One of Alpha Hospital’s emergency physicians has an opportunity to go on a four-day raft trip, a vacation he has been looking forward to for a long time.
In order to take the trip, however, he must switch a shift, and this means that he would work 24 hours continuously.
Alpha Hospital has a very busy emergency department and often receives more than 100 patient visits in 24 hours.
As in all emergency departments, patient arrivals at Alpha Hospital emergency department are not distributed evenly, and 30 or more patients may appear within some two-hour periods.
The admission rate, including many major surgical and medical cases, is higher than 20%. The physician would have to work solo for 24 straight hours under these conditions. Is this fair to his patients? Can he provide adequate quality of care to all patients?
Commentary
The problem posed by this case presentation is frequently faced by those who practice emergency medicine: Is it ever justifiable to compromise or potentially compromise the provision of quality medical care in a facility which markets itself as providing emergency services on a continuous and unrestricted basis?
Two specific questions need to be addressed with regard to this case. First, how many patients can a single emergency physician care for on an hourly basis?
(One may assume that the physician works with a well-trained nursing staff in a properly equipped emergency facility.)
Second, what is an acceptable continuous length of time that a physician can actively care for patients before there is a deterioration in judgment or skills?
In analyzing the situation at Alpha Hospital, we find that there is:
(a) single physician coverage;
(b) a potential average of more than 4 new patients per hour;
(с) a peak of 15 or more new patients arriving per hour; and
(d) an admission rate of 20%, that is, perhaps 1 new patient per hour.
These facts describe a busy emergency department which must be very stressed by single physician coverage.
It would appear that there must be an emergency physician on call who can respond in time of heavy patient care demands or that there are extensive patient waiting times.
The patient volume in this emergency department at times may even justify double coverage. Although these are not the specific questions addressed by this case presentation, they are very worthy of comment.
I am unaware of any published studies which document the maximum number of patients that can be properly evaluated and treated by a well-trained emergency physician on an hourly or shift basis.
My personal experience with a large number of well-trained emergency physicians would suggest that the maximum number of emergency patients of this type who can be properly managed is between 3.5 and 5.0 patients per hour. During a 12-hour shift, this would amount to 42 to 60 patients.
This amount of hourly volume does not usually allow for extensive breaks or meals.
Similarly, I know of no study which documents the maximum number of continuous hours a physician can work without breaks or meals and be assured that his or her judgment or skill level will not deteriorate.
My experience would suggest that some physicians work best on an 8 to 10-hour shift.
Most seem capable of 12-hour shifts, although fatigue, hunger, and irritability begin to set in. No one, in my experience, can maintain the pace presented in this case for a continuous 24-hour period without experiencing some deterioration in judgment and / or skill.
If one accepts the aforementioned discussion as accurate, the answers to the questions posed at the end of the case are obvious. A 24-hour solo shift is clearly not fair to the patients who will present to Alpha Hospital for emergency care.
The physician will not be able to provide adequate quality of care to all patients.
What then do we have to offer to our colleague who wants to go on the four-day raft trip? It appears that we have responsibility, reality, and compassion to offer.
He must be helped to recognize both the individual and the institutional responsibility to patient care that his contract presumes. It is very difficult to deny oneself a personal pleasure which one believes one deserves. But this kind of a denial is a harsh reality which one must sometimes face.
Compassion and understanding should accompany each conversation involving this subject. Ideally, the involved physician will be led to the conclusion that he cannot appropriately work a 24-hour shift.
Even if he does not come to this conclusion, however, the director should refuse his request. The final decision rests with the director, whose primary concern is to assure high quality of patient care.
In relation to this case presentation, the term “quality of life” takes on major significance. Initially, one might consider it to relate primarily to the physician’s desire to go on the raft trip.
Upon further reflection, one recognizes the need to address the “quality of life” issue in relation to medical practice in general.
Do we maximize quality in this arena when we work long hours in a stressful environment without breaks?
Might we do better to sacrifice some of our financial gain for “quality?”
These types of questions need further thought and discussion as we evolve as a discipline which hopes to retain its practitioner for a full career.
