Originally created 05/04/01

Exhausted efforts



Nearing the end of a grueling 36-hour shift, Paul Houle was actually looking forward to more work.

"Am I tired? No. I'm going to go home and build my son's swing set," said Dr. Houle, a fifth-year resident in neurosurgery at the Medical College of Georgia and the Augusta Department of Veterans Affairs Medical Centers.

Earlier this week, advocacy groups petitioned the Occupational Safety and Health Administration to limit the shifts residents like Dr. Houle can be forced to work, such as keeping to a still daunting 80-hour week.

"I think 80 hours sounds awesome," said Dr. Houle, 33, who has about a year left on his residency. Advocates such as Washington-based Public Citizen are taking the approach that the federal government should limit resident shifts to protect the residents and the public in much the same way that it already limits how long a truck driver can drive or a pilot can fly.

"If it is important enough to get a tired trucker off the road, it is important enough to prevent an exhausted resident from entering the operating room," said Peter Lurie, deputy director of Public Citizen's Health Research Group.

The petition asks that OSHA limit shifts to a maximum of 24 hours, require a minimum of 10 hours between shifts and limit the number of nights on call to no more than every third night. MCG already tries to limit on-call shifts to every third night and gives residents at least one day a week off, said pediatric neurosurgeon Ann Marie Flannery, associate dean for graduate medical education at MCG. Of the 37 residency programs and 390 residents at MCG, very few exceed those limits or see the 80-hour weeks, Dr. Flannery said. And there is an extensive system of backups, from a senior resident to an attending physician, to ensure that patient care isn't compromised, said Dr. Flannery, who oversees the residency programs.

"In general the structure here and elsewhere is to focus on patient safety," Dr. Flannery said. "People are very conscientious about the fact that while residents need to have exposure to a broad range of patients, and broad groups of diseases, and that it is good for their education to experience these conditions over longer periods of time, we also want to be sure our patients are getting the very best possible care."

In its petition to OSHA, Public Citizen and groups such as the Committee of Interns and Residents, a union representing 11,000 medical residents, cite the physical and mental impact exhaustion has on residents. For instance, six of seven surgical residents report falling asleep while driving, a nearly universal experience for them, according to an informal survey published in 1988 in the Journal of the American Medical Association.

Sure, Dr. Houle said, it has happened to him.

"I've fallen asleep at a red light," he said. "Someone knocked on my window."

While it would be nice to have limited shifts, Dr. Houle said, it leaves open a big question.

"Who else is going to do it?" Dr. Houle asked. "People don't get sick between the hours of 9 to 5."

That is part of the reason why residents are pushed into long hours because it allows hospitals to take advantage of the relatively low salaries residents are paid and avoid hiring additional, and possibly more expensive, support staff, Dr. Lurie said. But it would be unfair for the federal government to cap the hours residents can work and also cap the number of residencies that Medicare will pay for, Dr. Flannery said.

And it may lengthen an already lengthy residency period, which Dr. Houle said he would rather avoid. The long hours come with the territory, and you adjust, said Dr. Houle.

"Medicine isn't an ideal environment," Dr. Houle said. "If things go wrong, if people get sick, you have to be there all the time in order to learn. It takes a long time to get that experience and with that experience comes confidence."

Reach Tom Corwin at (706) 823-3213.