Published in the February 2019 issue of Today’s Hospitalist
Nocturnist Arash Nadershahi, MD, sometimes can’t believe he found his dream job. A self-described “night owl” who never had trouble pulling all-nighters during college or medical school, he admits he’s a loner who doesn’t yearn to “be a member of a committee or in a multidisciplinary huddle,” and he’s a family man who relishes having two weeks off out of every three. He is, he says, a perfect fit for working overnight shifts in hospital medicine.
But even Dr. Nadershahi has had times when he doubted whether to continue covering nights. Despite being “wired” for it, the job can sometimes feel unbearable. First and foremost are the physical demands of what he calls the “flip” from night to day. Then there are the mental and psychological stresses that come with increasingly busy night shifts. As nearly everyone who does this work agrees, being responsible for all overnight admissions, cross-coverage, critical care, codes and even procedures can become overwhelming the longer you are at it.
But each time he has questioned his career choice, Dr. Nadershahi says his group in Bellevue, Wash., has “managed to find a way to sweeten the deal.”
“They have found ways to make the job more palatable, more livable, and 17 years later, here I am.”
~ Arash Nadershahi, MD
To improve the night shift at Overlake Hospital where he works, there have over the years been pay raises, shift reductions, clinical and support staff additions, responsibility cutbacks, special recognitions, and improved creature comforts like a comfortable break room. He calls all those the “gravy.”
“They have found ways to make the job more palatable, more livable, and 17 years later, here I am,” he says. Today, his full-time position is seven days on followed by 14 off, with 11-hour shifts (8 p.m. to 7 a.m.). Compensation is competitive, intensivists cover the ICU, he doesn’t need to respond to codes, and his hospitalist colleagues help him out during the evening swing shift.
Further, night-time radiologists are available, and he has access to good technology and UpToDate so he can work on his CME during lulls. And perhaps most importantly, the emergency physicians he works alongside every night are “superb,” Dr. Nadershahi says. Because the “bulk of the work we do is in the ER, your ER staff has a big impact on the quality of the work you do and your pain and suffering.”
Unfortunately, many hospital medicine experts say that Dr. Nadershahi’s experience is out of the ordinary. Although most hospitalist groups say a top priority is to attract and retain nocturnists, they sometimes sabotage their own best intentions by throwing even the best recruits into unsustainable circumstances that lead to burnout and disproportionate turnover.
So how do you make nocturnists happy? Several nocturnists weighed in on what has (and hasn’t) kept them on the job.
What makes or breaks working nights?
According to Julianna Lindsey, MD, MBA, a Dallas/Ft. Worth-based hospitalist and hospital medicine consultant, if the nocturnists aren’t happy, no one in a hospitalist group is happy. For most of the last 20 years, Dr. Lindsey has worked as a nocturnist in different hospitals.
“There is no logic behind seven-on/seven-off unless the nocturnists want that schedule.”
~ Julianna Lindsey, MD, MBA
In her experience, here’s what happens when nocturnists leave: “Your daytime people have to rotate into the night positions or you have to hire locums to fill those slots.” Or nocturnists who are overworked, sleep-deprived and burning out make “errors of cognition and omission, and you won’t be able to trust them as diagnosticians. That’s a big dissatisfier and can be very destructive to your hospitalist operations.”
In her experience, Dr. Lindsey says, the make-or-break factor in covering nights is the schedule. “I personally put a hard stop on any more than four nights in a row because I know myself and I know that I am getting tired on that fourth night shift. I don’t want to risk making a bad decision as a result of exhaustion.”
She also points out that sleep-deprived health care workers are more likely to get irritable or to miss something, “and I never want to be irritable with the nurses, patients or families. I never want to compromise a patient’s care.”
One common mistake that groups make, which predictably cuts short nocturnist careers, is to insist on seven-on/seven-off schedules. “There is no logic behind seven-on/seven-off unless the nocturnists want that schedule,” Dr. Lindsey points out. “You need to let your nocturnists work whatever is sustainable for them.” Dr. Nadershahi, for example, says he had tried five-on/10-off but prefers seven-on/14-off instead.
Shaving back shift lengths
Other career nocturnists say that shift length and the number of shifts per month make a big difference in happiness and sustainability.
“You wouldn’t think two hours would change anything, but the difference between a 10and 12-hour shift is immense,” says Jalila Hudson, MD, a hospitalist who has worked as a nocturnist in several programs over the last eight years. Because it takes her two to three days to “re-acclimate” after a stint of overnights, Dr. Hudson says that 12 shifts a month— not 14 or 15—works better for her long term. For the last year and a half, she has been a telenocturnist for Catholic Health Initiatives of Omaha, Neb., covering patients in eight hospitals throughout Nebraska and Iowa from her home in Nashville.
“It would be great if every day-shift person did a week of nights and every night-shift person did days.”
~ Jalila Hudson, MD
Catholic Health Initiatives
Working from home at night, she says, alleviates some of the downsides of nocturnist work: bad food and little time for exercise. “When I first started doing nocturnist work, I gained a lot of weight, and you are wearing scrubs, so you don’t notice that you are spreading,” she points out. “And they don’t restock the break rooms. You will go in and all the water is gone because nobody rechecked for the night shift.”
In fact, she adds, “just being remembered” by the daytime staff goes a long way toward nightshift sustainability.
“It would be great if every day-shift person did a week of nights and every night-shift person did days, maybe as part of their orientation when they are hired,” she says. “Do it for a week, and you’ll remember it forever.”
That would at least stop “the Monday morning quarterbacking” by some day doctors who complain about nocturnists. “They say, ‘Why didn’t the nocturnist get that med list done?’ Well, there were three family conferences, 10 admissions, and cross-cover calls for stool softeners and anti-nausea medications, so it didn’t get done. It changes your respect for the shift.”
There is no one formula for how to get it right for nocturnists, says consultant Leslie Flores, MHA, founding partner of the La Quinta, Calif.-based Nelson Flores Hospital Medicine Consultants. But one thing Ms. Flores has seen is that just paying a lot more money but not providing adequate support “is not a recipe for success in most cases.” Paying nocturnists a higher salary is the most common way hospitalist groups differentiate between nocturnists and day-timers.
But what passes as “adequate support” varies widely from hospital to hospital. While a “very general rule of thumb in most places,” she says, is that a nocturnist can reasonably handle up to eight admissions a night plus some cross-coverage, a lot depends on other factors.
One of the most relevant may be the extent of nocturnists’ ICU responsibilities. Solutions to overwork can also include everything from hiring another nocturnist, adding advanced practice providers (APPs), employing scribes, staggering shifts, using telemedicine, creating better standard order sets, setting expectations about what day doctors must accomplish during the day and not dump on the night shift, negotiating with nurses about how to work with physicians who are responsible for floor call, and working out better lines of communication and coordination with the ED.
To support nocturnists, Ms. Flores recommends that group leaders “make sure that relationships are good with the ED doctors, nurses and intensivists or whoever is covering the ICU at night, if it’s not them.” While nocturnists may be loners by nature, “they still want to feel well-supported and valued by their day-shift colleagues.”
As chief of a hospitalist group with more than 100 FTEs covering three St. Peter’s Health Partners hospitals around Albany, N.Y., Thea Dalfino, MD, says she focuses on a range of things to keep her nocturnists happy.
First, the group offers flexible scheduling, both in terms of how many shifts nocturnists want in a block and how long they want their shifts to be. Some do seven nights in a row, while others do only three; some do 12-hour shifts, while others do 10.
Base pay for nocturnists is 16% higher than that of day-time doctors, and nocturnists can earn productivity-incentive money just like their day colleagues. To make sure that bonus is achievable, Dr. Dalfino says the group hired nurse practitioners to take care of nearly all the cross-cover and floor calls so the nocturnists can focus on more RVU-intensive admissions. In addition, a swing shift helps during busy evening hours so nocturnists aren’t exhausted even before they get going. And importantly, all schedules include a 30to 60-minute overlap in the morning to help encourage collegiality.
“I can tell you our nocturnists are far from forgotten,” Dr. Dalfino says. “The day team comes in and they thank them every morning. Seriously.” All that investment and effort seems to be paying off: One of the group’s nocturnists has been there 20 years, another for four.
John Shoffeitt, MD, a nocturnist since 2010 at the 600-bed FirstHealth Moore Regional Hospital in Pinehurst, N.C., part of FirstHealth of the Carolinas, agrees that flexible schedules, adequate support and collegial appreciation go a long way to promoting nocturnist longevity. He has also had to learn to be flexible, giving up a little himself for sustainability. While he enjoyed doing ICU work at night, for instance, he accepts that giving that up means more manageable shifts. (In the last few years, intensivists became available to cover the ICU 24/7.)
“I had some mixed feelings when the closed ICU program started because I enjoyed the ICU work,” he explains. “But we are so busy that it’s been nice to have that responsibility alleviated.”
Dr. Shoffeitt and his fellow nocturnists work 13-hour shifts—6:30 p.m. to 7:30 a.m.—usually six in a row. (Some of the nocturnists work longer or shorter stints because “everybody is a little different in how much switching back and forth” from night to day living they prefer to do.) Full-time nocturnists work 12 shifts per month, compared to daytime full-timers’ load of 15.
One benefit of the 13-hour shift: It allows for “a dedicated half hour at the beginning and end of the shift for face-to-face signouts with our daytime providers,” he says. “That is great for our patients but also helps us not feel we are strangers in the group.”
The program also tries to be mindful about when it schedules important meetings or seminars—usually 5:30 p.m., so both nocturnists and day physicians can attend, he says. Both his group and Dr. Nadershahi’s in Washington also have regular nocturnist meetings with group leaders to discuss nightshift special needs, such as how to work more collegially with the ED or how to make sure that nocturnist workflow includes time to write the second note required by the sepsis core measure.
And one of the best ways to attract and keep nocturnists, says Dr. Shoffeitt, is to tell them “they won’t be responsible for all the floor call because you have APPs to take the majority of it.” It also helps if nocturnists can earn a productivity incentive based on the number of admissions they do (see “Nocturnist incentives” and are incentivized to “perform shared visits with our APP providers.” Base salary is also higher than that of day doctors, and nocturnists who want a scribe can have one. He notes that working with a scribe keeps him from having to stay late—more than 13 hours—to finish documenting all the admissions before he leaves.
Like Dr. Nadershahi, Dr. Shoffeitt says he naturally has the kind of personality that fits with nocturnist work. But he also knows that making a long-term career of it requires group and hospital leadership to be “mindful of the challenges nocturnists face.”
And as Ms. Flores points out, “How great would it be to be a nocturnist and have your hospitalist group send pizza delivery to you out of the blue when you weren’t expecting it, to make your evening a little easier and nicer? Little things matter.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
“The productivity incentive is one of the most popular things with our night providers.”
~ John Shoffeitt, MD
FirstHealth Moore Regional Hospital
According to this year’s Today’s Hospitalist Compensation & Career Survey, nocturnists are much more likely than hospitalists overall to be paid a straight salary (44% vs. 33%). But some nocturnists report that they have the same productivity and quality incentives as their day-time counterparts.
Others, however, report different productivity incentives than the day doctors in their group. Typically, physicians working only days earn their productivity incentive by exceeding RVU thresholds, while nocturnists track their productivity in terms of their number of admissions. Quality bonuses in most groups are usually paid out as group incentives, and nocturnists get a cut just like everyone else.
John Shoffeitt, MD, who works at FirstHealth Moore Regional Hospital in Pinehurst, N.C., says that he and his fellow nocturnists appreciate their productivity incentive. “That is one of the most popular things with our night providers, knowing that when we have an exceptionally busy night, there is at least a performance incentive,” he points out.
By the numbers
ACCORDING TO the 2018 Today’s Hospitalist Compensation & Career Survey, nocturnist shifts are more lucrative than daytime ones. The mean compensation reported by nocturnists in this year’s survey is 12% higher than of daytime-only hospitalists: $319,520, compared to $281,709. Further, nocturnists are more likely than hospitalists overall to say they are “satisfied with my current compensation”—54% vs. 44%.
In terms of demographics, nocturnists are proportionately more likely to have trained in family medicine than in internal medicine: Family medicine-trained physicians make up 15.5% of hospitalists overall but 24% of nocturnists. They also tend to be a little older on average: The mean age for nocturnists is 49, while the average age reported by hospitalists overall is 46.
And this year’s survey from the Society of Hospital Medicine (SHM) found that “nocturnist differentials” vary widely depending on group size, employment model and geographic region. While 58% of hospitalist groups overall pay “higher compensation” to nocturnists, that’s true among nearly 90% of multistate hospitalist management company-owned groups, compared to only 29% of private multispecialty groups.
By contrast, multistate hospitalist management companies are the least likely across all employers to cut nocturnists a break on the number of shifts per month they work. Only about 2% report that full-time nocturnists “worked fewer shifts” than their full-time day colleagues, compared to 16% of groups owned by hospitals or health systems. (On the Today’s Hospitalist survey, nocturnists report working about the same number of shifts per month on average—15—as day-only hospitalists.) The SHM survey also found that 28% of hospitalist groups overall reward nocturnists with both fewer shifts and higher compensation.