Clocking Out: Shift Work in the Emergency Department

Shift work is widely used to make workers available for round-the-clock work and to allow them planned times off. Although shifts have defined times, work often is neither predictable nor precisely defined. I examine strategic behavior in emergency department (ED) shift work. Consistent with increasing time costs past end of shift (EOS), I find that physicians discharge patients increasingly earlier as they approach EOS; patients arriving in the last hour prior to EOS are discharged 72% sooner than those arriving in the middle of the shift. Physicians also order more diagnostic tests and are 18% more likely to admit patients arriving in the last hour prior to EOS, suggesting discretion in the production of information for discharge decisions. I exploit variation in the structure of shifts to show that physicians dramatically reduce their acceptance of new patients near EOS and particularly before another physician peer arrives to relieve their work. Shifts with late-arriving peers, in which this reduction is delayed, show the greatest distortion in patient care. That is, when the performance of work is difficult to monitor or manage, it may be second-best optimal to allow workers to avoid work.