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Work shift duration for emergency physicians – the shorter, the better

the French Experience

Philippon, Anne-Laure

European Journal of Emergency Medicine: December 2019 - Volume 26 - Issue 6 - p 396–397
doi: 10.1097/MEJ.0000000000000639
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Emergency Department, Hôpital Universitaire Pitié-Salpêtrière, Assistance-Publique - Hôpitaux de Paris (AP-HP), Paris, France

Correspondence to Anne-Laure Philippon, MD, Emergency Department, CHU Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris, 83, boulevard de l’hôpital, 75013 Paris, France, Tel: +33 6 24 62 50 41; fax: +33 1 42 17 70 01; e-mail: annelaurephi@gmail.com

What do we know about the impact of extended shifts? We know that this is bad for both patients and physicians. Since the early 2000s, many studies have compared the impact of extended versus limited shifts. Landrigan et al. [1], in 2004, showed that interns in intensive and coronary care units made 36% more serious medical errors during an extended-hours schedule than during a limited-hours one. Further reports have also showed that reducing interns’ extended work hours would increase sleep duration and decrease attentional failures during overnight duties [2]. Extended-work shifts also affects physicians themselves as highlighted in two studies that reported an increased risk of percutaneous injuries and of motor vehicle crash [3,4].

Moreover, many studies reported an impairment of the physicians’ performances after a night shift. In fact, cognitive performance decreases after a night shift and with it our working memory capacity, speed processing information, perceptual reasoning and cognitive flexibility [5]. When comparing extended shifts with shorter ones, Arnedt et al. [6] found an impaired performance among the interns, comparable with impairment associated with a 0.5 g/L blood alcohol concentration. In France, Persico et al. [7] found a decrease in cognitive performances after a 24-hour shift, which was not reported after a 14-hour shift. These cognitive performances are involved in the emergency physicians’ abilities to sort out patients, make diagnoses and apply algorithms. More recent reviews reported some positive effects on the patients’ safety and on residents’ quality of life when reducing or eliminating work shifts exceeding 16 hours [8,9].

Extended shifts also have a cumulative impact that can affect long term health. Reports show that emergency physicians are subject to circadian rhythm sleep disorders, that they also have poor sleep quality and that it is worse compared to the “normal” population [10,11]. These disorders can lead emergency physicians to a higher risk of overuse of pharmacological sleep aids (benzodiazepine, alcohol, and melatonin) after or within the night shift or to a consumption of stimulants (coffee and modafinil) to help within the night shifts [12,13]. The last important point is the perception by emergency physicians of the sleepiness within the shift and on his consequences. Sleeping during the night shift is not a good sleep: it is a fragmented one, of poor quality and leads to impairment of waking activity [14]. In addition, emergency physicians overestimate their cognitive or physical conditions after a nightshift [7].

Those different works allow us to describe an emergency doctor after extended night shifts: exhausted, performing similarly to a drunk person, with reduced capability for work due to the loss of several abilities. They are prone to making medical errors and can also endanger their own life. The longer they work, the less effective they become.

Following these findings, in 2017 the American College of Emergency Physicians recommends that emergency services organize themselves so that working hours do not exceed 12 hours in a row: ‘Overly long shifts […] should be avoided whenever possible. In most settings, shifts should last twelve hours or less’. And when they talk about duration of 24 hours, it is to recommend ‘that practitioners have regularly scheduled periods of at least 24 hours off work’.

In France, most emergency departments have adopted the 14-hour shift as the longest shift. However, a proportion of ‘irreducible emergency workers’ still hold out against the change, especially among prehospital physicians. Most of them are still happy to 24-hour shifts. What are their main reasons for this preference? First, they prefer to combine their shifts, in order to have fewer commutes to work and more days off at home, even if those days are between extended shifts. Second, for those whose work is exclusively in the prehospital environment, they simply do not believe that an extended shift may put them at risk, especially because they can have rest periods between patient.

In my department, we recently proposed to decrease shifts times during the weekend from 20 to 14 hours. Because there was clearly contention within the workforce regarding whether reducing shift time would be popular or not, a vote was organized with the choices of retaining the existing shift duration or reducing them. Maintaining the existing shift duration won by a single vote, with the primary argument being that maintaining extended shifts enabled more weekends off than would exist in reduced shift durations.

Nevertheless, in the light of what we have just described, we can ask several questions: is it still reasonable to work in a 24-hour shift when we know that it could be unsafe for the patients or for the physicians themselves [1–4]? And is the life outside the hospital pleasant when you are tired, suffering from sleep disorders? So even if we believe that spending more time away from the hospital is good for us, we can really ask the question of the real quality and benefices of these times [9].

As underlined by Votey [15], ‘circadian disruption and sleep deprivation have been the Achilles heel of emergency medicine […] we have responsibility to address sleep deprivation among the practitioners of emergency medicine as an important wellness issue for ourselves and our peers’. So let us take the issue in a different direction: the shorter we are at the hospital, the better we are for the patients and for ourselves. Therefore, it is our responsibility to stop our extended shifts in order to increase safety of both patients and emergency doctors. It is the responsibility of legislators and stakeholders to prevent physicians to work 24-hour shift, and most importantly, our national scientific society (French Society of Emergency Physician SFMU) needs to have a clear position on this important matter and should make a clear statement as this is its responsibility and duty.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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References

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