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Back away from the donuts!

January 2013

Published in the January 2013 issue of Today’s Hospitalist

Before he began working nights exclusively three years ago, Sandeep Sachdeva, MD, did his homework, and he knew the kinds of risk he was about to run. Study after study has linked night shifts to an increased risk of cardiovascular disease, diabetes, cancer, long-term fatigue and lower immunity.

But instead of falling prey to those physical tolls, Dr. Sachdeva “who works at the 1,462-bed Swedish Medical Center in Seattle “is in top form. Since he began his stint as a nocturnist, he took up running, lost 20 pounds and finished his first half marathon last summer. His goal this year is to run the 2013 New York City Marathon.

His strategy? To go on the offense. Instead of noshing on the omnipresent snacks at the nursing stations or the fried food in the cafeteria, he consciously devised and stuck to a plan. While his new work schedule forced him to change his sleep schedule, he took that opportunity to also change his eating, exercise and stress-reduction habits.

“I was conscious of the downsides of working nights,” says Dr. Sachdeva. “Going in, I realized I needed to have a regimented life.” That regimen covers exactly when and how to sleep, when (or if ) to drink caffeine, what to eat, what exercise to do and how to make time to do it, and how to stay connected to family and friends.

Many potential upsides of working nights can make up for the sacrifices it requires: a more independent work environment, more clinical care and fewer social issues, and reduced hours and a bigger paycheck. But as patient acuity and ED volume rise, the job is getting more stressful, putting pressure on nocturnists to be physically and emotionally prepared.

“It’s not for everybody, and you have to have an understanding of what night work is about and self-select into it,” Dr. Sachdeva says. “Look at the personal and work aspects and ask yourself, ‘Is this going to work for my health, my family and my career?’ ”

By the clock
Some physicians choose night work because they tolerated it well during residency, as a locum tenens or on a moonlighting stint, says Eric W. Schaefer, MD, assistant professor at Chicago’s Northwestern Memorial Hospital and author of a recent study looking at the effects of night work on hospitalists. But Dr. Schaefer says that getting the right shift length or number of days doesn’t guarantee success when working nights. Instead, the key is sticking to a strict schedule and recognizing “and dealing with “stress.

When Dr. Sachdeva’s 7 p.m.-7 a.m. shift ends, for instance, he leaves no later than 7:30 a.m. and is asleep by 9 a.m. He sleeps between six and eight and one-half hours, waking in time to see his kids when they come home from school and taking part in his active household. He transitions to day hours after his last shift by staying up until about 10 a.m., eating lunch, and having an early nap.

Being able to stick to a schedule extends even to real estate. When nocturnist Eric Shigeno, MD, joined Scripps Coastal Medical Group in San Diego last spring, he scouted out the perfect location: an apartment across the street from the hospital. The apartment allows him to walk to work, which spurred him into adopting a new health regimen that helped him lose ” and keep off “15 pounds.

Raymonda Tompkins, MD, a nocturnist at the 440-bed St. Peter’s Hospital in Albany, NY, says staying healthy hinges on “getting selfish.” Faced with a family history of diabetes, blood pressure and obesity, she knew she’d have to be proactive about her health and limit stress when she went on the night shift.

“When I leave here, I leave here,” she says. “I don’t join committees that meet during the day, and I’m selfish about the times I sleep.” Her regimen has paid off: “I don’t have a six pack,” says Dr. Tompkins, “but I’m not obese.”

Sleep techniques
For W. Oren Blalock, MD, a nocturnist at Ochsner Health System in New Orleans, the key to a good day’s sleep is the third floor walk-in closet in his house, which helps him control his sleep environment. Dr. Blalock has outfitted the closet with a Tempur-Pedic bed and an iPhone speaker with a rainmaker app. He also keeps the closet pitch black, quiet and cold.

While some take melatonin or Benadryl to ensure sleep, Dr. Blalock is able to skip the sleep-inducers. Every day after his shift, he religiously adheres to an hour in the gym. He’s in bed by 10:30 a.m., falls asleep within 10 minutes and stays asleep until 6:30 p.m.

He credits that routine for keeping his weight, blood pressure and cholesterol stable despite his rigorous seven-on/seven-off schedule, and he hasn’t taken a sick day in three years. He transitions back to day hours by staying up the last day he’s on service, forcing himself to watch a movie or pay bills.

Jalila Cunningham, MD, a nocturnist at the 240-bed Hamilton Medical Center in Dalton, Ga., uses a similar strategy to control her sleep environment: She drags a trundle bed into her home theater and uses an eye mask to stop sunlight from interrupting her sleep. While the strategy has helped, the outside world occasionally interferes in the form of neighbors mowing the lawn or people cheering on the nearby golf course.

While some factors can’t be controlled, many can. Dr. Sachdeva, for example, asks his family members to be part of the “sleeping team.” His kids know they can’t dribble a basketball in the house while he’s sleeping, and his wife tries to avoid clanking dishes when she cooks.

Do all the techniques work? Dr. Shigeno from Scripps says he’s so well-attuned to his schedule that while he sets two alarms, he doesn’t need them. “When you work the night shift enough,” he explains, “you don’t need the alarm because your body is up.”

Managing diet
To keep the body up and going, caffeine early in the shift can be an option. (See “Tips on making night shift work.” Dr. Sachdeva has a cup of tea when he wakes up and coffee when he gets to work, but no caffeinated beverages after 9 p.m. Others stretch that timetable. Dr. Cunningham, for example, limits caffeine after midnight, while Dr. Blalock has a large cup of coffee only before his shift.

Regimenting diet is another given. With a family history of diabetes and high blood pressure, Jessie Kimbrough-Sugick, MD, MPH, knew working the night shift made watching her diet and exercise regimen even more important when she began at the 925-bed University of Michigan Health System in Ann Arbor.

Dr. Kimbrough-Sugick says some who work nights occasionally use it as an excuse to indulge. “I used to have that mentality, that I can eat whatever I want as my reward for being up all night,” she says. “But I had to get out of that once I began as a nighttime doc.”

Timing and food choice are critical. Some eat healthy foods for dinner before they go to work. For Dr. Cunningham, that might be shrimp or fish on top of salad or a tuna sandwich. Dr. Sachdeva goes for vegetables, beans or pasta, and he avoids red meat or fried foods. Dr. Blalock eats lean meat or fish with vegetables at 6:30 p.m.

“I want food that doesn’t weigh on me when I get to work,” he says. “I have to hit the ground running.”

Snacks are also on the healthy side: carrots, snap peas, nuts, energy bars, muscle milk, fruit and sugarless gum. Dr. Cunningham stops every two hours for a nutrigrain bar, granola or trail mix that she keeps in her pocket.
By 6:30 a.m., Dr. Sachdeva says he’s famished and stops for breakfast “oatmeal, granola, half a bagel or eggs “in the hospital. He says it’s critical to raise his blood sugar before driving home.

For Dr. Cunningham, the struggle is to resist the urge to eat in the middle of the night “a sure path to the weight gain and sluggishness she experienced when she first started working nights.

“I began buying new clothes because being in scrubs every day, you don’t know you’re spreading,” she says. After going up a size, she started restricting her food intake and adding in a run after her shift three or four times a week.

“I’m actually now a size smaller than when I started working the night shift,” Dr. Cunningham explains. “I took up running to help me lose the initial weight gained and now I use it to maintain my current weight.”

Healthy habits
Exercise “from taking the stairs to joining 24-hour fitness clubs “makes it easier to control weight and fall asleep. It also prepares nocturnists for their physically demanding job.

Hitting the gym at least three to five days a week works for many nocturnists. Dr. Sachdeva, for example, uses the cross trainer for up to an hour and does core muscle strengthening and stretching. He also rides a bike during the summer and, on his days off, plays tennis or ping-pong with his children for 30 or 40 minutes or uses the cross trainer to send his body the message that it’s morning and time to be active.

Dr. Tompkins avoids aerobic classes, because class times may not always work with her schedule. Instead, she walks several miles or does an elliptical machine for an hour.

A strict regimen doesn’t have to interfere with having a life on days off. Although many nocturnists continue their exercise routine or a modified version of it when they’re off service, they say you need to have some flexibility ” and some fun.

“On my days off, I eat the same meals but sometimes have a drink,” Dr. Blalock says. “I live in New Orleans, after all.”

Finding balance
Working nights gets a bad rap because physicians think they won’t be around for family and social events, and they’ll lose personal connections. But nocturnists say that’s overplayed, and that they actually see their families more because they’re around during the day.

“When I was working days, I definitely didn’t see family when I was on 21 days in a row,” Dr. Blalock says. Now he uses his week off to catch up with friends or take vacation.

Dr. Kimbrough-Sugick chose night work specifically for the flexibility it gave her to be with her children and pursue her interests in research and education. When her children, ages 9 and 13, complain about her hours, she reminds them that when she worked days, she was gone for 12 hours a day.

“Now, my schedule is much more flexible with more availability to attend school functions and pick them up and drop them off at activities,” she says. “That’s especially true when I’m not scheduled for my night shift blocks.”
Dr. Cunningham chose to work nights five years ago to be on the same schedule as her husband, a police officer who at that time also worked nights.

Another social plus is the camaraderie with others pulling the same hours. For Dr. Blalock, staying social during his shift instead of holed up in an office creates bonds that keep him happy on the job. “Highly sociable people who do nights stay on them,” he says. “Every time I go in at night, it’s like family.”

But there are downsides, such as not having as many doctors who’ll take your shift in an emergency or the need to stay flexible in personal relationships.

Now that Dr. Cunningham’s husband is working days, for example, she says she sometimes stays up after work to eat with him. And when her two daughters were little, Dr. Tompkins would put Christmas gifts out, but her children would have to wait until she returned from work to open them.

“I explained,” she says, “that there’s a price for everything.”

Can it last?
While regimens can stave off the potential ill effects in the short run, what about the long term? Dr. Schaefer points out that there’s no evidence yet on the long-term effects on nocturnists. But Dr. Cunningham says that she worries about the stress on her personal life as well as cumulative chronic fatigue, especially as she gets older. She’s planning to cut back from 16 shifts per month to 10 or 12.

Even if your health is good, an overworked nocturnist won’t last. “You have to enjoy the job or this falls apart,” says Dr. Blalock. When patient volumes rose last spring, so did his stress level. “It was unsustainable,” he says. Instead of bailing, he worked with the hospital to add another nocturnist.

Even the best plan can’t put off the inevitable tug to work when everybody else does or pursue other interests. Dr. Kimbrough-Sugick says she’ll stick with it for now, “but I don’t foresee being 50 and doing night shifts.” While Dr. Shigeno likes the excitement and independence of night work, he’s hoping to move from his 5 p.m.-7 a.m. slot to a new 3 p.m.-10 p.m. swing shift. The 42-year-old Dr. Blalock, on the other hand, says he’s in it for the next eight years, when he plans to retire from night work.

Even if the hours don’t stay the same “Dr. Sachdeva has already reduced his number of night shifts and now spends one-quarter of his time on the palliative care team “working nights can have a positive legacy.

“The health habits will stay with me,” Dr. Sachdeva says. “That’s now in my DNA.”

Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.

Tips on making night shift work

ACCORDING TO Eric W. Schaefer, MD, assistant professor at Chicago’s Northwestern Memorial Hospital, the problem with working nights is obvious: “Our circadian rhythm is designed for us to sleep at night and be wakeful and alert during the day.”

Dr. Schaefer, who’s done research on the effects of night work on hospitalists, offers these tips for doctors who choose to upend that rhythm.

  • Use circadian adaptation techniques such as avoiding bright light during the day and adding bright light (with the use, say, of a bright light box) during the middle of the night. Use the light box for 15 minutes two or three times per shift to help shift your circadian rhythm.
  • Wear dark sunglasses during the day.
  • Focus on good sleep hygiene, including temperature control; most people prefer a cold, well-ventilated room. Invest in a comfortable mattress and pillow, steer clear of TV and pets, and make your sleep environment as dark as possible.
  • Consider taking melatonin before daytime sleep. It may help in the short term, and there’s no evidence of long-term downsides.
  • Get as much uninterrupted sleep during the day as possible. Five to six hours is realistic.
  • Go for a jog after you wake up to get your energy level back up.
  • Take a 45-minute nap in the early afternoon before you go to your shift. There’s some evidence that napping for an hour or more can lead to grogginess.
  • Drink caffeine (150-400 ml “a medium cup of coffee) right before your shift.
  • Take caffeine before heading out if you tire on the ride home. Keep the radio loud and roll down the window. If necessary, pull over or take a one or two hour nap before leaving your shift.