The Price of Shift Work

FigureMany physicians chose emergency medicine for the reliability of scheduled shifts, and they 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 physically and emotionally. A recent exchange on emed-l, the emergency medicine mailing list, about the challenges of shift work in emergency medicine raised several issues, including drug and alcohol use, sleep patterns, family schedules and support, scheduling arrangements, compensation arrangements, and personal preferences for particular shifts. (Subscribe to emed-l at www.ncemi.org/cgi-ncemi/edsubscriber.pl.) 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. 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 supportive of individuals and concerned about the risk of inappropriate use of pharmaceutical agents. One colleague in the discussion commented 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 it as key to achievement and well-being in our profession. This past week, in presenting at a conference on the history of resident training in emergency medicine, I had several founders of our specialty call into the conference. Without prompting, they remarked about the joy they experienced from their practice and the importance of maintaining physical and emotional fitness in their sixth and seventh decades of life. Discussing shift work with your group can only be worthwhile For the sake of wellness and because of observations of my colleagues' struggles in coping with shift work, I'm taking up this topic again. I've dusted off my NordicTrack, and 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 a.m., noon, and 8 p.m. to ensure that part of every night would be spent in one's own bed and so that commuting times would be offset from rush hours. That seemed sensible to me until I spoke to several female physicians in our group, and even those who commuted by car were unhappy with the prospect of driving city streets at 4 a.m. The solution will have to be local to your group. Another emergency physician suggested that if some physicians agreed to reduce their incomes by $5000 to $8000 a year, enough money could be pulled together to support several physicians who would preferentially work night shifts. “I recommend a solution that creates wide enough differentials for night and weekends until “happiness is maximized.' I suspect there is no ideal formula,” said one contributor. “At my last job, we increased the base rate by 25 percent for all hours after 8 p.m. 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 emed-l participants remarked how a reduction in hours and incomes had simplified their lives, reduced their possessions in number and grandeur, and made them more able to enjoy 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. The discussion also noted that genetic and personal preferences for shift work and night work would always be part of the mix. One participant remarked: “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 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 portion of current practitioners. Getting this issue out into your group discussions and planning can only be worthwhile. I encourage you to review the ACEP policy statement on shift work (www.acep.org/1,4244,0.html) and a Canadian Journal of Emergency Medicine article on the issue (www.caep.ca/004.cjem-jcmu/004–00.cjem/vol-4.2002/v46–421.htm#Optimizing%20shiftwork%20in%20EM), and then raise the discussion in your own group — soon.

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