Circadian Rhythms: Challenges for the E.D. Provider

Posted on Wed, Aug 10, 2016
Circadian Rhythms: Challenges for the E.D. Provider

By Jeff Slepin, MD, MBA, FACEP

Adequate rest and sleep are essential to preparing for and enduring a shift. These necessities contribute to physicians providing high-quality patient care and better patient experiences. Yet, consideration of the circadian rhythm, the natural 24-hour body-clock, in the design of an emergency department (E.D.) work schedule can cause quite the scheduling conundrum for scheduling and an ongoing challenge for the provider.

The topic of the circadian rhythm and challenges of shift work in the practice of emergency medicine are not new.  They remain a topic of discussion in the clinical practice, business operation and academic emergency medicine settings. An erratic schedule can be one of the most stressful aspects of the practice of emergency medicine. The American College of Emergency Physicians (ACEP) issued a policy statement in 1995 regarding shift work. ACEP noted that, “Well-being is adversely affected by constantly rotating shifts; the effects of rotating shifts are cumulative, and represent the most important reason physicians leave the specialty.” The policy included scheduling options that take into account factors regarding circadian rhythms based on research findings showing the detrimental effect of shift work on emergency physicians’ longevity. If not properly managed, shift work continues to be one of the most significant risk factors for attrition from the practice of emergency medicine.3

Coping with the Challenges of Shift Work

Despite the research and practical application of scheduling, there is no consistent method that works for every individual to adjust to the challenges of rotating shifts. Scheduling alternatives have included:

  • “Permanent” night shifts for a prolonged period of time (weeks, months or years)
    • Long-term adjustment of the circadian rhythm facilitates adaptation
  • Isolated night shifts (generally including the entire timeframe from 2 a.m. to 7 a.m.)
    • Easier for some providers because there is no partial resetting of the circadian rhythms
  • Short strings of night shifts – preferably no longer than three in a row
    • Resulting in less accumulation of sleep deprivation

To minimize the disruption of the sleep cycle, for providers who must work a variety of shifts, most individuals function better with rapidly changing shift times, as opposed to longer strings of shifts. A slowly rotating schedule (preferably clockwise) may allow for better adaptation to working during the night, but can result in the longer-term buildup of a sleep debt. Rotating scheduling using a clockwise rotation (morning, afternoon and night) rather than a counterclockwise rotation is less disruptive of the circadian rhythm. Humans find it easier to phase-delay than phase-advance the circadian rhythm. Clockwise shift rotation also results in a longer period of time off between shifts.

Varying shift lengths and start times may also be useful. A delay of even one hour when beginning the morning shift can result in improvement of morning workers’ sleep and alertness. The tradeoff, however, of a longer night shift may be difficult for the provider working overnight. A solution may be to start the night shift at a later hour and have longer shifts during the afternoon and evening hours, although these are generally peak times of volume and acuity in many E.D.s. Other solutions include shorter shifts, more days off after a night shift to allow for recovery, and shift differentials in compensation so that “full time” night providers can work fewer shifts.

The most disruptive schedule is one in which there are sporadic strings of night shifts interspersed with day and evening shifts. This type of scheduling leads to desynchronosis – a condition that is very difficult to cope with for many providers. Desynchronosis occurs when humans disrupt the normal synchronization of their sleep-wake and light-dark cycles, and attempt to override the circadian control of the sleep-wake cycle. This, in turn, results in an internal desynchronization between circadian rhythms and sleep. An example of temporary desynchronosis is jet lag, which results in fatigue, sleepiness, lethargy, insomnia, gastrointestinal tract disorders and poorer mental performance. Jet lag differs from shift lag because the individual experiences a rapid shift in the timing of sunrise and sunset (light-dark cycle), but generally for only a brief time. Re-entrainment, or the matching of the endogenous circadian rhythm to environmental timing clues, is aided by social cues as well as the ability to sleep during the dark cycle. Contrast this to the occasional or short-term night shift worker, who is attempting to sleep during the light period of the cycle and whose family and societal schedules are diurnal. For these individuals, family and social cues cannot be used for entrainment.

What to Do?

Understanding the circadian rhythm and its impacts on shift work are crucial not only for consistent performance but optimal outcomes in terms of patient and provider satisfaction and well-being. No particular solution works for everyone – the decision regarding how to cope with and adapt to shift work is up to the individual. Key strategies for success include having realistic expectations of performance, achieving work-life balance with compensation not necessarily being the driving factor for the volume and frequency of work, and avoiding dependence of medications, supplements or other substances (such as ethanol) to cope with sleep deprivation. Schedulers should be aware of circadian principles and be as flexible as possible in preparing schedules. Providers should protect themselves from daytime duties when working night shifts. Providers should collaborate with each other and the practice manager to facilitate a scheduling methodology that considers the importance of proper rest and preparation for work which balances the importance of not increasing the risk to patients (due to fatigue and other adverse effects of circadian rhythm disturbance) while fostering a reasonable and healthy lifestyle for providers.

Sleep Management

Sleep management is important for quality of sleep in general, but especially crucial for adjusting to shift work. The sleep environment should be consistent and dedicated to the activity of sleeping. The room should be dark and quiet, so that sleep is not interrupted. Ear plugs, fans or other sound-attenuating devices (“white noise”) can be used to screen out disruptive ambient noise. Avoiding light by use of sunglasses when going home from work to avoid the start of the diurnal rhythm may also help. Daytime responsibilities should be limited so that blocks of time for daytime sleep can be scheduled. Because sleep debt is incurred during night work, the emergency provider must be prepared for the need to sleep longer periods of time in the days immediately after a string of night shifts and not schedule extra activities during this period. Finally, taking a nap before a night shift may increase objective and subjective alertness, oral temperature and performance on complex cognitive tasks during the night shift.

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Dr. Jeff Slepin

M. Jeffrey Slepin, MD, MBA, FACEP, is a residency-trained, ABEM-certified emergency physician who has been a Regional Medical Director for EmCare since 2003. He attended Emory University and completed his medical education at the Medical College of Virginia. Following his residency at the University of Florida Health Sciences Campus in Jacksonville, he practiced in Virginia and Florida. He obtained his MBA at the College of William and Mary Graduate School of Business prior to joining EmCare.

  • Kuhn, Gloria. Circadian rhythm, shift work, and emergency medicine. Ann Emerg Med. 2001; 37: 88-98.
  • American College of Emergency Physicians. Emergency physician shift work. Ann Emerg Med. 1995; 25: 864
  • Hall, K, Wakeman, N, and Levy, R. Factors associated with career longevity in residency-trained emergency physicians. Ann Emerg Med. 1992; 21: 291–297
  • Hall, K and Wakeman, J. Residency-trained emergency physicians: their demographics, practice evolution, and attrition from emergency medicine. J Emerg Med. 1999; 17: 7–15

Physician Feedback

"Working in the emergency department, the demands of prolonged hours combined with the physical and emotional requirements can be quite taxing on the physician. These things are a given, and are expected. However, where the employer proves so invaluable as a manager is in the consideration of the physician's time away from the E.D. This is where physician satisfaction and longevity in this specialty is determined - and this is exactly where EmCare excels. Whether in the consideration of the physician's geographical location or his or her family obligations, EmCare partners with clinicians to help provide work/life balance. I have worked with many E.D. management companies. EmCare continues to demonstrate a commitment to satisfaction and service that’s incomparable.” - Christopher Smith, DO, an emergency physician at Wiregrass Medical Center in Geneva, Ala.

“The experience that I’ve had as a long-time emergency medicine contractor with EmCare has been unmatched by any other company in my more than 20 years in this field. Schedulers work diligently to mesh my needs with those of my colleagues to ensure everyone gets the shifts they desire. It’s just not possible to do it any better!” - David Porterfield, DO, an emergency physician at Jack Hughston Memorial Hospital in Phenix City, Ala., and LV Stabler Memorial Hospital in Greenville, Ala.

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