WELLNESS
Dark Nights, Dark Moods: Recommendations for Fatigue Mitigation for Emergency Physicians
SAEM PULSE | JULY-AUGUST 2023
By Katren Tyler, MD, Simiao Li-Sauerwine, MD, MSCR, Mengchen Cao, MD, Ashley Palmer Stevenson, MA, MS-4, Amanda Deutsch, MD, and Al’ai Alvarez, MD, on behalf of the SAEM Wellness Committee
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Fatigue contributes to safety lapses, errors, and burnout. Fatigue affects performance by increasing reaction times, impairing situational awareness, increasing lapses in attention, and impairing reasoning. The effects of fatigue have been demonstrated in multiple industries, including health care. We present a framework for contributors to fatigue and suggestions for solutions to mitigate fatigue in emergency medicine (EM) physicians.
Types of Fatigue
There are three primary types of fatigue. 1. Transient fatigue — a short-term fatigue experienced after sleep restriction or extended periods of being awake over several days; 2. cumulative fatigue due to repeated mild sleep restrictions or extended hours awake across several days; and 3. c ircadian fatigue, which refers to reduced performance when the
individual is usually asleep and is often felt during the individual’s window of circadian low (WOCL) — typically between 2-6 a.m.
Impact of Chronotypes on Shift-Related Fatigue
Fatigue is directly associated with shift work, especially cumulative and transient circadian rhythms disruptions. Chronotypes are defined as the timing of natural mid-sleep on workfree days. Chronotypes tend to shift earlier with age, although substantial individual variation exists. Scheduling against chronotype, such as a late chronotype physician working an early shift, contributes to all three forms of fatigue, especially circadian fatigue. Circadian fatigue, or social jetlag, is a complex interplay between the social clock, the sun clock, and our biological clocks. Switching from standard time to daylight savings time in the spring leads to circadian fatigue, despite
the time change of only 60 minutes. Many experience circadian fatigue when traveling across time zones. EM physicians will generally experience the most significant circadian fatigue during and after overnight shifts, and it may take several days to return to baseline. Early chronotype physicians are more likely to struggle with night shifts, while late chronotype physicians struggle with early shifts.
Shift Scheduling and Work-Life Integration EM physicians have various roles outside of clinical work. Nonstandard working hours can be productive but draining. Navigating work schedules to meet other life demands is challenging for EM physicians. EM departments should ensure that at least one daily shift fits within the regular business day to facilitate child or elder care. This is especially necessary for EM physicians who are single parents or