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Dear Director,
I’m 62 years old, and have been with my group for 20 years. Although we evenly split the overnight shifts, I’m having a hard time doing them, both physically and mentally. Don’t you think there’s an age cut off where we shouldn’t have to do overnight shifts anymore? I still want to practice emergency medicine and feel I can still contribute to my group and my patients’ care, but if I can’t stop doing overnights, I might have to leave the ED. I’m just not ready for that.

Whether it’s the weekends and holidays away from our children when we are in our 30s and 40s or the physical stress of working night shifts in our 50s and 60s, shift work will eventually take its toll. Given this often punishing schedule, it is critical that we find ways to keep our active workforce intact. We need to help emergency physicians in the final years of their career adapt and transition into an environment that keeps them engaged, while delivering good care to patients. Many physicians are facing the problem you mention right now and either want, or need, to work full-time clinical. For many of the physicians who face your issue now, their groups may not be flexible enough to make rapid and innovative changes to the schedule, other than simply eliminating overnight shifts, which also might not be immediately feasible.

Laying the Groundwork
The easiest way to make this transition is to plan ahead. If you want to eventually have a policy that eliminates night shifts for everyone 62 and over, start talking about it before it applies to you. Think ahead and put policies in place now that benefit your older colleagues and have you bearing some of the burden of the additional nights. That will lay the groundwork for a good career transition as you age.

We don’t always have the luxury of time, however. So let’s look at it from another perspective, assuming you want to cut back your own shifts right now. Let’s start by examining the impact to the rest of the group. How many people in your group would not have to do any nights if a 60+ age group rule came into existence? If you’re in a 14-person group, and you’re the only one over the age cut off, your 2-3 monthly nights could get absorbed easily. However, if you’re in an eight person group and three are above 60 years old, you’re now asking your younger colleagues to almost double there night shift commitment, and that might not be so attractive to them. The exact circumstances of your group, the number of physicians impacted, and what that total impact may be will likely dictate whether you can eliminate nights.

Talk To Your Chairman
Once you’ve considered your timing and the impact to the group, a logical next step would be to discuss this with your chairman. Explain how you have the ability and desire to contribute, but that the regular night shifts have become too physically challenging. Asking for their philosophy on rewarding age/experience and group longevity can be a good next step, and can gauge your chairman’s vantage point. The next step is to ask the chairman how he/she believes the group would react. Hopefully, you’ve spoken with a trusted colleague to see if your “friends” would support this as well.

Compromise
While I would love to see night shifts eliminated for everyone who has shown a long-term commitment to my group who is over a certain age, as a director I also have the responsibility to keep the department fully covered, retain talented physicians and recruit new physicians. Therefore, if your chairman believes that there would be support for your cause, offer up something to insure the support, such as additional weekends or holidays. Again, depending on the group size and age of the physicians, the younger docs might not mind a couple of extra night shifts if it means that they’ll have more weekends free to go out or attend their kids’ activities.

If that doesn’t work, there is always cold, hard cash. I used to work with a colleague who despised night shifts. He offered his own personal funds to compensate someone for trading for a day shift. Both docs were happy, and the shift was covered. On the broader scale, having a night shift differential large enough to truly motivate the hungry physician may be an excellent approach. How large a shift differential? 25% above regular day rates? 50% or even more? At some point, a shift differential becomes so attractive that people jump at the opportunity. However, this typically comes with the financial compromise of decreasing pay for the attractive shifts, thus keeping it budget neutral.  

Conclusion
I had an emergency physician friend and mentor, who ultimately became like a big brother to me, from the time I was an ED volunteer in college. He also happened to be an ED chairman, had promised me a job in a very desirable ED since medical school, and I couldn’t wait to finish residency and go to work for him. However, during my “interview,” he told me the good news was that my first few years would have a regular and fixed schedule, but it came as the full-time Friday-Monday night physician. I wondered if that’s how family was treated, what would happen to the random, well-trained residency graduate. Honestly, I never subscribed to the torture-and-eat-your-young philosophy that was probably more common in some groups in the past than it is now. I am okay with the philosophy of paying your dues, but that definition is up for debate (I might consider it an extra holiday or weekend shift but not full time nights) and how we recruit and retain our young and talented physicians is as important as how we retain our older, experienced physicians. If we offer up a “pass” on night shifts for the last 3 years of your career, it means that the younger physicians will bear a good bit of that responsibility. For better or worse, I don’t see that becoming a universal culture in emergency medicine. Therefore, to compete for the new hires, most offer fairness when it comes to the schedule.

When we chose emergency medicine, we knew we were signing up for shift work in a 24/7 business and that included nights, holidays and weekends. If you continue as a full time clinician, it’s reasonable to expect to take the good and the bad of the shift work.  Ultimately, I look at my responsibility as chairman as striking a balance in recruitment, retention and talent. While I can’t afford to lose the future of my group by telling my youngest doctors that they’re now on full-time nights, I also feel that experience and commitment should be rewarded. Initiating change takes the right timing on your part, deciding how to approach your chair and group, and it takes a talented medical director who can make it a win/win for the whole group. Throw in some creative group financing with a night shift differential and some extra weekends on your part and you may be able to get to a straight day and evening rotation.

Michael Silverman, MD, is a member of Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center in Arlington, Virginia.

 

Comments   

# Dr. J 2011-04-25 08:21
It is important for every group to have an exit strategy to wind down the careers of valuable senior physicians. Some options include group ownership of an urgent care centre staffed by the emerg group, with no overnight hours and progressive scheduling of older physicians in urgent care. Academic groups can preferentially schedule teaching shifts for senior physicians.

I am a big fan of offering financial incentives for undesirable shifts, which tends to get them covered by young, debt laden docs solving the problem.

Finally if there are a couple of older docs in a group they could consider combining their nights and casino shifting them, working 23:00 to 03:00 and 03:00 to 08:00 for instance. This approach seems counterintuitiv e as it may mean more frequent short night shifts, but for some people short casino type shifts may be totally doable where long nights are not.
Dr. J
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# Let the market solve the problemWhite Coat Investor 2011-06-12 20:37
This problem was easily solved in our group. Those who want to work less shifts for the same pay, or want to make more, work the nights. Those who don't work nights make less. We ratcheted up the differential until all the nights were covered. The night shift pays about 50% more than the day shift, and 25% more than the evening shift. I'm not sure why any group would approach this any other way. It seems the fairest way to me by far.
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