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Going to the dark side

December 2009

I have thoroughly enjoyed working as a day-time hospitalist although I frequently worked nights, mainly as a moonlighter. Having experienced the entire spectrum of hospitalist care delivery–days, nights, those swing shifts in between–my interest was piqued when night-time spots became available as a result of team expansion. I return to the blogosphere to share my experience on transitioning to the dark side!

Night shifts are neither popular nor sought after. Some colleagues, hospitalists as well as specialists, were surprised or even shocked that I made the switch after working days for about 10 years. A few just stopped short of saying, “Are you crazy?” although that’s what the look on their faces amply conveyed.

I did think long and hard about this transition, weighing the downsides and upsides. Importantly, I spoke with our existing nocturnists to get their take on the vagaries of night-shift work as well as quality-of-life issues. What swayed me was the extra time off and the fact that I have always been a night owl. And more than ever, I felt comfortable working alone.

Having a dedicated nocturnist team is an essential anchor for an effective day-time contingent. Programs in which day-time hospitalists work a lot of nights typically have lower job satisfaction rates, mainly because night work is not for everyone. And being compelled to do night work is a sure route to retention problems for people who want to work just days. Placing a premium on night work–more time off, extra remuneration or a combination of both–is a good way to overcome some of the relative unattractiveness of night work.

Now, having worked night shifts exclusively now for three months, was it a good or bad decision? You could argue that three months is too short a time to make any definitive judgments. On the other hand, it could be enough time to realize that this is not my cup of tea!

So far, I love it, and the best part has been the extra time off. I have been able to spend more time with family and be more involved with my children’s extracurricular activities; indulge in cooking, which I find relaxing; and help my spouse out. I have been able to go to the gym regularly, not only a function of having more time off but making a conscious effort to offset the deleterious effects of night work. I certainly feel fitter than three months ago.

Sleep: A major issue for sure, and a major reason why night shifts are so distasteful for many. We are all wired to sleep at night. For anyone contemplating being a nocturnist, the ability to sleep during the day is a bedrock requirement. That means you need an environment at home conducive to sleeping six to seven hours during day, with a quiet, dark room sans any intrusions, electronic or otherwise.

Nocturnists eventually figure out what works and what doesn’t in terms of getting much needed shut eye during the day. As one colleague remarked, we all come up with varied individual pre-sleep rituals based on personal habits, likes and dislikes. What has worked for me is having a busy night, so I fall off to sleep the moment my head hits the pillow. Nights when the workload is light and I have an opportunity to either sit or lie down are when falling off to sleep becomes a challenge. After I finish my quota of shifts, reverting back to sleeping at night can take up to two nights to accomplish. It is essential that nocturnists get back into the natural sleep/wake cycle for health reasons.

Food! This is another area that required adjustments and adaptations, which took me by surprise. I quickly realized that to get at least six hours of sleep, I needed to eat a robust breakfast. Otherwise, my stomach would start growling at noon, which would disturb my sleep.

The other problem is dinner. What time is the right time to have dinner, given that you will be up the entire night? Should you have a light snack before going to work and then break for dinner mid-shift, which will always be subject to workload and probably skipped? Or should you have a proper dinner before going to work and a snack during the night? I have chosen the latter. I did, however, have to figure out what snacks to eat because night-time snacking is more likely to cause weight gain. I am careful to select “lighter” snack items that are healthier.

What do I like about night work? For one, it is quieter. I do not miss the unplanned or “ambush” variety of family conference. I’ve had to be more precise with triage to avoid frivolously waking up specialists in the middle of the night and to make the right call about an emergent medical situation.

Certainly, nights aren’t the time for the softer consults, the ones with the subtext of, “I don’t know what I am doing,” or “Can you validate my thinking on this case?” or “Am I missing anything else here?” I do not miss the lengthy discharge summaries or interim notes, and I do not have to call primary care providers either.

I like the fact that night hours are limited. Nocturnists are not expected to “hang around” after the end of their shift. I can pass on ongoing issues to my able day colleagues without feeling guilty.

My day colleagues in turn are always very grateful that nocturnists are there to relieve them in the evenings. In our absence, guess who would have to do nights? But let me add: To have a successful nocturnist program, there has to be a plan A, B and C to handle night-time volume surges as opposed to the old dictum of, “Just tighten the belt, only the weak ask for help, figure out some way to just do it,” which obviously is not good for patient safety.

What is the mind set for night work? Be calm, collected and confident. You should have a Zen attitude about pagers and being paged incessantly. If you are someone who gets frustrated or anxious when the pager goes off, do not even think about night work.

Keep an open mind about receiving information from nurses about any issue, and repeat this mantra in your head: There is no stupid query or concern coming from a nurse; they are just doing their job. You need to thrive on putting out fires and handling codes efficiently, which means taking leadership and control of an inherently chaotic situation. Having the skill set to intubate (rapid sequence intubation) as well as to place central lines is a plus for any shift, but particularly for nights. Develop a knack for triaging especially when there are simultaneous new admissions.

Night-time resources are limited, and providing the most appropriate care is a constant challenge. Be prepared to face the physiological wall that hits between 3 and 6 a.m., just when the body’s innate ability to deal with stress is at its ebb. Nothing taxes your physiological and cognitive abilities more then tackling a crashing patient during those challenging hours.

What do I miss about working days? The most obvious loss is not being able to bond with patients. As a night physician, I am one of many nameless/faceless (from a patient’s perspective) individuals who will touch the patient during his or her stay. I see them when they are exhausted from their stay in the emergency room, are in pain or distress from an acute problem, have had medications to alleviate their pain, or are simply delirious.

The ones that do have some degree of attention or retention will likely remember me as the physician who wrote the order for them to have a midnight snack! I am less likely to receive a thank-you note from a patient as compared to when I worked days. I also miss in-depth interaction with the specialists, those cerebral conversations regarding vexing medical issues!

I feel this transition has added to my repertoire, and overall I feel more whole as a hospitalist, someone who has the ability to work both days and nights.

I honestly don’t know if I’ll remain a nocturnist for the rest of career but so far it has been a welcome transition, indeed. Working nights has given me a better perspective on the challenges of delivering night-time care. I would love to hear from readers, their take on what it means to have nocturnists. Or if you are a nocturnist: How did you adapt to night work, and what level of support do you receive from day colleagues? And have you come up with any imaginative solutions to mitigate some of the challenges of providing care during those dark hours?