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What happens to your body and clinical judgment when you’re managing a code blue at the exact hour your biology demands deep sleep? Chinyelu E. Oraedu is an academic hospitalist and nocturnist with 17 years of post-residency experience who has dedicated her career to understanding the science and human reality of night shift medicine. In this episode, based on her KevinMD article “How night shift medicine exposes the reality of physician stress,” she breaks down why the 2 to 3 a.m. window is the most dangerous period for both patients and providers, when melatonin peaks, alertness bottoms out, and emergencies keep coming. You will learn practical strategies for surviving and thriving on night shift, from the right timing for caffeine intake to using light therapy at your workstation to suppress melatonin secretion. Oraedu explains why sleep is the single most important factor for night shift workers and why she tells every resident to protect it above exercise, meals, and everything else. She also shares surprising early data from her own research showing that night shift workers who build intentional structure around their schedule report high satisfaction. Whether you are an incoming intern about to start your first night float rotation or a seasoned nocturnist still battling fragmented sleep, this conversation offers a practical framework for reducing the hidden health risks of working against your circadian rhythm.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Chinyelu. She’s an academic hospitalist and nocturnist. Today’s KevinMD article is “How night shift medicine exposes the reality of physician stress.” Chinyelu, welcome to the show.

Chinyelu E. Oraedu: Thank you so much. Thank you, Kevin. It’s lovely to be here.

Kevin Pho: All right, so briefly introduce yourself and then let’s jump right into why you decided to share this article on KevinMD.

Chinyelu E. Oraedu: My name is Chinyelu. I’m a hospitalist. What it means is that I work in the acute inpatient setting, so I am board certified in internal medicine. I take care of adults from 18 upwards. Sometimes we do a little pediatric, based on whether it is a diagnosis, or if there are cases where they have adult-related problems, we could manage them in the hospital setting. So I’m a hospitalist, nocturnist, and general internal medicine. Everything in the hospital after hours, I take care of that. I just make sure that patients are all-round cared for at all times and hours of the day, 24/7.

In that role, I work in a community hospital. My role has kind of expanded beyond just hospitalist medicine. I do a little bit of perioperative medicine too. I started off full-time, part-time, and then I started doing a little bit of part-time and locums, because I think that internal medicine trains you in so many ways. We have a lot of skills. At some point you want to expand and have that experience both in the outpatient setting, inpatient setting, and everything else in between.

In my role as a hospitalist, I used to work with residents and I’ve done a lot of authorship. I’ve written some books in collaboration with other women. Notably it’s “Thriving After Burnout.” It’s a book that I collaborated on with 50 other female physicians, and I think it’s important that I mention this because April is National Stress Awareness Month. It’s really important that people do pay attention to their health and their wellbeing, and also of course their mental health.

As a person, I love medicine. I love the physiology involved in internal medicine. Recently I started to deeply dive into night shift medicine, having worked as a nocturnist for 17 years post residency. In between, like I said, I’ve done other things, because I think it’s good for you to be in tune with the future of medicine, which is that we have a rapidly aging population, and a lot of care would need to be done in the outpatient setting.

That’s part of the reason, when I talk about night shift medicine, I try to not just unearth the problems that night shift workers have, but I also like to, especially for early and mid-career physicians, show all the ways that you can actually not just navigate, but the skills from working at night. Night shift is considered not just the negative health risk associated with night shift, but on the positive side, when you work in a situation, in an environment that is considered resource poor, in the sense that there’s limited people at night, you need to be clinically very strong in terms of patient management, acute management of patient diagnosis. It kind of gives you skills. It gives you a lot of skills, clinical skills, human skills, because as physicians, we also carry leadership roles. You have to mitigate a lot of other issues that come up at night with nursing, with difficult patients, with family members.

So I look at the whole spectrum of night shift from different angles, the pros of night shift and the cons of night shift, and how people who work at night can have a wholesome experience and then use it to navigate life long after night shift. From my own pain of raising children, I have three kids. I’m still married after 23 years, because there’s a lot of issues with night shift and relationships. It’s a situation where I feel a gap, that there’s a huge gap within the night shift ecosystem, people who work at night. So I provide the guardrails and the guidance. I think that’s what it is, so people can navigate the problems, the pain, and some of the perils, and still have some normalcy with your irregular lives.

Kevin Pho: Sure. You mentioned that you talk about night shift medicine from many different angles, and I would love to have you come back on the show to talk about each of those angles. This particular KevinMD article talks about how night shift medicine exposes the reality of physician stress. For those that don’t get a chance to read this particular article, just tell us briefly what’s it about.

Chinyelu E. Oraedu: When thinking about this article, I always tell people that people worry about AI all the time. AI is going to replace physicians, but I tell them that a lived experience is what’s going to separate AI from the next thing to come. People who have a lived experience, because you look at the science. Based on the science behind whatever idea you have, then you build practical strategies, and then you insert the human side of it, of your own lived experience.

So when I talk about physician stress, I’m kind of leaning more towards that, April. There’s a lot of awareness around stress in the month of April, leading with the spring and everything going on, people getting a little bit more active. I look at night shift and what happens 2:00 a.m. I just wrote an article on social media about two to 3:00 a.m. being a very, not just a pivotal and critical time, but in human physiology, the peaking of the melatonin, and also all the physiologic processes that happen at night.

Then the fact that you deal with a lot of emergencies. Studies show that people usually, more people die during the early hours of the morning. So in my experience, looking at the stress of working at night, you see that there’s a heightened level of awareness that, OK, it’s this time of the night, a rapid response, a code blue, or somebody deteriorating, and everybody’s scrambling trying to save every life. When you have emergencies at night, it adds a layer of stress to the physician, not just your health, your mental health, your wellbeing.

Another layer of that is that, if you’ve worked night shift for a sustained period of time, if you remember night float, working night float, most physicians do have some experience with working nights. It’s part of the training. Around that 2:00 a.m., 3:00 a.m. period, that is when your level of alertness is lowest. And that corresponds with the peak in your melatonin. That’s when normal people have the deep sleep and go through the cycles of the REM sleep and all that. So if you have to be awake at night, it’s a very difficult time, two to 3:00 a.m. in the middle of the night.

Majority of the stress that we go through as providers, doctors and in the health care space, has to do with the disruption in your circadian rhythm. That is the genesis of night shift, the ill health associated with night shift work. So two to 3:00 a.m., I made a reference to that time frame, because it is the most difficult time to stay awake in the middle of the night. And on the other side of it, a lot of people who work nights will resort to caffeine. You need a boost of caffeine at this time to get through the next few hours, and then you find out that now you suffer the consequences of the long half life of caffeine, which is perhaps up to six hours. Then you post-shift and then you can’t sleep.

So it’s, when I bring in, like I said, the lived experience of being somebody who’s worked night and navigated life in so many ways, family, academics and growth, professional development, that’s something that is very important at night. In that article I was kind of unearthing the stress of 2:00 a.m. in the life of somebody who works night shift. It’s a biological stress test, night shift, nobody’s talking about. I think that we can put in stops and create a system that really helps a lot of people who have to do the night shift lifestyle, especially in the health care setting. It’s essential. It’s not something that people can be replaced at. At least as of now, doctors will still, and nurses and everybody else who does night shift.

Kevin Pho: You said that the two to 3:00 a.m. hour is when the body is most stressed. What happens to clinical judgment during that time? Because even though the body is at its highest stress, there’s still things like code blues and there’s emergencies throughout the hospital. What happens to clinical judgment during that time?

Chinyelu E. Oraedu: That’s the thing about, when I talk about it, you as a physician, you have to maintain a high level of alertness. You just have to. And there are remedies for that. Since I started talking about night shift medicine, the right time to take caffeine before your shift, on your way to work. Using light as therapy to increase your level of alertness so that you can work, because it’s all about peak performance. My take on this is that when you sign up to work at night, you have to be awake at night. It’s kind of swimming against the grain, but that’s what you signed up for.

The nature of what we do, there’s very narrow margin for errors. So a lot of people who work in health care at night understand that light is therapy. Maybe some people don’t in other spaces, other jobs that do nights, maybe manufacturing. There’s a whole lot of occupations that do night shift. So it has to do with, like I said, the strategic use of caffeine, light, and snacking. I do always advise people to avoid heavy eating at night. First of all, your metabolism is not built for you to eat through out the day and out through the night. So the strategies in place that help you maintain alertness, and if you need a little caffeine, perhaps you should, just to make sure that you can do your job. It’s very important for us in health care and even other people who work nights that you perform at your best.

As somebody who works night shift, something else I have to add is the whole idea, not just idea, but we know that we have the chronotypes. We have different people who function at the highest level at different times of the day. For the most part, about 70 percent of people are morning larks, the day people, but you have a subset of people who function best at night. So perhaps it’s something else, an area that hasn’t really been fully explored, that when people work in alignment with their natural chronotypes, perhaps they do better on the night shift.

Kevin Pho: When you say light therapy, what exactly does that look like?

Chinyelu E. Oraedu: Light therapy has to do with, it’s fluorescent lights at a certain level of frequency. I just don’t remember the exact, I don’t want to misquote, but you use it at the beginning of the shift. The reason is that light inhibits secretion of melatonin. Melatonin is a hormone that makes you sleep. So if you can inhibit the maximum secretion of melatonin, you can maintain more alertness. But what I see sometimes is that people turn off light when they’re coming to work night shift, and few hours later everybody’s asleep.

Some hospitals do have those kind of lights already built in at the desktop, so that people can use them if they are aware of the benefit of using such light. At my hospital, we do have that. And the earlier you expose your workstation to the effect of those fluorescent lights, it’ll help you maintain alertness for a longer period of time. But the two to 3:00 a.m. hour, it’s a difficult one. It’s still extremely hard for even ER physicians. I was having a conversation with her, she said two to 3:00 a.m. you’re struggling.

Kevin Pho: Now you’ve been doing this for 17 years. Does it ever get easier? Do you still feel that your body’s at its most stress at two to 3:00 a.m. after doing this for 17 years?

Chinyelu E. Oraedu: Some days are better. And that’s why I tell people, there was a study that was done, not just between, there’s a lot of studies on nurses actually. Day shift versus night shift nurses. I think they’ve done a good job of showing the level of sedentary, the night shift nurses are more sedentary compared to nurses who do day shift. So activity helps you maintain alertness at night too. Moving around from one station to the other station, taking a few laps. It helps you stay awake.

In addition to that too, talking about my personal experience as somebody who’s thrived, initially I struggled up until after the pandemic. I think that was a pivotal time. That was when I started to kind of dig more and read around night shift a lot, and all the studies that have been done, what things are missing, how people can do better. What I noticed is that for you to thrive on the night shift, you have to understand that your biology, your body is working against the grain. It’s working at a time everybody else is sleeping. So you don’t have to align with people who work day shift. You have to find that you have to consciously, intentionally build a system that allows you to sleep. It’s the intentionality around it.

And sleep is the biggest issue. Anybody who works night shift will complain about they don’t get enough sleep. It’s fragmented, it’s disrupted. It’s because people work night shift to care for their families. A lot of women who do nights are caregivers for dependent children, or perhaps aging parents, in addition to people who work nights while getting a higher education. There are subsets of people who do all this, but the overarching thing is to find a way that people can navigate their working non-standard hours, and also minimize the risk of the lifestyle.

For me, 17 years later, I can tell you that within the last five years, that was when I totally had a 360 turnaround with sleep. I don’t compromise my sleep. I just don’t compromise it. I don’t pretend that I work during the day. I have stop limits. And somebody actually was asking me, and he’s like a fellow, how to navigate sleep, especially during spring hours, when springtime going into summer, when you have longer days. It’s a very difficult time for people who work night shift.

So from my personal experience and looking at the science, the first thing I can tell people is that alignment, you work at night, you have to tell people that you work at night, first of all, so that they could just give you the time to sleep. I think once you are able to maximize your sleep, 7, 8, 9 hours post night shift, the two to 3:00 a.m. stress minimizes. You perhaps may be able to go through a night shift stretch without having that difficult time that a lot of people do complain about, because your body’s rested, and you can carry through the night.

But the caveat to that is that some jobs require stretch of night shift. People do seven nights, eight nights. It’s hard. There are studies that have shown how many hours people should work at night, eight hours at night, perhaps not more than three to four stretch at a stretch. So when we push the limits of night shift, then the stress increases and people just try to get through it. But it’s a biological stress test. And people just need to find ways to survive and hopefully the systems will catch up and create a safer environment.

Kevin Pho: This discussion is giving me some almost like PTSD memories when I was doing night float over at when I was an intern and resident. In fact, my first rotation when I was an internal medicine intern was in fact night float. So just like one week ago, I graduated from medical school, and my first two weeks as an internal medicine intern was night float. So I haven’t done anything like that since in a 24-year. But talking about this is bringing back some memories of my experiences with night float at the hospital.

Now we’ve talked a lot about some tips that can help during these night shifts. If you were to prepare a doctor doing a nocturnist role, or an intern or resident doing night float for the very first time, what’s the single best thing that they could do to prepare themselves, if you were to just name the most important thing?

Chinyelu E. Oraedu: Sleep routine. Create a sleep routine. Find all those tips, those tools, the trade-offs, the techniques, anything that is going to allow you to make sure you maximize on sleep. If you don’t sleep as somebody who works night, or if you have inadequate sleep, it’s going to be hard for you to control your weight. It’s going to be a big problem to control your weight, because your body’s going to crave all the bad food, the fatty food, the starchy food, the salty sugar. And unfortunately, that’s just going to be what’s available in the hospital. These are the kind of foods you find after hours at the vending machine. So that’s part of the problem too.

The question comes up a lot. Should I sleep or should I go to the gym? Should I sleep or should I eat at the ungodly hour? And I always tell them sleep. As a matter of fact, I’m actually doing a mini kind of quality improvement study in other night shift study. And a lot of people that are filling out all the survey, I found out that, I mean, I’m still working on the data, but majority of people who are single and have a form of structure around their night shift, they’re very happy. On a scale of one to five, how, what is your level of satisfaction with night shift? All of them are giving me fives. So I’m still looking at the data. I haven’t even analyzed it. I’m like, oh, wow. Some people actually do thrive at night. They don’t have health problems. They go to the gym, they eat healthy, and they sleep enough.

So that kind of tells you that the intentionality around night shift could help people to be happier, but one factor is sleep. If people don’t sleep enough, they’re just not happy.

For any resident, because I have a couple of residents that I mentor, I just tell them how to get ready. Especially the incoming interns, I just tell them, if you’re single, if you’re married, long-distance relationship, your relationship is very important, because any disruption in your relationship affects other aspects of your life. Of course your sleep suffers. So we talk about tools. You have to get the dark curtains. You have to make sure the room is conducive after work. You have to have the right food. So meal prep is important. And then you have to have the support around the community.

It is really interesting. Somebody brought it up and said, how do I deal with my landscaper? I get back from my night shift and my landscaper shows up. This is somebody who just started working nights, and I guess he started working nights late in the fall, early winter. So nobody does landscaping during the winter, so he never really had to deal with that. And now with spring and his landscaper comes and disrupts his sleep. It is pretty funny. I just told him that is a conversation that needs to happen. Perhaps you tell them when you’re off, or the right time to come. They come early in the morning, but when you’re still back from your shift and trying to settle down to rest. So these are tips that you don’t find in books or in science journals, but they’re real tips and tools that are human facing, what the person is dealing with. And it helps the person when they can have this conversation with people in their circle of friends, people that help them, their communities, their neighbors, so that they can sleep. Something as simple as putting a note in front of your door, “Don’t ring the bell. I’m sleeping.” That kind of thing.

So I pride myself that I give practical tips, practical strategies. I think that’s what people really need in order to thrive on the night shift. We know the science, the science has been there, some inconclusive, but it’s a needed ecosystem in modern work. And I think we created night shift. When I say we, I mean humanity. It’s a human thing. So we have to work around ways that we can minimize the negative effects that human beings suffer.

Kevin Pho: We are talking to Chinyelu Oraedu. She’s an academic hospitalist and nocturnist. Today’s KevinMD article is “How night shift medicine exposes the reality of physician stress.” Chinyelu, let’s end with some brief take-home messages you want to leave with the KevinMD audience.

Chinyelu E. Oraedu: I just started my night shift platform, Dr. Yara. Like I told Kevin, Yara, to me it is night shift. It kind of signifies the last part of my first name and the beginning part of my last name. And that’s kind of night shift to me. I go in towards the end of the day. I go to work at dusk and I emerge at dawn. So I think about all the pain that people who work night shift have to deal with, the pain, the downside. Out of that I create purpose. And that’s what I tell people that it’s helping you go to school. A lot of people do nights, going to school, raising children, and you look at your children and you’re happy that you actually participated as a parent. You go for all their school activities, daytime school activities.

And that’s how people try to, and that’s why a lot of people do nights actually. They can be chaperones, they can be mystery readers. As a mother, as a woman, that was what I did. That was because my parents were always hands-on. It was kind of very important to me, and I’m an immigrant. It was very important to me that I raise my children the way I was raised, and I participate in any way that I can. But at the same time, I understand that there’s a season for night shift. And that’s what I tell people. It’s kind of a season in your life, and you have to have a reason that you do it. And then while you do it, you have to look for other opportunities to do other things. I don’t think it’s one stop shop. That’s not what I, when I sit one-on-one with people, because for now we know that it carries risk. And you have to know your family history. You have to know the risk of cancer in your family if you have that. So I help people to minimize risk. That’s what I say. I’m helping you so you minimize your risk. So you optimize your health within the shift that you do, the night shift, and then you prioritize things that matter.

I did write an article about maternal health, talking about my story. When I was in residency, I was diagnosed with gestational diabetes. I didn’t know I had gestational diabetes. I did the test, the glucose tolerance test that every pregnant woman does here in the U.S. I had it. I did the test, I think, when I was like seven months pregnant. And I didn’t even know, because that was way before MyChart. We didn’t have MyChart, we didn’t have patient portal. So you do a test and you wait to hear from your doctor. You wait to discuss the results with your doctor. I was a resident in Brooklyn and busy program. I was going about my life, and I was pregnant then. And it was later on, almost at term, that I got the call from my doctor that your test is abnormal. Your test is abnormal. The baby needs to come out now. I’m like, I did this test almost two months ago. How come I didn’t get the results of it?

So these are part of the issue sometimes, both in residency and people who have very busy jobs. You tend to lose sight of your own health. So I do emphasize people prioritizing their health, not just as night shift workers, but as people who are high performers and busy, and taking care of other people.

So in a nutshell, I’m just all about focusing on night shift workers, because I think they have a lot of stress. I think a lot of them struggle, they feel unseen. At the same time, they are actually the drivers. They help to keep, put the economy and everything that happens during the day. They have helped to rev up production during the day. They support things that happen during the day, although kind of in the back end of things. So I just want people to look at night shift through binocular lens. I was just thinking about it when I was driving home from work. Not just monocular, but just put on the binocular lens, and just look at the pros and the cons and how can we support this group of people who help society and just want to be productive, but science has shown that they do suffer a lot of risks as a result of this.

Kevin Pho: Chinyelu, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Chinyelu E. Oraedu: Thank you. Thank you, Kevin. Thanks for having me.