Abstract
Objectives
Clinical productivity is an important operational and educational metric for emergency medicine (EM) residents. It is unclear whether working consecutive days and circadian disruption impact resident productivity. The objective of this study was to determine whether there is a correlation between consecutive shifts and productivity.
Methods
This was a single‐site retrospective observational study using data from academic year 2021–2022 (July 1, 2021–June 23, 2022). Productivity was defined as primary resident encounters with patients per hour (PPH). Postgraduate year (PGY)‐1 and PGY‐2 productivity data and schedules were abstracted from the electronic medical record and scheduling software. Descriptive statistics, including arithmetic mean, standard deviation, and confidence interval (CI), were determined for each shift number and stratified by PGY level. Subgroup analysis of night shifts was performed. Analysis of variance and linear regression analysis were performed.
Results
A total of 2950 shifts were identified, including 1328 PGY‐1 shifts and 1622 PGY‐2 shifts, which involved a total of 32,379 patient encounters. PGY‐1 residents saw a mean of 0.88–0.96 PPH on sequential shifts 1–7, respectively (y‐intercept 0.923, slope 0.001, 95% CI −0.008 to 0.009, p = 0.86). PGY‐2 residents saw a mean of 1.61–1.75 PPH on Shifts 1–7, respectively (y‐intercept 1.628, slope 0.004, 95% CI –0.007 to 0.015, p = 0.50). A subgroup analysis of 598 overnight shifts (11 p.m.–7 a.m.) was performed, in which residents saw a mean of 1.29–1.56 PPH on Sequential Shifts 1–7 (y‐intercept 1.286, slope 0.011, 95% CI −0.011 to 0.033, p = 0.34).
Conclusions
EM resident productivity remained relatively constant across consecutive shifts, including night shifts. These findings may have educational and operational implications. Further research is required to understand patient‐ and provider‐oriented consequences of consecutive shift scheduling.
INTRODUCTION
The number of patients seen per hour is a common proxy for emergency medicine (EM) physician productivity. 1 , 2 , 3 For EM residents in training, productivity is an important metric tracked for educational and operational purposes. Residency program directors use productivity as one marker of a resident's growth and progression through a training program. 1 , 2 , 4 From an operational perspective, an understanding of physician productivity is essential to ensure appropriate staffing levels and match anticipated patient arrivals with provider capacity. 5 , 6 , 7 Previous research has described the typical number of patients seen by EM resident physicians stratified by postgraduate year (PGY). 1 , 2 , 3 However, the potential impact that fatigue sustained from consecutive shifts has on productivity has not been extensively studied.
Work‐related fatigue in EM, particularly in the setting of circadian disruptions and night‐time shift work, has been shown to negatively affect cognitive function and physician wellness. 8 , 9 , 10 Prior research has demonstrated that working serial night shifts results in a significant decline in cognitive performance on standardized intelligence testing. 8 It has not been well studied whether these findings translate to a change in EM resident productivity. A prior study using data from 2006 showed that EM residents maintain or make gains in efficiency and productivity over the course of sequential shifts. 11 However, this prior work has not been replicated at other sites, evaluated only a small data set from a 3‐month time period, and did not account for night shifts. The purpose of this study was to use contemporary data to assess EM resident productivity variability over consecutive shifts and to perform a subanalysis of productivity variability over consecutive night shifts.
METHODS
This was a single‐site retrospective observational study conducted at an academic medical center with a 3‐year residency training program. Resident productivity data were abstracted from the electronic medical record. No patient‐level information was accessed. Residents were deidentified and not interacted with in any way. Resident productivity data were linked with schedules during the time period corresponding to the academic year (July 1, 2021, through June 23, 2022). Productivity was defined as primary patients per hour (PPH). Sign‐out patients were not included in the analysis. Only EM PGY‐1 and PGY‐2 shifts during the study period were included, as PGY‐3 residents within the program generally function in a supervisory role. Consecutive shifts were defined as shifts starting on sequential calendar days without a day off in between. The resident schedules were generated by automated shift scheduling software (ShiftAdmin) and aligned to follow ACGME duty hour rules and favor forward cycling circadian schedules. 12 The vast majority of shifts are 8 or 9 h in length.
Descriptive statistics, including arithmetic mean, standard deviation, and confidence interval (CI), were determined for each shift number and stratified by PGY level. Analysis of variance and linear regression analysis were performed to determine the relationship between variables. Linear regression was performed by least‐squares method. Statistical significance was set at p < 0.05. CIs are provided at the 95% threshold. Analyses were performed using Microsoft Excel and GraphPad Prism. The project was reviewed by the institutional review board and approved as a quality improvement initiative.
RESULTS
A total of 2950 shifts from the 2021–2022 academic year were included in this study, which includes all shift types. There were 1328 PGY‐1 shifts and 1622 PGY‐2 shifts. A total of 32,379 patient encounters were performed by these residents. Productivity data stratified by year of residency and overnight shifts are presented in Table 1. PGY‐1 residents saw a mean of 0.94, 0.92, 0.91, 0.88, 0.94, 0.96, and 0.94 PPH on Sequential Shifts 1–7, respectively (y‐intercept 0.923, slope 0.001, 95% CI −0.008 to 0.009, p = 0.86). PGY‐2 residents saw a mean of 1.64, 1.62, 1.65, 1.66, 1.62, 1.61, and 1.75 PPH on Shifts 1–7, respectively (y‐intercept 1.628, slope 0.004, 95% CI –0.007 to 0.015, p = 0.50). A total of 598 overnight shifts (11 p.m.–7 a.m.) were included in this study. Residents saw a mean of 1.28, 1.29, 1.35, 1.44, 1.37, 1.56, and 1.39 PPH on Sequential Night Shifts 1–7 (y‐intercept 1.286, slope 0.011, 95% CI −0.011 to 0.033, p = 0.34). There was no statistically significant change in resident productivity based on shift number (see Figures S1 and S2 for graphical representation of resident productivity by shift, stratified by year of training and time of shift).
TABLE 1.
PPH and counts of shift type, stratified by PGY and overnights.
| Shift number | PGY‐1 a | Shift count | PGY‐2 a | Shift count | Overnight a , b | Shift count |
|---|---|---|---|---|---|---|
| 1 | 0.94 ± 0.27 | 415 | 1.64 ± 0.37 | 509 | 1.28 ± 0.51 | 95 |
| 2 | 0.92 ± 0.26 | 328 | 1.62 ± 0.41 | 418 | 1.29 ± 0.57 | 110 |
| 3 | 0.91 ± 0.27 | 232 | 1.65 ± 0.40 | 294 | 1.35 ± 0.59 | 116 |
| 4 | 0.88 ± 0.28 | 156 | 1.66 ± 0.38 | 188 | 1.44 ± 0.55 | 110 |
| 5 | 0.94 ± 0.26 | 100 | 1.62 ± 0.40 | 100 | 1.37 ± 0.51 | 74 |
| 6 | 0.96 ± 0.29 | 47 | 1.61 ± 0.41 | 59 | 1.56 ± 0.54 | 39 |
| 7 | 0.94 ± 0.27 | 27 | 1.75 ± 0.42 | 31 | 1.39 ± 0.60 | 27 |
| All c | 0.92 ± 0.27 | 1328 | 1.64 ± 0.39 | 1622 | 1.32 ± 0.55 | 598 |
Abbreviation: PPH, patients per hour.
Data are reported as mean ± SD.
Overnight shifts defined at 11 p.m.–7 a.m., performed as a subgroup analysis inclusive of PGY‐1 and PGY‐2 shifts.
Totals include small numbers of Shifts >7 in sequence.
A multivariate regression was performed. Variables included PGY, shift number in sequence, shift start time (hour), and overnight status (binary). The model yielded an R 2 of 0.52. The y‐intercept was 0.97 PPH (95% CI 0.92 to 1.02, p < 0.0001). PGY contributed 0.71 PPH (95% CI 0.68 to 0.73, p < 0.0001). Shift number in sequence contributed 0.005 PPH (95% CI −0.003 to 0.013, p = 0.21). Shift start time contributed −0.005 PPH (95% CI −0.008 to −0.001, p = 0.02). Night shift status contributed 0.039 PPH (95% CI −0.010 to 0.088, p = 0.12). See Table S1 for summary data regarding regression modeling and Figure S3 for further details regarding regression analysis).
DISCUSSION
This study analyzed the clinical productivity of PGY‐1 and PGY‐2 residents at our academic medical center over the course of the 2021–2022 academic year. Our work demonstrates no significant change in EM resident productivity as measured by PPH over sequential shifts. This finding remained true with a subgroup analysis of night shifts. Linear regression modeling showed strong effect of the year of residency training and small effect of shift hour of day. As shown in previous research, PGY‐2 residents tended to see a greater number of PPH than their PGY‐1 counterparts. 3 These findings add evidence to the existing literature that sequential shifts do not appear to reduce resident productivity as measured by PPH. 11 Importantly, the current study utilizes contemporary data over a longer time frame than previously studied and adds consideration of shift type.
These findings are in some ways counterintuitive to the body of research on fatigue in EM, which show that consecutive night shifts result in a cognitive decline and negative impact on standardized intelligence testing. 8 , 9 , 10 While PPH is just one measure of clinical output and educational outcomes, it nonetheless has critical implications on staffing and residency program design. Operationally, the data suggest that staffing levels may not require specific adjustments to account for sequential shifts. Similarly, sequential shifts do not appear to affect the number of resident patient encounters, which serves as an important educational metric. 1 , 2 , 4
LIMITATIONS
This study has a number of limitations. This study was a single‐site retrospective observational study, which may impact generalizability. Data were not stratified by patient acuity and may be confounded by variation in patient illness severity. Furthermore, data were aggregated over the course of a full academic year and may not reflect changes in resident productivity. In addition, PPH is just one metric of clinical output and does not reflect complexity, acuity, or educational goals. Our definition of resident productivity does not reflect resident capacity, which could be limited by patient availability due to staffing or ED volume. Additionally, resident productivity does not address patient‐centered outcomes, such as quality of care and errors. Finally, we did not study the potential impact that consecutive shifts have on resident wellness.
CONCLUSIONS
Emergency medicine resident productivity remains relatively constant across consecutive shifts, including consecutive night shifts. These findings may have significant operational and educational implications. Further research is needed to understand the impact of consecutive shifts on patient‐oriented outcomes and resident wellness.
AUTHOR CONTRIBUTIONS
All authors participated in the study concept and design. Daniel L. Shaw, Max S. Kravitz, and David T. Chiu acquired relevant data. Daniel L. Shaw and Max S. Kravitz analyzed and interpreted the data. All authors contributed substantially to manuscript drafting and revisions. Daniel L. Shaw and Max S. Kravitz contributed equally as first authors.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
Supporting information
Figure S1.
Figure S2.
Figure S3.
Table S1.
Data S1.
Shaw DL, Kravitz MS, Stenson BA, Lewis JJ, Chiu DT. Emergency medicine resident productivity across consecutive shifts. AEM Educ Train. 2024;8:e10935. doi: 10.1002/aet2.10935
Presented at the 26th Annual SAEM New England Regional Meeting, Worcester, MA, April 2023; and the 2023 Society for Academic Emergency Medicine Annual Meeting, Austin, TX, May 2023.
Supervising Editor: Teresa Y Smith
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1.
Figure S2.
Figure S3.
Table S1.
Data S1.