Hidden Workload of Academic Emergency Physicians: Extra‐Clinical Duties and Their Impact on Fatigue and Recovery

Emergency physicians (EPs) face a uniquely demanding work environment characterized by high patient volumes, unplanned visits, rapid clinical decision-making, and exposure to high-stress situations and traumatic events. Additionally, EPs work night and rotating shifts, leading to suboptimal sleep quality and circadian disruption, causing sleep debt and fatigue over time [1]. Perhaps due in part to the demands of the clinical work and the challenges of rotating shifts, burnout in emergency medicine has been estimated at 40%–60%, some of the highest of all medical specialties [2]. Like all physicians, EPs employed in academic departments (affiliated with medical schools and residency programs) frequently perform additional work-related duties outside of their scheduled clinical workdays, including clinical documentation, education of students and residents, research and administrative responsibilities, and institutional service. However, because academic EP work shifts during times that often do not correlate with a “typical” workday, these extra-clinical duties (ECD) occur during periods of time intended for rest. Figure 1 illustrates a typical academic EP scheduled for a 3–11 pm shift on both Monday and Tuesday. The schedule shows and counts only these two shifts, each an 8-h workday, with both mornings available for rest. However, this same EP attends two work-related meetings on Monday, completes preparation for a lecture, works clinically from 3 to 11 pm, and stays late to complete patient care responsibilities and documentation. He returns early Tuesday morning, gives one resident lecture, attends a resident conference, and then works another shift from 3 to 11 pm, staying late to complete his clinical work. Furthermore, this illustration includes only 2 days. When this pattern happens multiple times a week, the lack of recovery time can result in rapidly accumulating sleep debt. The importance of physical and psychological recovery in buffering work-related demands is well documented [3]. Inadequate sleep and recovery between shifts have been associated with sustained fatigue, impaired performance, and elevated burnout risk among clinicians [4-6]. Both the timing and quantity of ECD may affect sleep and recovery time and quality, and, over time, may impact EP fatigue and burnout. This study aims to (1) quantify the time academic EPs spend on a variety of ECD and (2) evaluate the effects of ECD on EP recovery and fatigue. Furthermore, because EPs in academic medical centers often have “protected time” (PT) for their academic and other duties, we examine ECD as a function of the amount of PT. The Prisma Health institutional review board determined this study to be exempt. Participants were EPs in a large hospital system in the Southeastern United States; this system is affiliated with a medical school and an emergency medicine residency program and employs 170 physicians in a hybrid academic/community model. A full-time EP without protected time is scheduled for 130 clinical hours per month, with shift lengths ranging from 8 to 10 h. Participants were faculty volunteers from the Department of Emergency Medicine who consented to participate in the study and to receive daily text messages containing individual survey links. In thanks, participants received either credits towards variable compensation or Amazon gift cards, both prorated based upon the number of surveys completed. Next, participants were asked to specify the amount of time in hours and minutes that they spent on each ECD type. Exhaustion/recovery was assessed using a single-item slider scale measure ranging from 0 to 100%, where participants were asked, “Think about your state of exhaustion/recovery TODAY, April __, ranging from being ‘extremely exhausted/0% recovered’ to ‘not at all exhausted/100% recovered.’” Demographic data were collected prior to the first daily survey and included gender, age, ethnicity, percentage of PT, and years worked. Shifts worked by each EP were captured through evaluation of the final published schedule. All analyses were conducted using R version 4.4.2. Descriptive statistics were conducted on all study variables. Differences in ECD as a function of PT and shift hours, and ECD as predictors of exhaustion/recovery, were tested with linear mixed models. For all analyses, day-level ECD hours greater than 20 were determined via outlier analysis to qualify as outliers and thus were removed. Data were collected from EP (N = 46). Most respondents were white (91.11%), female (62.2%), and between 31 and 45 years of age (80.0%). Of a possible 1288 surveys (46 EP, 28 surveys each), participants completed a total of 1168 daily surveys, representing a 90.7% response rate. Participants worked a total of 536 shifts across the 28-day period, for an average of 11.7 shifts per EP, with an average shift length of 8.69 h. EP worked an average of 3.49 shift hours per day. They spent an average of 1.77 h on ECD per day (SD = 2.75), with 2.06 h spent on ECD on days off (SD = 3.29) and 1.57 h spent on ECD on shift days (SD = 1.57). On average, EP spent the largest proportion of ECD time on administrative work (33.19%), followed by education (17.97%), staying after shifts (16.99%), clinical documentation (16.15%), professional development (7.71%), engaging in other unspecified ECD (4.07%), and research (3.93%). Twenty-five EPs reported PT ranging from 0% to 10%; 10 EP reported PT ranging from 11% to 20%; 10 EP reported PT greater than 20%. A linear mixed model with Tukey-adjusted pairwise comparisons revealed that EP with more than 20% PT had significantly more ECD than the 0%–10% PT group (estimated mean difference = −3.08, SE = 0.54, p < 0.0001) and the 11%–20% PT group (estimated mean difference = −2.36, SE = 0.65, p < 0.01). No significant difference was found between the 0%–10% PT group and the 11%–20% PT group (estimated mean difference = 0.72, SE = 0.54, p = 0.386). A linear mixed model with a random intercept for physicians was conducted to examine the effect of working a shift and total ECD hours on exhaustion/recovery the following day. Working a shift had a significant effect on next-day exhaustion/recovery, t(1121.45) = −14.06, p < 0.001, indicating that EP reported lower recovery following a shift day compared to a non-shift day. Total ECD hours were also a unique significant predictor, t(1096.46) = −3.60, p < 0.001, with greater hours of ECD associated with reduced recovery. Unlike most specialties, emergency medicine is structured around shift work. The rotating and irregular hours of shifts, combined with uncounted ECD, combine to create circadian disruption and insufficient recovery between shifts, both of which contribute to burnout [4, 7]. While prior research has examined the effects of shift stressors [8], no previous research has examined extra-clinical workload. This research demonstrates that workload, when represented solely by clinical shifts, is underestimated in EP. These EPs spent approximately 50% more time on ECD than their scheduled clinical hours alone would suggest. Thus, the true work burden was undercounted by scheduling models. Academic EPs are expected to fulfill their ECD during times that typically would be used as recovery windows, potentially affecting sleep duration and quality and decreasing the ability to recover. This is evidenced by the fact that ECD predicted lower daily recovery and higher fatigue in EPs, independent of shift and commute time. Limitations to this study do exist. This study was performed in a single health system, so the generalizability of the findings is unclear. Self-reporting of ECD and fatigue may have introduced recall bias, although daily surveys should have helped mitigate this effect. Additionally, although ECD timing impacts workday length, this study did not evaluate the timing of ECD worked. More research on ECD in EP is needed to assess how ECD manifests across diverse types of hospitals and health systems and to assess the impact of ECD timing. Future research should also incorporate sleep and actigraphy monitoring to quantify the sleep impacts of ECD. This study is the first to empirically quantify the actual time spent on ECD and evaluate its impact on fatigue and recovery in EP, empirically demonstrating what has long been understood anecdotally—that EP perform substantial work beyond the shift, infringing on recovery time. ECD must be recognized in workforce planning, compensation models, and burnout mitigation strategies to protect EPs and their patients. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.