How Shiftwork Distorts Patient Care

In the last hour before they clock out, emergency department doctors see their patients less but order more tests. What are the lessons for hospitals?

The Essentials

Just before their shifts end, emergency department doctors tend to change their approach to patient care, says David Chan, assistant professor in the School of Medicine at Stanford University. Chan has found that, in such situations, physicians spend less time with their patients but order more diagnostic tests, in an effort to decide whether to send patients home or admit them. Chan suggests that building in overlaps may address some of the “behavioural distortions” at shift transition times.

Chan talked about his research in a presentation at The Monieson Centre for Business Research in Healthcare. In this video, he explores the practical implications of his findings with Scott Carson, director of The Monieson Centre.

Video Highlights

2:14     David Chan explains his rationale for studying the decision-making of emergency department (ED) physicians in the last hour before their shift ends. At that time, physicians are supposed to stop accepting new patients and go home if their work is complete. But it is rarely as simple as that; they often require more time to complete the care of their existing patients or to pass off patients who might stay particularly long. If physicians incur a private cost for staying late — perhaps having to drop family obligations — such pressures can affect their decisions in the emergency department.

4:56     In the last hour before their shifts end, ED doctors have two areas of discretion. One, they can decide whether or not to accept a new patient. Two, they can change their approach to patient care. Chan has found that, in such situations, ED physicians spend less time with their patients but order more diagnostic tests, in an effort to decide whether to send patients home or admit them.

6:40     These findings should prompt hospital administrators to consider how they structure shiftwork and the transitions between shifts. Chan suggests that building in overlaps may address some of the “behavioural distortions” at end of shifts. Hospital administrators may also want to consider how patients are assigned in a work shift structure. Do ED doctors have performance or social incentives to maximize the number of patients they see?

8:58     Healthcare has changed dramatically, says Chan. The proliferation of medical technology that allows for new interventions that are time sensitive, combined with new performance measures and the growing importance of team-based healthcare, have all led to greater emphasis on scheduling and management control. 

11:00    Chan cites the economic theory of “moral hazard,” which refers to a situation in which a party takes risks because the party is shielded from the potential costs of the decision. Such is the case with the performance of ED physicians when they are close to the end of their shifts. But that doesn’t mean they have a moral failing, Chan says. “It’s just that we need to recognize these differences in objectives. In some cases, the organizational setting itself leads to these differences in objectives.” 

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