Tips for Surviving Shift Work in Medicine

Andriy Popov/123RF.com

Flipping between night and day shifts is like being perpetually jet lagged. You're irritable, tired, hungry, and confused. But if you're a physician, it's a feeling you're accustomed to.

The chaotic work schedules of physicians can be described as "shift work". According to the National Sleep Foundation, "shift work" refers to work schedules that take place outside of the typical 9-5 work day. The shifts can start earlier, end later, or squeeze working hours into fewer days. Accordingly, working shifts can cause you to want to eat, wake, or sleep at unnatural times.

Our schedules are first disrupted during college and medical school - we pull the occasional all-nighter, take an exam in the morning, and then crash for the rest of the day. We tolerated this well because these were relatively isolated events. We could find time to recuperate, as we had a little more control over our schedules. The days were more predictable.

It also didn't hurt that we were in our twenties!

However, as you move into clinical rotations, you start having regular disruptions. You take call. You work the night shift. You see the residents and attendings taking call every three or four days. The culture of medicine lulls you into the belief that you'll survive it too - that this is just part of the game.

And to some degree, you're right - this is just part of the game. Patients can't predict when they'll fall ill or need a surgery; they don't know when they'll need us. Medicine is an around-the-clock business and depends on constant access to physicians.

Unfortunately, it's our bodies that pay the price for being this accessible.

Circadian Rhythms

When we talk about circadian rhythms, we're talking about our internal clocks. You get the best sense of your clock when you're not adhering to an externally imposed schedule. When you're free to follow your body's natural cycles, you fall into a pattern of eating, waking and sleeping. This is your circadian rhythm.

Shift work and circadian rhythm are separate but related concepts - the external schedule that shift work imposes will impact your circadian rhythm.

Evidence has shown a link between disruption of your circadian rhythm (for example, by undertaking shift work) and mental illness, poor metabolic health, cancers, cardiovascular disease, and poorer social relationships.

It's also been linked to premature death.

The more you disrupt what is natural to you, the worse off you are.

The best solution to this problem (Don't do shift work) isn't always possible. If you have to work shifts, don't do it at night. If you do work at night, try to take a shift that best reflects your circadian rhythm. If that's not possible, it's probably better for you to stay on a night schedule than to flip back and forth constantly.

The less flipping you do and the more you can mirror your natural rhythms, the better.

Tips to Lessen the Negative Impact of Shift Work

If avoidance of shift work is impossible, there are a few tips that can be used to lessen the damage it causes. Being aware and implementing them early in your career may help decrease the risk of this occupational hazard.

1. Take it easy on yourself. Messing with your circadian rhythm makes you irritable and moody. Any combination of symptoms that gets its own name (Shift Work Disorder) is worthy of your respect and patience. You're better off if you can identify the symptoms in yourself and understand that these symptoms are the result of your schedule, not of you. Develop this insight early - it will help with your frustration as you transition back and forth. Be aware of how much shift work is impacting your functionality and be kind with yourself.

2. Anchor Sleep. This means finding 3-4 hours/day of sleep that will remain constant - working or not.  These hours "anchor" your sleep pattern.

For example, say you were scheduled to work 11p-7a shifts between Tuesday and Saturday for two weeks in a row. This gives you off Sunday and Monday, but you aren't going to flip back to days for only two days and then flip back to nights.

On the days you work, you get off work at 7a and go to bed around 9a, waking at 4p.

On your days off, you would go to sleep at around 5a and sleep until noon. This would "anchor" the hours of 9a-noon every day of the week (even your days off), thus giving your body some reset point where you can reliably rest.

This is particularly helpful if you're going to have long blocks of night shifts.

3. If you're switching from night shifts back to days: Get off work, put your sunglasses on, go home and sleep for about 4 hours. Get up and restart your life at about noon. Go to bed at a normal time that night (9 or 10p-ish). This is more helpful if you only have a night or two in a row and then you're back on days.

4. If you're switching from days to nights, wake up a little early that day and live your life. Take a nap the afternoon that overlaps with the anchor sleep you will be having as much as possible. Get up, eat "breakfast," and go to work.

You probably won't be able to take a four-hour nap on the day that you're first switching, but you can begin establishing this as anchor sleep time, even if you don't get the whole nap in.

5. If you have to work at night with any regularity, it's worth making a cave in your home - a room dedicated to your sleep that is set up for your sleeping success. Light is the enemy; it is the most powerful tool your brain is using to keep your circadian rhythms on track.

Block out all light with black-out curtains and avoid electronics prior to sleep. Keep it cool and dark. Make your day sleep as much like night sleep as possible. Wear dark sunglasses before leaving the hospital to trick your brain into thinking it is night when you leave in the morning.

6. Limit distractions - let people know early that you're on nights and not to call or disturb you. Put your phone on "do not disturb.” Limit all noise in the house when you're sleeping. Use a white noise machine (there are apps for this) to help limit sound.

7. Keep a routine as much as possible. Working only nights is probably not as bad for you as switching constantly between nights and days. If possible, keep your work schedule going on days off rather than flipping back and forth.

8. If you're going to take in liquids, choose water - don't drink caffeine or energy drinks at least four hours before you know you'll be going to bed. Avoid alcohol. Alcohol will further disrupt your sleep-wake cycles. It fools you into falling asleep sooner but doesn't keep you asleep.

9. Watch what you eat; working nights makes people crave carbs and fats. This craving, coupled with the impulsivity caused by staying up all night easily leads to weight gain. I combat this by buying sufficient quantities of lean proteins – nuts, fruits and vegetables before night shifts. I snack on this throughout the shift and when I come home, this is my only option to eat. I prevent binging on unhealthy foods by making it impossible to do so; I know I won't be cooking or stopping at the store on the way home!

10. Use food to your advantage to trick your brain into your new rhythm. Eat a breakfast, lunch, and dinner as you normally would. This is a part of establishing a rhythm.

11. Exercise. You will probably not get the solid exercise regimen you're used to, but some exercise is better than no exercise. If your hospital has a gym in it, use it. Even going in for a few 15 minute work-outs throughout your shift is beneficial (and at least as effective as a cup of coffee in my experience). At a minimum, you can still stay active - you can take the stairs, bike to work, park farther from the hospital and not sitas much during your shifts.

12. Medications. Ideally, you can develop sleep hygiene, eating, and exercise patterns to limit the negative impact of shift work. Despite this, some people still look to medications for assistance. Many sleep aids shouldn't be taken long term, but Melatonin seems to be the only exception this. You can buy it over the counter at a local drug store and take it according to the label. Melatonin may help you adjust to new sleeping schedules, is not habit forming, and is considered safe.

If you are able, adopt a working schedule that mirrors your natural rhythms. If not, these tips can help control the damage done by shift work.