Shift work and doctors' health

Thanks to new European legislation on working hours, more doctors will have to work unpopular shift
systems. John Hobson spells out how shift work can affect your health and performance, and what you
can do to protect yourself
Shift work is a recognised risk factor for ill health and can affect safety and social wellbeing. Although it has
become a fact of modern life, shift work is certainly nothing new in medicine, which has always provided
care around the clock. The implementation of European legislation is new, however, and since 1 August
2004 all doctors, including those in training, should be working within the guidelines, which stipulate a
maximum 58 hour working week for doctors. The European Working Time Directive provides guidelines on
breaks and continuous working and requires employers to assess the health of shift workers. The directive
is causing problems throughout Europe, and most countries will be left with a shortfall of doctors if they
apply the rules fully.
Traditional medical shifts
In the meantime, most doctors at some stage in their careers will experience an extended period of nonstandard working hours because of their on-call duties. This is unlikely to be the classic rotational shift
pattern worked by those in industry, nursing, or the emergency services. In medicine, historically, doctors
have worked a normal day and then remained on call through the subsequent night or weekend. This has
more far reaching effects than working a rotational shift pattern--not only is there disruption of the normal
circadian rhythm, but fatigue or daytime sleepiness as a result of prolonged working periods can have
significant effects on general efficiency.
Health hazards of night work
Even if doctors adopt classic rotational shift patterns, they and their employers need to be aware that these
shifts can have an effect on health.1 2 Night work causes a mismatch between the circadian timing system
and environmental synchronisers, and many psychophysiological functions, such as the sleep-wake rhythm,
are disrupted.
Shift lag syndrome
In the short term, "shift lag" syndrome is characterised by feelings of fatigue, sleepiness, insomnia,
disorientation, digestive trouble, irritability, poorer mental agility, and reduced performance efficiency. These
are important contributory factors to human error and accidents at work, and are increasingly recognised as
being common in healthcare workers compared with workers in other sectors, such as in the airline industry,
where working patterns are more tightly controlled.
In the longer term shift work can lead to more severe disorders, although individual susceptibility varies
considerably. Age, gender, personality traits, and behaviour such as neuroticism, rigid sleeping habits, and
difficulty in overcoming drowsiness are all associated with difficulty in coping with irregular work schedules.
Many people opt out of shift working because of these symptoms.3
Sleep disturbance
Disturbed sleep is the commonest effect of shift work on health, and shift workers report more sleep
disturbances than day workers.4 These effects vary depending on the shift timing but normally clear within
two to three days of finishing shift work and there is no clear indication that long term shift work results in
chronic sleep problems. Night work is characterised by increased subjective and objective sleepiness, and
studies frequently report full-blown sleep during night shift working, particularly in the early morning. After a
night shift there are between two and four hours loss of rapid eye movement sleep and it usually takes two
nights of sleep after the last night shift before normal sleepiness is restored. Importantly, shift workers are
more tired when driving to and from home than non-shift workers.
Other health effects

Gastrointestinal disorders are more common in shift workers, who complain of pain and alteration in bowel
habit. There is strong evidence linking shift work to peptic ulcer disease, and rather strong evidence linking
shift work to coronary heart disease.5 Potassium, uric acid, glucose, cholesterol, and total lipids are all
increased during night work but return to normal during day work, although the evidence for a link to
diabetes is inconclusive. There is rather strong evidence in support of an association between shift work
and pregnancy outcome in terms of miscarriage, low birth weight, and preterm birth (box 1). There is no
evidence that night work increases the risk of cancer or that shift work affects longevity.
Effects of shift work

Disruption of normal circadian rhythm

Subjective and objective sleepiness
Loss of rapid eye movement sleep after night shift
Potassium, uric acid, glucose, cholesterol, and total lipids all increased during night work.
Impaired performance with a trough at 3 am

Good evidence of increased risk of:

Peptic ulcer disease

Coronary heart disease
Miscarriage, low birth weight, and preterm birth
Injury during night shift, compared with morning shift

No evidence of effect on:

Cancer risk
Lifespan

Effects on performance and safety

In addition to its effects on health, shift work affects functioning and therefore efficiency and safety.6
Alertness, performance, and metabolism all reach a nadir in the early morning and are at their peak
(acrophase) 12 hours later. Multiple studies of practical ability and efficiency have shown significant dips
between 10 pm and 6 am, with a trough at 3 am. A number of incidents, such as those at Bhopal, Three
Mile Island, Chernobyl, and the Rhine and the Exxon Valdez chemical spillages, all occurred at night.
Risk of injury is 30% higher on night shift compared with morning shift and is highest in the first two to three
hours; the risk then increases over successive night shifts so that the fourth night shift carries 36% more
risk than the first. With extended working hours, risk increases more or less exponentially and in the 12th
hour of work it is twice what it was during the first eight hours. The risk of injury is also increased by not
taking breaks and rises linearly and substantially with time from the last break; there is twice the risk of
injury 90 minutes after the last break compared with immediately after a break.

SAMUEL ASHFIELD/SPL
It's been a hard day's night, and you've been working like a doc...

How to protect yourself

If you want to minimise the effects of shift work on your health and performance, consider the design of your
shift and take breaks, naps, and, possibly, melatonin.
The healthiest shift
The best rotating shift system is fast forward rotation, for example, two mornings, two afternoons, and two
nights.7 The worst is a backward rotation of a week of nights, a week of afternoons, and then a week of
morning shifts. The optimal time for shift changeover is 7 am. There are good arguments for women to
avoid shift work during pregnancy.5
When and what to eat
When working nights you should take your main meal break between midnight and 1 am, when a protein or
health food meal should be taken, followed by a shorter break between 3 am and 4 am (box 2). Exercise,
adequate light levels, a cool workplace, music, and opportunities to interact with colleagues all enhance
alertness on night shifts. The jury is still out on bright light exposure.8
Box 2: Tips for night workers

Take small breaks at least every hour

Drink coffee in the first half of the shift only
Take a main meal break of protein or health food between midnight and 1 am and a smaller food
break between 3 am and 4 am
Try to take naps
;Be aware of sleep inertia for 15 minutes after waking
Try to avoid driving to and from work after working at night or for prolonged shifts
Healthy eating and keeping fit will help you cope with shift work

Take power naps

Napping is thought to be the most effective countermeasure against sleepiness at work. Several studies
have shown that "cockpit naps" (half an hour to two hours) taken during the first night awake counteract the
profound fall in alertness around the circadian trough during the early morning. There is a period of impaired
alertness (sleep inertia), however, lasting five to 15 minutes after awakening, which can have implications
for doctors who have emergency responsibilities.
Melatonin might help you sleep better
Although there is good evidence that melatonin prevents jetlag after eastward travel, the evidence for sleep
enhancement after night work is less solid. Taking 0.5 mg to 5 mg of melatonin before going to sleep may
improve sleep quality,9 but it does little to improve alertness during shift work.
Keep fit, don't smoke, and use earplugs
After shift work, sleep is made easier if noise and light are reduced (for example, by using earplugs or
blacking out windows with plastic) as well as by avoiding caffeine, smoking, alcohol, and sleeping pills.
Good physical fitness and proper sleep hygiene can favour tolerance to shift work because they increase
performance efficiency, lessen fatigue, and improve recovery mechanisms.
Training and assessment
Some companies offer training sessions for shift workers. These sessions deal with circadian rhythms,
sleep disorders, impact on family and social life, alertness strategies, safe driving, nutrition, physical activity,
and coping with stress. Shift workers are entitled to undergo a free health assessment before their
assignment to night work and thereafter at regular intervals; this is normally implemented using
questionnaires, which should be administered every three years for those under the age of 45 and every
two years for those who are older. If this isn't happening in your corner of the NHS, ask why.

John Hobson, editor, Occupational Medicine, London NW1 4LB

Email: John.Hobson@mpcg.co.uk

studentBMJ 2004;12:393-436 November ISSN 0966-6494

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