As I write this column, I am on the second leg of an overnight flight back home to Austin, Texas. I think it actually went pretty well, considering my 2-year-old daughter was wide awake after sleeping for the first three hours of this 14-hour odyssey. The remainder of the trip is a blur of awkward sleep positions interspersed with brief periods of semilucidity. Those of you with first-hand knowledge of what this experience is like might be feeling sorry for me, but you shouldn’t. I am returning from a “why don’t I live here” kind of vacation week in Hawaii. The rest of you are probably wondering how anyone could write a coherent column at this point, which is fair, but to which I would reply: Aren’t all hospitalists expected to function at high levels during periods of sleep deprivation?
While the issue of resident duty-hours has been discussed endlessly and studied increasingly, in terms of effects on outcomes, I am surprised there has not been more discussion surrounding the concept of attending duty-hours. The subject might not always be phrased to include the term “duty-hours,” but it seems that when it comes to scheduling, strong opinions come out in my group when the duration of, frequency of, or time off between night shifts are brought up. And when it comes to safety, I am certain sleep deprivation and sleep inertia (that period of haziness immediately after being awakened in the middle of the night) have led to questionable decisions on my part.
So why do pediatric hospitalists avoid the issue of sleep hygiene, work schedules, and clinical impact? I think the reasons are multifactorial.
First, there are definitely individual variations in how all of us tolerate this work, and I suspect some of this is based on such traits as age and general ability to adapt to uncomfortable circadian flip-flops. I will admit that every time I wake up achy after a call night, I begin to wonder if I will be able to handle this in 10 to 15 years.
Second, I think pediatric HM as a field has not yet explored this topic fully because we are young both in terms of chronological age as well as nocturnal work-years. The work has not yet aged us to the point of making this a critical issue. We’re also somewhat behind our adult-hospitalist colleagues in terms of the volume of nocturnal work. Adult HM groups have long explored different shift schedules (seven-on/seven-off, day/evening/overnight distribution, etc.) because they routinely cover large services of more than 100 patients in large hospitals with more than 500 beds. In pediatrics, most of us operate in small community hospital settings or large academic centers where the nightly in-house quantity of work is relatively low, mitigated by the smaller size of most community programs and the presence of residents in most large children’s hospitals.
But I see this as an important issue for us to define: the imperative to define safe, round-the-clock clinical care and sustainable careers. Although we will need to learn from other fields, HM is somewhat different from other types of 24/7 medicine in that we require more continuity in our daytime work, which also carries over to night shifts both in terms of how the schedule is made as well as the benefit on the clinical side. The need for continuity adds an extra degree of difficulty in creating and studying different schedules that try to optimize nocturnal functioning.
Unfortunately, those looking for evidence-based, or even consensus-based, solutions might have to wait. A recent article in the Journal of Hospital Medicine does a nice job of synthesizing the literature and highlights the lack of clear answers for what kind of shift schedules work best.1
In the absence of scientific solutions, it might be too easy to say that we need “more research,” because what doesn’t need more research? (OK, we don’t need more research on interventions for bronchiolitis.) But in the same manner in which pediatric hospitalists have taken the lead in defining a night curriculum for residents (congratulations, Becky Blankenburg, on winning the Ray E. Helfer award in pediatric education), I believe there is an opportunity to improve circadian functioning for all hospital-based physicians, but more specifically attendings. This is even more important as residents work less and a 24/7 attending presence becomes the norm in teaching facilities. While the link between safety and fatigue may have been seen as a nonissue in past decades, I think that in our current era, this is something that we own and/or will be asked to define in the near future.
In the meantime, I think we’re left to our own schedules. And in defense of all schedulers like me out there, I will say that there are no proven solutions, so local culture will predominate. Different groups with different personalities and family makeups will have varying preferences. Smaller groups will tend to have longer shift times with less flexibility in “swing”-type midday or evening shifts, while larger groups might have increased flexibility in defining different shifts at the expense of added complexity in terms of creating a schedule with no gaps.
As we come up with more rules about night shifts, such as “clockwise” scheduling of day-evening-overnight shifts, single versus clustered nights based on frequency, and days off after night shifts, the more complex and awkward our Tetris-like schedule will become. I predict that this is something hospitalists will begin to think about more, with a necessary push for safe and sustainable schedules. In the short-term, allowing for financial and structural wiggle room in the scheduling process (i.e. adjusting shift patterns and differential pay for night work) might be the most balanced approach for the immediate future.
Dr. Shen is pediatric editor of The Hospitalist. Write to him at firstname.lastname@example.org.