Should the 12-Hour Shift be of Historical Interest Only?
Special Issue: AAEM Tales of COVID-19
Author: David P. Lisbon, MD FACEP
I listened with sadness and despair as reports of the death of Dr. Lorna M. Been were broadcast. There were a series of interviews with her heartbroken family. The one that sticks with me was that of her sister. I felt she was most able to convey the sense of fatigue and exhaustion that Dr. Breen felt. In her interview she said, “She had 12 hour shifts.”
In my practice life, I’ve worked both 12 and eight-hour shifts. My first position after residency was one where I contracted to work 12, 12-hour shifts. I trained in a residency program that had eight-hour shifts; I made the adjustment. At the time, my community ED saw 27,000 patients a year, we admitted about 21%, and we were a Level II trauma center. The year was 1995 and I was 25 years younger, the internet was dial -up, there were no cell phone cameras and Tintinalli was soft-cover and could be read twice in residency!
As time passed, patient volume, patient acuity, patient admissions, patient psychosocial issues, and my age all increased. As my children later reminded me; I sometimes struggled to not doze off as I read bedtime stories over the years. As I look back and consider the moment we’re in now, a few other things are clear to me. First, humans are not nocturnal, being your best at 4:00am is just not likely. Two, when I think of the close calls with cognitive, diagnostic, or procedural error, they almost uniformly occurred between 3:00am and 7:00am. Third, the recovery time needed after a string of 12-hour ED shifts in a modern busy ED is at least 24 hours.
I had the great honor to be the founding program director for the emergency medicine residency at The University Kansas School of Medicine. I served for 10 years. I used to joke with my residents that I was open to a discussion about any and everything; except, the implementation of 12-hour shifts. I know that the 12-hour shift has its allure in that one works less shifts a month. I am also aware that very low volume emergency departments might have a logistical need to staff with 12-hour or longer shifts.
Notwithstanding the aforementioned realities, I still believe shifts shorter than 12 hours should be our future. My conversations with colleagues and observations over the years lead me to believe that once an ED gets to 40,000 visits and an admit rate of 25%, the 12-hour shift needs to be rethought. Shift length should be evaluated carefully for its effects on ED physicians. Certainly, a number of operational variables can be considered; staffing matrices, trauma center status, chest, and stroke center designation etc., but cognitive and physical workload over a distinct timespan at some point become germane.
As a frontline response to COVID-19, emergency medicine has and will endure a lot. The 12-hour shift had a place when our mission was perhaps more limited, before medical treatments and medical complexity shifted into high gear and before the pathogenic devastation of the coronavirus struck like a tidal wave. When considering coronavirus one might even ask what degree of concentrated time exposure becomes hazardous?
All of us on the frontlines of healthcare, like Dr. Breen will aim to bring the best of ourselves to each shift. It might be time to ask if it is fair and just to expect that best self to be present at hour 11 and 30 minutes into a 12-hour shift.
AAEM Tales of COVID-19
AAEM wants you to have a forum to share your thoughts, emotions, opinions, and stories related to the COVID-19 pandemic. Thank you for sharing your ideas with other members so we can get through this crisis together. We will continue to share new stories weekly online and then all stories will appear in the print version of the July/August issue of Common Sense. Submissions are now closed for this special feature.