Published in the September 2015 issue of Today’s Hospitalist
EFREN MANJARREZ, MD, interim chief of the hospital medicine division at the University of Miami Hospital in Miami, has a big problem: “I can’t hire a nocturnist to save my life.”
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Faced with losing both his dedicated nocturnists (one to working days, the other to the military), he’s been placing ads for their replacements for months without a single bite. Dr. Manjarrez has even spent $30,000 to hire a search firm, but his prospects for a dedicated nocturnist to start ASAP haven’t improved.
Finding nocturnists never used to be a problem. But this year, Dr. Manjarrez hasn’t even been able to hire any “short-timers” ” doctors taking a gap year before applying for fellowship “to work nights. He admits the seven-on/seven-off schedule of 12-hour shifts may be a turnoff, and he’d be happy to negotiate something more flexible.
“I haven’t gotten to any discussion of money or hours or anything,” Dr. Manjarrez explains, adding that nocturnists in his group earn a 20% compensation differential. “We haven’t gotten any hits.”
On Chicago’s North Shore, Sally Faulkner, MSN, the administrative director of the hospital medicine division for NorthShore University HealthSystem, finds herself in the same boat: Even doctors working only a year or two before a fellowship will consider working only days.
And starting this year, says Ms. Faulkner, “even people freshly graduated from residency programs who want to join the division want to work only days,” she points out. “We’ve had people decline offers when they couldn’t have all days, so it’s been a real challenge.”
A shortage of nocturnists isn’t just a headache for administrators. Hospitalist directors say that having to rotate doctors through nights who’d rather work only days is hands-down the field’s No. 1 dissatisfier. It’s something they want to avoid at all costs, particularly in groups where day-time hospitalists have gotten used to working few nights or none at all.
The thinking of group administrators is simple: If nocturnists ain’t happy, to slightly spin the phrase, ain’t nobody happy.
As a result, hospitalist groups are looking for ways to cater to ” some might even say pamper “their nocturnists. Groups are reducing the number and length of nocturnist shifts, paying them thousands per year more than day-time hospitalists, and relaxing productivity metrics. Here’s a look at the strategies groups are using to attract “and retain “nocturnists.
Big benefits from dedicated nocturnists
In the not-so-distant old days of the specialty, group members rotated nights with the help of moonlighters to cover night shifts.
Some groups still rely on that approach, but program directors say that having dedicated nocturnists produces major benefits over having a revolving door of moonlighters or day physicians who work nights infrequently. Both Dr. Manjarrez and Ms. Faulkner, for instance, argue that dedicated nocturnists are not only a key tool for recruiting day physicians, but also critically important in terms of working relationships and patient outcomes.
“You don’t want people who are just trying to get through the night,” Dr. Manjarrez explains. “You want physicians for whom working nights is their job description.” Moonlighters or rotating day doctors don’t have the same relationships as dedicated nocturnists with nurses, consultants and ED doctors, he says.
And while Dr. Manjarrez doesn’t have hard numbers, he adds that “complaints and adverse incidents dropped in our group when we went to dedicated nocturnists.”
Stephen Lopez, MD, who’s now in his fourth year as a nocturnist for Seattle’s Virginia Mason Hospital, has seen that kind of appreciation for dedicated nocturnists grow over the past five years.
“We’re seeing fewer and fewer nocturnist positions being used as a way station for other career goals,” Dr. Lopez says. “Hospitals realize that they have to maintain the same quality around the clock. But to do so, they have to offer the flexibility and incentives that make night work sustainable.”
The right schedule
For Dr. Lopez, night work allows him to spend the greatest amount of time with his young family. He plans to work nights “indefinitely.”
So what makes working nights sustainable for him? He points to two factors, one of which is the schedule. Virginia Mason maintains a five-on/10-off night schedule, giving nocturnists the same full-time salary and benefits as the other members of the group who work seven-on/seven-off. That’s a 29% shift differential.
“Working seven-on/seven-off at night is not sustainable, especially for anyone with a family,” Dr. Lopez maintains. The other key component is having the right amount of staff around nocturnists at night.
“We have residents who work nights too, so it’s a great combination of teaching, doing our own admissions and doing cross cover,” he adds. “One benefit for me working nights is that there is more ebb and flow during those 12 hours.” Day-time hospitalists, on the other hand, he says, “go from 0 to 60 right away and don’t slow down until mid-afternoon.”
The draw of nine-hour shifts
Colleen McCoy, MD, hospitalist medical director at Williamsport Regional Medical Center in Williamsport, Pa., which is part of the Susquehanna Health System, points out that the nocturnists in her group do work seven-on/seven-off, like the rest of the hospitalists. But night shifts are only nine hours, from 10 p.m. to 7 a.m.
During their weeks on, full-time nocturnists work 63 hours, while their day colleagues work 84. That later start time, she points out, convinced several day doctors to flip to nights instead.
“The schedule lets nocturnists participate in their family life in the evening every day, even when they’re working,” she notes. It also allows them to power-nap if they need to before they come to work.
Nocturnists in her group also work each night with an NP or PA. And to counteract the RVUs they lose toward their productivity component from working nights, Dr. McCoy increased nocturnists’ base salary by 12%.
“Because we give nocturnists an increased base, I do ask for a six-month commitment,” Dr. McCoy says. “Everybody who’s signed on so far has exceeded that.” Nocturnists earn on average $10,000 more a year than their day-time colleagues, while working 25% fewer hours.
That’s put her in an enviable position: “I have a waiting list of group members who want to move into the nocturnist position.”
Fewer shifts and hours
At South Shore Hospital in Weymouth, Mass., the hospitalist group has moved to 100% nocturnist coverage at night since 2011. In four years, says practice administrator Stephanie Booth, the group hasn’t lost any of its three FTEs, several part-time doctors and one part-time advanced practice provider who work nights.
Full-time nocturnists work 12 shifts per month compared to 17 for day hospitalists (another 29% differential). And nocturnist shifts are 10 hours (7 p.m.-5 a.m. and 9 p.m.-7 a.m.), not 12.
In addition, Ms. Booth says, “We don’t schedule these dedicated nocturnists on long stretches. They prefer to work either three- or four-night blocks, and because they’re so key to the structure of the program, we give them the schedule that works best for them. The entire group respects the fact that these doctors work overnight so they don’t have to.”
Nocturnists also have their RVU thresholds lowered and their salaries bumped up by about $10,000. According to Ms. Booth, each nocturnist (and there are two on at night) takes between six and eight admissions. Between the two of them, they also cover two or three RRTs and cross cover a census of between 170 and 200 patients.
At John Muir Medical Group in northern California, which covers two separate hospitals, nocturnists also can choose the number of nights they work in a row, says Nicole Jones, DO, the hospitalist division chair at the Walnut Creek campus.
Some work blocks of only three nights, while others work as many as seven. Currently, two nocturnists cover nights in 12-hour shifts at each of the John Muir Walnut Creek and Concord hospitals.
But full-time nocturnists with John Muir work substantially fewer shifts per year than their colleagues. To qualify for the full benefits package, nocturnists need to work 145 shifts a year vs. 175 for the day hospitalists.
Nocturnists also earn a night differential of $120 per shift, while the weekend differential is $275 per shift with Friday night counting as the weekend. And nocturnists can choose the campus in which they want to work.
“Our turnover rate for nocturnists is incredibly low,” says Dr. Jones. “We have several doctors who have been working the night shift consistently for at least seven years.”
Another compensation perk for nocturnists at John Muir: “We have bonus goals internally in our group, like for discharges before noon, and we share in those bonuses equally,” says Dr. Jones. “That’s the case, even though nocturnists are not directly involved in morning discharges.”
The group also keeps a close eye on workload volumes at night to adjust staffing. According to Dr. Jones, John Muir is about to launch a third nocturnist shift at Walnut Creek and institute a noon-to-midnight swing shift at Concord to meet rising demand.
That raises another hot topic around nocturnists: What are appropriate performance measures? While groups are willing to sweeten the pot to recruit and retain nocturnists, they are also tracking data on night-time performance.
At John Muir, for instance, one of the two nocturnists at each campus is expected to do “night rounds” every night, checking in with the charge nurse on each unit.
And for groups that tie productivity to compensation, nocturnists may receive an adjusted RVU threshold. But some groups steer clear of RVUs altogether for night shifts. At New York’s Mount Sinai Hospital, for instance, Andrew Dunn, MD, the hospital medicine division chief, notes that the group decided against tracking RVUs for its nocturnists.
“The amount of patients that nocturnists see is too variable, so that wasn’t a sensible solution,” says Dr. Dunn. “Some shifts are busy, some are quiet, and a large percentage of their responsibility is oversight of the NPs, which is a less billable activity.” The nocturnists at Mount Sinai work fewer hours per year but receive no additional pay.
Metrics and incentives
Dr. Dunn says, however, that the nocturnists do have several performance metrics that can earn them a quality bonus that equals 10% of their compensation.
For three years, for instance, the group has tracked two objective metrics tied specifically to nocturnists’ incentive plan. One is charge lag, the number of days between when they saw the patient and when they drop the bill.
“It’s unfair to measure how much nocturnists charge,” he notes, “but we can at least make sure that when they do charge, they charge well.”
Nocturnists are also tracked on time from team assignment to admission order. They’re also assessed on teamwork and citizenship, which looks at factors like participating in work groups or committees, participating in or leading quality improvement projects, and administering the schedule for nights.
At Self Regional Healthcare, a hospital in Greenwood, S.C., Chad Friel, DO, the director of hospital medicine, says that the day hospitalists in his group have a physician engagement component as a quality incentive.
He’s thinking of adding that to the nocturnists’ incentives as well. But all five of the group’s nocturnists “three FTEs, two who job-share “live up to an hour away, Dr. Friel points out.
“It’s a lot harder for them to come to the community to attend meetings,” he notes. “The same is true for participating in quality improvement projects, which is another incentive we have for day-time physicians.”
Finding the right balance
At the same time, Dr. Friel notes that the group’s nocturnists, who work seven-on/seven-off in 12-hour shifts and earn a 17% compensation differential, are measured on many of the same metrics as their daytime colleagues: patient and referring physician satisfaction, VTE prophylaxis and warfarin education, statins for MI patients, and compliance with bridge orders.
But Dr. Friel says his big challenge is trying to identify the right workload for nocturnists. At Self Regional, two physicians work at night, each doing an average of 4.5 admissions. Both doctors together provide cross coverage for between 90 and 120 patients. (In Miami, Dr. Manjarrez points out that a typical night shift for one nocturnist includes five admissions and cross covering between 50 and 70 patients, alongside a third-year resident.)
“It can become a challenge when trying to suggest that nocturnists assist residents beyond their caps or to do admissions for a surgeon who’s in solo practice,” says Dr. Friel. “Nocturnists are driving an hour here for one reason: They like the work they provide. As soon as the workload increases to a level that’s not sustainable, I’m going to lose physicians.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
THE SOCIETY OF HOSPITAL MEDICINE’S 2014 survey delved into how much night coverage nocturnists provide ” and what incentives they receive in terms of shift or compensation differentials. Here’s a look at some of those results:
- More than half of all groups (58%) employed some nocturnists, with 39% reporting that nocturnists provided 100% of their night-time coverage.
- Close to two-thirds (60%) of groups with nocturnists offered a shift differential, with 72% of those offering up to 20% fewer shifts. For 22% of groups, that differential was between 21% and 40% fewer shifts.
- Schedule differentials were more common among academic hospitalist groups (80%) than non-academic ones (58%).
- Seventy-two percent of groups with nocturnists reported that nocturnists earn a compensation differential; the median amount was 10%.
- Regional differences emerged for both shift and compensation differentials. In terms of money, 83% of the hospitalist groups with nocturnists in the East paid a compensation differential vs. only 61% of groups in the South. Success with NPs/PAs at night AT THE UNIVERSITY OF MIAMI HOSPITAL, Efren Manjarrez, MD, the interim chief of the hospital medicine division, hasn’t had much luck finding NPs or PAs to work nights.”We tried to hire two and we weren’t successful,” Dr. Manjarrez says. “We found that a lot of nurse practitioners really want just straight Monday-through-Friday, daytime hours.”But in Wiliamsport, Pa., Susquehanna Health System hospitalist director Colleen McCoy, MD, has found the opposite to be the case. After hiring three NPs and PAs to work the swing shift, she was amazed when two of them asked if they could work nights with the hospitalist nocturnists instead. Dr. McCoy approved that move “”that solved the biggest headache we ever had” “as soon as the NPs/PAs became clinically able to admit patients on their own and do a good job cross covering.She says that the nocturnists really appreciate the collegiality at night. But the job satisfaction of the advanced practice providers has seen an even greater increase.
“One of their big dissatisfiers is having too many bosses, too many physicians to partner with, especially new grads coming out and learning on the job,” Dr. McCoy explains. “For one guy, it drove him nuts that
10 different hospitalists would tell him how to treat heart failure 10 different ways.”
For NPs/PAs who want to practice on their own, Dr. McCoy says, “they want to meet just one doctor’s goals and earn his or her trust and respect, so they can be cut loose and see patients with minimal supervision. Pairing them up with just one nocturnist, in terms of their professional satisfaction, was huge.”