Written by Katren Tyler, MD Clinical Professor of Emergency Medicine, Medical Director of Physician Wellness, Age-Friendly Emergency Department Physician Lead, Geriatric EM Fellowship Director, Vice Chair for Geriatric Emergency Medicine and Wellness, UC Davis.
Reprinted with permission from “Systems and Departmental Responses to Fatigue Management” SAEM Pulse, Nov-Dec, p50, Copyright 2022 by Society for Academic Emergency Medicine.
Many of us started our EM careers as bright-eyed, twenty-somethings who had no problems with shift work, working multiple overnight shifts and rapid schedule transitions. And frankly, this is reasonably easy to keep up in our 30’s as well, even as our external responsibilities get more complex. And then your 40’s happens.
Ludicrously, I have done two residencies in Emergency Medicine – one in Australia and one in the USA. But in this regard, I am a bona fide expert – in my adult life, I have never not been a shift worker. As a resident in Australia, I spent more than 20 weeks in a year on a rotating night-float shift schedule and loved it. Night shifts: I used to love them. I was a night owl and proud of it. Until I didn’t and wasn’t.
I don’t like night shifts anymore. I understand that we are a 24/7/365 business. But now, in my 50’s, I am at my best early in the morning – the circadian opposite of being a nocturnist Night shifts are, without a doubt, my highest risk for a cognitive error at work, and I don’t think I am alone.
Chronotypes are how sleep researchers describe your chronobiology. Your chronotype reflects your individual preference for going to sleep at night and getting up in the morning. As much as possible, you should estimate your chronotype when you are free of the external responsibilities of your life – work, kids, pets, all the business of modern life temporarily aside – ideally when you are on a vacation or at least on a non-work weekend. For the most part, researchers classify chronotypes as early, intermediate, and late. Sleep researchers recommend that we should try and make your work schedule match your chronotype. Obviously, this is a challenge in our specialty. For many people, our chronotype gets earlier as we get older and our tolerance for late and night shifts is reduced.
In healthcare, we place most of the responsibility for coping with shift work on the individual healthcare worker. System and department wide responses to the impacts of shift work as we age, or experience other physiologic challenges are limited. My call to arms for fatigue management systems is that our lack of protections for shift workers are also likely harming our patients, and that surely makes it a systems issue.
We know that shift work is a burden for emergency physicians and their families in terms of circadian desynchronization and fatigue. The evidence is clear: shift work, especially night shifts, get harder as we get older; night shifts are associated with short-term cognitive impairment across all industries. Moreover, longer periods of duty, especially longer night shifts, are associated with short–term cognitive impairment and increased errors across all industries.
We have known for decades that sleep deprivation can be as serious as alcohol intoxication. It is unacceptable to be inebriated at work. Yet we idealize and reward being exhausted in medicine. We have socialized and normalized fatigue in medicine for decades, recent changes notwithstanding.
Healthcare in general, and EM in particular, has not acknowledged the cognitive load and patient safety risks of shift work. There are very little systemic protections for physicians after training, and honestly, not that many protections during residency. We do not systemically evaluate if individuals tolerate shift work. Even if we acknowledge differences, we almost always put the responsibility on the individual. Multiple studies in healthcare and in other industries show people make more cognitive errors the longer that they have been awake. It will not surprise you to learn that other industries, especially the airline industry and some manufacturing industries have made stronger commitments to fatigue management than medicine has. Sleep is the only way to reverse sleepiness. Fatigue management systems promote a shared responsibility between the employee and the system. Sequelae of shift work include social jetlag / circadian desynchronization, cognitive impairment, and sleep disruption. Suggestions for protecting healthcare shift workers, and their patients, include evaluating the risks to ourselves and our patients, including pregnancy outcomes in health care workers, chronotype scheduling, access to sleep clinics, breaks on night shifts or extended shifts, access to food and water including cafeteria access, and the availability of call rooms or rideshare options. Driving home after a night shift is a significant risk for motor vehicle crashes. We have work to do on the systemic role of sleep and aging physicians; most literature acknowledges sleep deteriorates with age, especially in shift workers.
As people age, our chronotype typically gets earlier, meaning we generally need to go to sleep earlier and wake up earlier. We typically experience this change starting in our mid 40’s. If you are lucky, you have some late chronotypes on your faculty. Physiologically, late chronotypes can tolerate later shifts, including night shifts, with more sleep before and between night shifts. Late chronotypes may struggle with early morning shifts. Some individuals keep the same sleep-wake patterns they had when they were younger, are better able to tolerate shift work as they get older and are referred to as healthy shift workers.
Many departments have night shift crews and incentivize the night shift: the night shift crews should be incentivized as much as possible in time or money.
In our department, for some years, we have been able to opt out of night shifts at 55, and recently lowered the age to opt out of night shifts to 50 years of age. This earlier opting out of night shifts at age 50 added 2-3 nights shifts per year to those faculty less than 40.
Pregnancy is a common physiologic challenge faced by healthcare workers and the health systems that employ them. Pregnancy outcomes are worse in shift workers and those working longer than a standard 40-hour week. It is harder to protect the first trimester because schedules are often in place before people know they are pregnant, but protecting the third trimester and parental leave periods should be more straightforward than many EDs make it. Our department has adjusted our shift requirements for pregnant faculty so that there are no required night shifts in the third trimester, and no clinical shifts in the emergency department after 36 weeks’ gestation. As a department, we do have the option of telemedicine if pregnant faculty need to keep working clinical hours. Our health system provides 90 days of pregnancy leave for all faculty.
Moving forward, we should think about how we collectively protect ourselves and each other from the impacts of shift work – for ourselves, for our colleagues and for our patients.