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Dear Director,
We recently changed our coverage pattern from three 12-hour shifts per day to five eight-hour shifts. While this increases our daily coverage, we’re all working more shifts, despite hiring more docs. And now it seems like some of us get stuck doing more of the nights and weekends than others. What’s the appropriate length of shift? How do we divide them up evenly?

Few things rank higher than equitable staffing when it comes to physician satisfaction. Increased staffing coverage brings obvious advantages – more docs means a less chaotic environment, an easier shift, and hopefully better patient care. However, there are three elements to your transition of which you should be particularly aware.

Shorter is Better
Let’s face it, working 144 clinical hours a month seems more palatable when you only have to work 12 shifts, compared to 18 eight-hour shifts.  Most of us went into emergency medicine because it gave us a better work-life balance than surgery or interventional cardiology.   But take a hard look at efficiency and you’ll see that shorter really is better. Shorter shifts allow physicians to maintain their efficiency better throughout the shift, and the more rapid provider turnover is beneficial for shortening wait times and reducing length of stay. This also generally translates into improved patient satisfaction and a happier workplace environment.  Not only does productivity dramatically wane in the last several hours of a 12-hour shift, poor decision making and errors increase in this time period.  It’s interesting that resident work hours have been ratcheted back in the last several years and that other industries that are population and safety focused (aviation, for example) have limitations on the amount of time that employees can work because of error and safety concerns.

One of the hardest parts of transitioning to eight-hour shifts is getting everyone to realistically look at their monthly shift commitment. For many people, 18 shifts a month is just too many. As I’ve observed other EDs convert from 10 and 12 hour shifts to 8’s, I’ve come to a sort of magic number: 16 shifts per month (give or take one shift) seems to be optimal for balancing work, life and budget.

Shift Distribution
I’ve always felt that your typical schedule should be relatively reflective of the proportion of the group’s total day, evening, and night coverage.  If your schedule is supposed to be fair and even, yet you’re working predominantly evenings and nights while others in your group are predominantly day shift, then there is probably a problem. As weekday day shifts tend to be everyone’s favorites, I’ve never let people load up on them, but if I have physicians who prefer evenings or nights, I have certainly built their schedules around those preferences. This then gives others a more favorable day to evening ratio.

One issue to consider is if you have a particular shift that requires more experience or another skill set that not everyone may have. Specifically, I think about night shifts, which may require certain knowledge of the hospital that a new physician hire may not have reached in their first six months on the job. Or, you may feel that physicians need to be at least a year out of residency to be scheduled to work a specialized shift, such as triage, which may only be utilized in the evening. You mention that you are doing more nights and perhaps that is the reason. Scheduling five physicians a day generally requires 10-12 docs in the group, so the amount of nights each physician should be assigned can be determined by simply dividing up the days in the month by the number of physicians who do nights. Generally that comes to about three per month. If you have only two shifts a day, (7a-7p and 7p-7a), 50% of your shifts will likely be nights and that could be five or six shifts. In my own view, for the full-time practicing clinician, I think doing up to three night shifts a month is pretty reasonable (it comes with the territory of being in a 24/7 business), and that works out to be 20% of a 15 shift/month work load.

Weekends
Your weekend coverage should also be reflective of the schedule. Since weekends occupy 2/7th of the week, they should make up about 2/7th of your total clinical shifts. I try to stick to the rule that no one works more than 50% of the total weekends in a month, however, if you are an Ironman and work 22 shifts a month, it’s likely that you’ll exceed that threshold. Conversely, if you’re a regular part-timer or an administrator who works 8-12 shifts a month, you should work proportionally less weekends than your full-time colleagues (unless you have a minimum weekend requirement). For the typical full-time physician who works 15-16 shifts a month, following the 2/7th rule, this works out to be about 4 weekend shifts, or two weekends, in a typical four weekend month. Many facilities subsidize weekend coverage with part-timers who only do a few shifts a month. While these docs have pros and cons, I’ve always liked having them around since they typically absorb some of the weekend shifts, which in turn keeps all of my docs below the 2/7th rule.

Schedules are often seen as burdens to ED staffs, but it doesn’t have to be that way. They need to be fair and ratios can be determined to serve as a guideline. Ultimately, there’s always a little bit of pain when looking at our own clinical schedule and if you are the scheduler, it’s best to keep track of the painful shifts and rotate their frequency among the group. I applaud your group’s transition to shorter shift lengths – I am clearly an advocate for 8’s versus 12 hour shifts.  It benefits patient safety, patient satisfaction, physician longevity, and department efficiency.  I suspect that your group will get used to the more frequent trips to the hospital and will be pleased in the end.

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

 

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