Thursday, April 15, 2004

The Price of Shift Work

Many have chosen emergency medicine for the reliability of scheduled shifts and willingly take their turn as the schedule calls for it. Yet, as some are quick to assert, working shifts on a schedule imposes a discipline that can be costly both physically and emotionally.

A recent exchange on emed-l, (subscribe using the ED Subscriber) the emergency medicine mailing list, about the challenges of shift work in emergency medicine raised issues including drug and alcohol use, sleep patterns, family schedules and support, scheduling arrangements, compensation arrangements and personal preferences for particular shifts. Though not mentioned in that discussion, another “price” I observe in some settings is how scheduled shift work seemingly contributes to an erosion of professionalism among emergency physicians more generally.

The discussion included an exchange regarding various pharmaceutical agents as a tool for shifting between days and nights. This portion of the discussion included some personal experience, but mostly was theoretical or focused on military operations and advice for seeking neurological, sleep or psychiatric evaluation as appropriate. The nature of the discussion was both supportive of individuals and concerned about risk of inappropriate use of pharmaceutical agents.

One colleague in the discussion proffered a comment that “ . . . ours is an unforgiving specialty, that demands great health and is difficult to practice when one is not 100%. If you are one step slower and can’t pull your weight (especially under a compensation system that is based upon RVUs) you lose the esteem of your colleagues who pick up the slack. I have not seen much discussion about this issue as related to the ‘unexpected consequences’ of implementing this type of incentive [compensation] system. Clearly, as our thought processes and bodies slow, we will develop divides in groups.”

Regular readers know that I?ve long focused on internal motivation and supporting that internal motivation as key to both achievement and well-being in our profession. This past week, in presenting a conference on the history of resident training in emergency medicine, I had several founders of our specialty call into the conference. Without any prompting they included as a common theme in their closing remarks the joy they experienced in their sixth and seventh decades of life from their practice and the importance of maintaining physical and emotional fitness.

It’s for that reason of wellness and my observations of my colleagues’ struggles in coping with shift work that causes me take up the topic this month. So even as I’ve dusted off my own NordicTrack©, I’ve begun investigating some of the practical advice raised in the emed-l discussion that was new to me.

I was particularly struck by one commentator’s recommendation to move eight hour shift starts to 4 AM, Noon and 8 PM as a means of assuring that both part of every night would be spent in one’s own bed and so that commuting times would be offset from rush hours. Seemed pretty sensible to me, until I spoke to several women physicians in our group, even those who commuted by car were unhappy with the prospect of driving city streets at 4 AM. So, further evidence that the solution will have to be local to your group.

Another discussion point was the suggestion that for a reduction in income of a $5-8000 annually, enough money could be pulled together to support several physicians who would preferentially work night shifts. One contributor elaborated, “I recommend a solution that creates wide enough differentials for night and weekends until ‘happiness is maximized.’ I suspect there is no ideal formula. At my last job, we increased the base rate by 25% for all hours after 8 PM and for weekends. We also had two weekend days and three weekend nights (Friday, Saturday, and Sunday). Further I think our specialty should promote career night owls, just like we see with nurses. I think such docs assuming they have excellent clinical and interpersonal skills are worth twice the usual rate.”

Several commentators remarked upon how with a reduction in hours and incomes they had simplified their lives, reduced their possessions in number and grandeur and were enjoying more time with their families. Yet, others at different points in the cycle-of-life remarked that they couldn’t forgo the income such a reduction in hours would necessitate.

Lastly, the discussion brought out a considerable body of opinion that there were likely genetic and personal preference factors for shift work and night work especially that would always be part of the mix. One participant remarking, “A neurologist who specializes in sleep disorders told me that there is no solution to shift work—some people like it and some are constitutionally not suited for it. I personally don’t think that playing around with circadian rhythms helps anybody. I’ve been doing nights for 30 years and I like it. One thing I’ve found it is that the ‘night after’ is important. This is the night when you’re re-acclimating, and you’re not good for much, so it’s a night of ‘entitlement,’ when you can see a schlock movie, read a mystery story, watch a cable basketball game—whatever, with no guilt.”

Though many residents are graduating training in emergency medicine every year, we “baby boomers” constitute a considerable fraction of current practitioners. Getting this issue out into your group discussions and planning can only be worthwhile. I encourage you to review some of the resources I’ve noted below, but then raise the discussion in your own group and soon.


1. ACEP policy statement on Emergency Physician Shift Work (Policy #400166) approved September 2003.

2. Frank JR and Ovens H: Shiftwork and emergency medical practice. CJEM/JCMU 4(6):421ff, November 2002.

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