WELLNESS Dark Nights, Dark Moods: Recommendations for Fatigue Mitigation for Emergency Physicians

By Katren Tyler, MD, Simiao Li-Sauerwine, MD, MSCR, Mengchen Cao, MD, Ashley Palmer Stevenson, MA, MS-4, Amanda Deutsch, MD, and Al’ai Alvarez, MD, on behalf of the SAEM Wellness Committee

Fatigue contributes to safety lapses, errors, and burnout Fatigue affects performance by increasing reaction times, impairing situational awareness, increasing lapses in attention, and impairing reasoning. The effects of fatigue have been demonstrated in multiple industries, including health care. We present a framework for contributors to fatigue and suggestions for solutions to mitigate fatigue in emergency medicine (EM) physicians.

Types of Fatigue

There are three primary types of fatigue.

1. Transient fatigue — a short-term fatigue experienced after sleep restriction or extended periods of being awake over several days;

2. cumulative fatigue due to repeated mild sleep restrictions or extended hours awake across several days; and

3. circadian fatigue, which refers to reduced performance when the individual is usually asleep and is often felt during the individual’s window of circadian low (WOCL) — typically between 2-6 a.m.

Impact of Chronotypes on Shift-Related Fatigue

Fatigue is directly associated with shift work, especially cumulative and transient circadian rhythms disruptions. Chronotypes are defined as the timing of natural mid-sleep on workfree days. Chronotypes tend to shift earlier with age, although substantial individual variation exists. Scheduling against chronotype, such as a late chronotype physician working an early shift, contributes to all three forms of fatigue, especially circadian fatigue. Circadian fatigue, or social jetlag, is a complex interplay between the social clock, the sun clock, and our biological clocks. Switching from standard time to daylight savings time in the spring leads to circadian fatigue, despite the time change of only 60 minutes. Many experience circadian fatigue when traveling across time zones. EM physicians will generally experience the most significant circadian fatigue during and after overnight shifts, and it may take several days to return to baseline. Early chronotype physicians are more likely to struggle with night shifts, while late chronotype physicians struggle with early shifts.

Shift Scheduling and Work-Life Integration

EM physicians have various roles outside of clinical work. Nonstandard working hours can be productive but draining. Navigating work schedules to meet other life demands is challenging for EM physicians. EM departments should ensure that at least one daily shift fits within the regular business day to facilitate child or elder care. This is especially necessary for EM physicians who are single parents or functionally single parents (e.g., with a significant other who is deployed, longdistance or travels frequently for work). The department’s burden of overnight shifts may decrease by incentivizing a nocturnist team with fixed scheduling or shift/pay differential.

Interactions Between Personal Health and Shift Work

EM departments must have guidelines for facilitating time off during pregnancy and postpartum periods for faculty needing assistive fertility treatments, faculty with aging family members, planned procedures, and unexpected illnesses. At other times, EM physicians must use leaves of absence for an extended period, including weeks to months off the clinical schedule, which may necessitate adjustment of clinical hours for a given year.

Recommendations for Pregnancy

Night shifts and extended work hours are associated with adverse pregnancy outcomes in the first and third trimesters. Whenever possible EM departments should avoid scheduling pregnant physicians for these periods of increased risk. To reduce burdens on colleagues in case of late-term calloffs, prioritized scheduling of alternative clinical duties (e.g., telehealth services) allows physicians to keep working without depleting limited parental leave. Prioritized scheduling for more easily coverable/cancellable shifts is another option.

Night Shifts and Physician Age

Chronotypes tend to shift earlier as we age. For many physicians beyond middle age, late or night shifts become more grueling and arduous, and the duration of circadian disruption following a night shift is extended. Extrapolating from work in other health care professions and from other industries, EM physicians should be able to opt out of night shifts from an age that the physician and the department agree is feasible and achievable; we recommend that EM physicians should be able to opt out of night shifts at age 50.

Allowing for Fatigue Mitigation on Shift

EM departments should also provide time and space for clinicians to take short breaks during shifts. Research shows that microbreaks and 6-20 minutes of intentional rest are enough to improve concentration and reduce errors in judgment. Caffeine naps have more benefits than caffeine or a nap alone. Crucially, this involves ingesting the caffeine equivalent of an espresso and directly followed by a maximum of a 20-minute nap. This nap period offers the sleep benefit while the caffeine takes effect. Alternatively, those struggling to nap quickly may use non-sleep deep rest (NSDR) techniques, which utilize a full body scan and provide instructive relaxation, leading to rejuvenating benefits. NSDRs are easily accessible by phone and can be done within a 15-minute break during a shift. Finally, to prevent motor-vehicle crashes and nearmisses from micro-sleeping while driving EM departments should provide sleep pods and ride-sharing options at the end of shifts, whenever clinicians feel unsafe driving due to fatigue.

Fatigue Mitigation for Physicians is a Shared Responsibility and Essential to Quality Patient Care

Fatigue management in health care is a complex problem with multiple layers and should be considered part of a patient safety framework. Substantial evidence from other industries and the chronobiology literature shows that the risk of safety lapses, near misses, and errors increase as fatigue progresses Health systems should recognize the inherent shared responsibility of fatigue management for all health care workers and acknowledge that shiftwork tolerance may change over time. The shared responsibility for fatigue management should include preferential scheduling for periods of physiologic challenges such as pregnancy, fertility treatments, aging, planned procedures, unexpected illnesses, and flexible scheduling options around caregiving burdens for young children, family members with disabilities, or elder care.

Fatigue in physicians with shift-based scheduling is inevitable. Still, with planning and institutional infrastructure, we can mitigate the impact of circadian rhythm disruptions, optimize physician well-being and professional fulfillment, and address attrition and burnout that ultimately impact patient care.

Recommendations

1. EM departments should provide anticipatory scheduling for pregnant physicians to mitigate pregnancy complications and facilitate parental leave following delivery. Accommodations include limiting required night shifts in the first and third trimesters and offering modified clinical schedules from 36 weeks’ gestation.

2. EM departments’ clinical schedules should allow interface with standard child or elder care hours.

3. EM departments should have easily accessible, formal, and clear Family and Medical Leave Act policies.

4. EM departments should allow EM physicians over the age of 50 to opt out of night shifts.

5. EM departments should consider individualized chronotype scheduling for EM physicians.

About The Authors

Dr. Tyler is vice chair of geriatric emergency medicine and wellness in the emergency department and the medical director for physician wellbeing at the University of California Davis. @katren_tyler

Dr. Li-Sauerwine is assistant residency program director and clinical associate of emergency medicine at The Ohio State University. @theSimiao

Dr. Cao is an assistant professor in the department of emergency medicine at UT Southwestern Medical Center.

Ashley P. Stevenson is a medical student at Stanford University School of Medicine. @ashpalm

Dr. Deutsch is a clinical instructor in emergency medicine and an emergency medicine wellness fellow at Stanford Emergency Medicine. @amandajdeutsch

Dr. Alvarez is director of wellbeing at Stanford Emergency Medicine and chair of the SAEM Wellness Committee. @alvarezzzy