. By the time you get to the second month, you realized you are going to be on call every fourth night.
“It’s just part of your life. Most residents would acknowledge there are people out there that have worked just as hard as we do. When you are an intern you don’t realize that, but as you progress you realize you don’t have a lock on the workload. Although we still complain to each other - and our spouses when they let us.”
At-home life
For the most part, Papoi said his residency doesn’t interfere with his family life. Being the husband of a working mother in law school while parenting his 9-year-old daughter, he hasn’t had trouble balancing his job and his family.
“We know in advance our call schedule - we know the nights we are on call so we just work around that. It’s pretty difficult for single mothers and single fathers, if they have kids.”
The biggest concern from first-year interns is how difficult the nights are, because they have to do it every four nights for a year.
“It is not the hours per week that kill us, it’s having to work 34 hours in a row,” he said. “There is a difference between up all night, like I was last night, and sitting around waiting for babies to be born, and being up all night and going from room to room. People are having heart attacks, and you’re resuscitating them. You’re putting in lines so they can get the appropriate medications. You’re constantly on your feet not getting anything to eat. By the time you get to this point in the morning and it’s been 26 hours that you’ve been awake, it can be pretty frazzled.”
But Papoi said he is on call only 25 or 30 times a year because he is close to his graduation from his residency, which comes in June.
“I actually feel pretty good,” Papoi said as he came to the end of his 28-hour shift. “Tired, but not go-to-sleep-tired. Typically, I go home and start doing stuff with my family. Sometimes you hit a wall and just have to nap. Some days you don’t, some days you just power through.”
He leaves the hospital parking lot and shuffles into Lansing’s traffic - after 28 hours of sleeplessness.
“It’s typically not a big deal for me,” he said. “There were days when I drove home as an intern and I don’t remember driving.”
Casey McNenly can be reached at mcnenlyc@msu.edu.
