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Night shifts: great for programs, hazardous to your health?

December 2007

As someone who has been recruiting hospitalists for the last seven years, I can testify that, in such a competitive market, hiring a good hospitalist feels like winning the state lottery. And landing a good nocturnist is like hitting Powerball.

Recent developments may not make that task any easier. According to the International Agency for Research on Cancer, an arm of the World Health Organization, the graveyard shift will now be considered a carcinogen. (I wonder: Was the appellation “graveyard” coincidental or prophetic?) Imagine the following H&P questions: “Do you smoke? No. Do you drink? No. Are you now or were you ever a nocturnist? And if so, how many shifts per month do you work? Doc, honestly, I just quit, but for 10 years I had a 20-shift-per-month habit.”

There are many reasons why, in my current situation, we really need a good nocturnist program. No matter how large your program is, it probably pays to have a doctor in-house at night. But our program is large enough to generate real financial returns from night coverage.

With more than 10 admissions every night (and a daily census that tops 70), there is no question that we need 24/7 coverage. That type of volume means that the hospitalists are close to breaking even or even making money at night–which in turn means that the hospital has to provide less of a financial subsidy for night coverage.

But here’s perhaps an even bigger benefit of a nocturnist program: It helps recruiting on the dayside. Let’s face it, most of us don’t want to work nights, and I have lost some excellent candidates to other positions that did not require in-house night coverage. But nights are not going away. In fact, I think that the majority of hospitalist programs at midsize and larger hospitals that don’t already have around-the-clock coverage will eventually move to this model.

What I began this position in August 2007, our nights were covered by multiple “PRN” nocturnists. Many were excellent docs, but this was moonlighting for them, and when the sun came up (so to speak), their primary responsibility was to their own practice.

Because that arrangement was not working well, we decided to work our own nights for the time being while continuing to look for good, dedicated nocturnists. This translates into one busy week of nights every three months, not an unreasonable sacrifice to have nights covered by physicians who are fully vested in our program.

Some programs may get lucky, but I suspect that, in the end, given our current overall shortage of hospitalists, most programs will have difficulty maintaining a dedicated nocturnist program. So, what will the future look like for night-time coverage?

I often draw an analogy to ER medicine. Most ER departments have one or two docs who prefer working nights only. The rest wrangle mightily to avoid this shift. It usually boils down to a matter of seniority, with those at top of the hierarchy working fewer night shifts. Such “reverse age discrimination” seems inevitable in hospitalist medicine.

As seniority develops in our field, I suspect older hospitalists will generally “grandfather” their way out of nights, hopefully just before their circadian rhythms lose the flexibility of their youth. As I age, I find that the morning after working a night shift feels uncomfortably like the morning after having had one too many.

In college, “one too many” meant “several more than a few.” Subject to Pavlovian conditioning as I am, “one too many” now means just a few, so I have adjusted my social habits accordingly. If only finding a way to avoid nights were as easily conditioned!