© 2007 American Thoracic Society
Burnout in Intensivists and Configuration of the Working WeekTo the Editor:We read with interest the study by Embriaco and colleagues, which documented a high level of burnout amongst French intensive care staff (1). In this study, it was the configuration of the working week rather than the total number of hours worked that was most associated with burnout. This contrasts with studies performed in the United States, which showed that reducing the total number of hours worked decreased burnout in internal medicine residents (2, 3). These apparently conflicting results may be reconciled when one considers that despite the introduction in July 2003 of work hour restrictions in the United States, these remain excessive by European standards. It seems that as the working week shortens, the configuration of shifts becomes increasingly important in determining adverse psychological symptoms. An extensive literature exists outside medicine, exemplified by the aviation industry, detailing the harmful effects of various work patterns. Working at night is far more onerous than working during the day and impairs psychomotor performance in much the same way as excessive alcohol. Moreover, both the length of shift and the consecutive number of shifts worked can increase fatigue and risk (4). Consequently, it should come as no surprise that Embriaco and coworkers (1) found that a higher Maslach Burnout Inventory (MBI) score was associated with the number of night shifts per month, time since the last nonworking week, and a night shift before the survey. Despite the availability of many well-validated tools, a potentially important variable that was not measured in this study was that of sleep. Night shift workers often experience poor-quality sleep, sleep deprivation, and fatigue. While the relationship between fatigue and clinical error is well documented, a recent study has also demonstrated linkage between clinical error, depression, and burnout in junior doctors (5). We would speculate that individuals with a high MBI score were in fact sleep deprived. Careful consideration should be given to the configuration of the working week, as this is an essential strategy for reducing the prevalence of burnout. Improved rosters can be designed using online tools, which take into account the optimal length and number of night shifts and calculate minimum risk and fatigue indices (6). Finally, here in the United Kingdom, the Royal College of Physicians has produced a guide for doctors entitled "Working the Night Shift: Preparation, Survival and Recovery," which is freely available at www.rcplondon.ac.uk.
University Hospital of Wales, Cardiff, United Kingdom FOOTNOTES Conflict of Interest Statement: Neither author has a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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