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Night work without burnout

September 2008

Imagine working a full shift, yet being home to see your kids off to school and tuck them in at night. Or having enough daylight hours to pursue another interest like real estate or martial arts. Or getting a 15% bump in pay for working fewer hours.

If this sounds too good to be true, you’re partially right. To get all these benefits while working as a hospitalist, you have to work when the rest of the world sleeps, as a nocturnist.

While most physicians associate night work with sleep deprivation, there are plenty of hospitalists who find working as a nocturnist to be a perfect fit for their personal and professional lives.

Admittedly, the topsy-turvey timetable of night work isn’t for everyone. But for the right people and the right reasons “and maybe just for the time being “working nights may not only provide a sustainable schedule, but an optimal career move.

Here’s what five nocturnists had to say about why they work nights and how they make the hours “and the lifestyle “work for them.

David R. Tomlinson, MD, didn’t just want a night job. He needed it.

The family physician “who had a mechanical engineering background from MIT and spent seven years in the Navy “was already devoting his daylight hours devoted to working on an invention: a circumcision tool to help prevent HIV that has recently been cleared by the FDA. When he learned that South County Hospital in Wakefield, R.I., needed a physician to cover nights, he jumped at the opportunity.

“I started picking up shifts when I was still in the Navy and the program was just getting started,” Dr. Tomlinson says. “I told them, ‘I can work only nights.’ ”

Four years later, he says he has it all: A 9 p.m.-7 a.m. shift on Mondays, Tuesdays and Wednesdays that frees up his days not only to work on his invention, but also to spend time with his three young daughters. “I can go to every school function I want. I’m here for my kids all the time. That benefit outweighs everything else.”

Dr. Tomlinson says it also helps that he doesn’t need a lot of sleep, which comes in handy when he has to pull an all-nighter on Mondays and get by with only four hours of sleep on Tuesdays.

While he initially worked 15 shifts per month, he’s dropped down to 12. He wanted to devote more time to his invention and free up his Fridays to attend research meetings or just to have a four-day weekend.

Dr. Tomlinson also talks about the advantages of being the only doctor in the hospital at night. “I’ve always been a mad scientist type,” he says. “The autonomy is outstanding.”

He says lobbying for a daytime admitter took the pressure off so that now he may handle as few as three admissions per night while he covers all patients.

While acknowledging that the job can get lonely, he says the advantage is having time to really connect to patients. He talks about a woman he just saw who wasn’t that sick, but needed someone to talk to. “I took an hour and talked about life,” he says. “I could never do that as a family physician.”

When a company offered him a chance to work a 9-5 business job, he took a pass. “My commitment to my boss, the community, my hospital, the patients and the flexibility it gives my family keeps me at South County,” he says.

Dr. Tomlinson can see going to two shifts per week at some point, but for now there’s no stop date. In fact, staying current on clinical skills gives him fodder for new inventions.

“I don’t think I’d ever stop,” he says. “I intend to work the job until they don’t need me anymore. I’m lucky to have found them.”

Shannon Bryan, MD, says she always liked night work as a resident.

So when the program at Swedish Medical Center in Seattle was hiring nocturnists, the director asked Dr. Bryan to give it a try. “I thought it would be great to do for a year as a bridge to whatever I’d do next,” she says.

Eight years later, she’s still working nights because she likes the hours. While the hospital pays its nocturnists an extra $10,000, Dr. Bryan says that the extra money is not the draw.

Instead, the hours translate into more time to spend with her 3-1/2-year-old daughter. Dr. Bryan typically works 7 p.m.-7 a.m. for seven nights, then has one to two weeks off. Sometimes that shift alternates with one of six nights on for 10 hours, then eight days off.

She acknowledges her schedule might not work for everyone, noting that her musician-husband works at home and is able to provide child care during her weeks on. But to her, the advantage is clear: “On my week off, I’m really off.”

Dr. Bryan also likes the variety of night work, being able to spend an average of an hour with each admission, and not having to do daily rounds on patients. That helps make the job relatively stress-free, she says, noting that she makes up for any lack of contact with other hospitalists by going to outside events on work-related issues and attending team meetings.

For her, the key to staying rested and balanced is to have a long stretch of nights on, then off. Her routine during her weeks on consists of sleeping from 9 a.m.-4:30 p.m., taking a short jog, doing the nighttime routine with her daughter, then going to work.

Dr. Bryan says she would consider switching to days when her daughter starts school, but that it may actually be hard to change her family’s routine. “Could I do this for 20 more years?” she asks. “Maybe.”

Nocturnist Richard Rothman, MD, works nights because he gets to focus on patient care instead of administrative duties.

“Nights are better because there’s more independence than in the daytime in terms of meetings and rounds,” he explains.

Dr. Rothman says his background in ER medicine from a three-year stint in the Air Force and as a moonlighter makes his job at Staten Island University Hospital in Staten Island, N.Y., a natural fit. (He was also chief resident there.) There are fewer people around to interact with, he admits, but having only nurses, patient care associates and intensivists in the mix keeps things simple. “The focus is on direct patient care,” he says.

Dr. Rothman consults with intensivists and subspecialists when needed, but he likes doing it all, from the critical cases to the blood draws. “I’m the one making the decisions.”

It’s still a rigorous schedule: 5 p.m.-7 a.m. weekdays and 3 p.m.-7 a.m. weekends, alternating three then four shifts per week. To get extra time off, he has to do back-to-back stints and ask daytime hospitalists to fill in if he or the other nocturnist on staff takes vacation.

And while the job definitely limits the amount of time he has available for socializing, Dr. Rothman sees himself working nights for the foreseeable future.

“This is what I’m comfortable doing,” he explains.

The night shift is a good fit for what Rebecca Y. Mumpower, MD, calls her “old-fashioned” take on medicine.
As an example, she describes how she was able to talk for more than an hour about the difficult options ahead for the family of an elderly patient who came in with multisystem organ failure. “I felt I could really connect, that the family knew I was their doctor, their mother’s doctor,” she says. “The nights allow me to be that kind of doctor.”

Dr. Mumpower says it’s also a good fit for her “somewhat introverted and laid-back” personality. Far from feeling isolated, she enjoys having time alone.

And because she’s in her third year as a nocturnist and a veteran member of the team, Dr. Mumpower has been assigned the responsibility of making the night schedule for the faculty attending service as part of MCV Associated Physicians at VCU Medical Center, Richmond, Va. As long as she works 180 shifts per year “that must include two 14-day blocks spent supervising residents on wards during the day “there’s complete flexibility.

“There’s no set schedule,” she explains. “I make it exactly the way I want it so long as my schedule doesn’t interfere with requests from my fellow nocturnists. I can say, ‘I want this weekend off’ or front load my month, then take 10 to 14 days off.” This July, that translated into a one-week cruise in Alaska. Last year, it meant the opportunity for a mission trip to Mexico.

It also gives Dr. Mumpower time to pursue a growing interest in real estate, including renting out two houses just 10 minutes from the hospital to medical students and residents. “I won’t be leaving medicine for real estate,” she adds quickly. “It just kind of happened,” earning her the nickname among her colleagues as “Donna Trump,” which has morphed to “Donna Mump.”

Although she’s put a 10-year limit on working nights because of the stress on her body, a recent stint covering the day shift for a colleague reminded her why she swears to never do that again.

“Some people are admitters, some rounders, some night folk. Everyone’s finding his or her own niche,” she says. “Mine is nights.”

Although he’s never particularly liked working nights, Sanjiv Panwala, MD, says it was a slam-dunk decision given his strong views on child rearing.

“Parents should raise children, not babysitters and not nannies,” says the father of a 10- and 12-year-old.

When working days had left him stressed out trying to juggle the family’s needs, he changed to nights at Providence St. Vincent Medical Center in Portland, Ore., in 2002. He started working three night shifts from 7:30 p.m. -7:30 a.m.

But when the admissions and crosscover increased and his stress level rose, he decided to go part-time, working Monday nights and either a late swing shift (4 p.m. – 2 a.m.) or a short day shift. The goal was to maintain his part-time status of two to four days in a row.

The schedule allows him to sleep for four hours after a shift, then pick up his children from school, take them to their tennis or piano lessons, make dinner and help with homework.

If it’s a night he needs to go to work, he feels like his children are on the “right track for the night until I leave,” Dr. Panwala says. Working part-time also gives him time to spend a few hours running a Web site for medical education, or go for a run or to a martial arts class.

Even on a part-time basis, isolation can become an issue. He counters that by coming in during the days just to hang out with the rest of his hospitalist group and by playing on the ER night-shift softball team, which plays the day-shift team, he notes.

Dr. Panwala says the nights are sustainable for him only on a part-time basis. The stress of the shift and the physical demands are getting tougher as he gets older (he’s 42), but for now, at least, the trade-offs are worth it.

“I’m still not as happy to work at 4:30 a.m. as I am at 4:30 p.m.,” he says. “But it works for me and my goals.”

The sleep zone

“DADDY’S TIRED” IS A PHRASE that carries a lot of weight with the family of Sanjiv Panwala, MD. Hearing that, his 10- and 12-year-old know the drill: Let Dad sleep on the couch in the living room and wake him only for an emergency or when it’s time for lunch.

As a nocturnist trying to find quality and quantity time with his family, Dr. Panwala says he’s perfected the art of sleeping through almost anything and waking quickly and refreshed.

“If my kids have piano lessons, I can drive them there and sack out in the car for 45 minutes,” Dr. Panwala says. “It helps to be able to catch up when I have the opportunity.” That includes during lulls when he’s on his shifts. “If there’s nothing happening, I can fall asleep and wake up to do a cross cover call,” he explains.

While Dr. Panwala has learned to put a hand over his eyes to block out bright light, other nocturnists say complete darkness is crucial to getting a good “night’s” sleep during the day. Nocturnist Rebecca Y. Mumpower, MD, for example, says she began to get a solid six to seven hours of sleep only once she blacked out her windows. Other nocturnists say they use ear plugs and turn off the telephone.

One tip to make nights work is to determine how many hours and nights you can work consecutively while maintaining a solid sleep schedule. “The magic number of nights in a row that keeps me happy and well-rested is three to four,” Dr. Mumpower says, noting that she starts at 10 p.m. and works hard to finish her handoffs by 8 a.m. “If I work an extra hour,” she notes, “it messes up my whole sleep schedule.”

She also made a big change in her quest for a good “day’s” sleep. She bought a house in a quieter neighborhood to avoid the “nightmare” of waking up at 3:30 p.m. “an hour and a half before she wanted “to the honking horn of her neighbor’s babysitter.

“I’ve found that I rest better now that I no longer live in a neighborhood with lawn mowers, horn-honkers and kids playing basketball outside,” she says.

Still, she and other nocturnists acknowledge that they know the sleep issue will eventually take its toll, that it gets harder to bounce back as they get older.

“For health’s sake, it’s probably not wise to work nights indefinitely,” says Dr. Mumpower, who just turned 32. “I don’t see doing it past 40.”

Not on my watch

THE ANSWER TO substandard care at night, the subject of a recent high-profile Wall Street Journal article, is a nocturnist who really wants to be there, according to the physicians who talked to Today’s Hospitalist.

“Some physicians are just trying to get through it, but because I love the people I work with, I try to make sure the work is done, that it’s not just a band-aid on a problem,” says David R. Tomlinson, MD a nocturnist at South County Hospital in Wakefield, R.I. “My care is higher at night.”

Many acknowledge that care at night suffers from physicians who are just rotating in and out, and that the quality varies from hospital to hospital. Only 6% of the 3,242 hospitalists responding to the 2007-08 Society of Hospital Medicine survey identify themselves as nocturnists, although 14% of nonnocturnists said they provided some night coverage. According to veteran nocturnists, physicians who only dip their toes into the waters of night work never have a chance to create a pattern that works for them to prevent exhaustion.

Or “a lot of doctors try to do phone medicine at night because they don’t want to see patients,” says Rebecca Mumpower, MD, part of MCV Associated Physicians at VCU Medical Center, Richmond, Va. In contrast, patients on her floor, she says, are her top priority. “I take pride in being able to put on hold something that can wait and be a bedside physician,” she says.

Moreover, she says night shift workers tend to work with the same nurses, which results in greater consistency. “That’s a benefit,” she adds.

The greatest challenge may be finding others with the same commitment and work ethic to share the load, not just piecing together a solution of hospitalists, residents and community physicians.

“You can’t just fill in the gaps,” Dr. Tomlinson says. “You need to find people who are committed to the hospital and the community it serves.”

Published in the September 2008 issue of Today’s Hospitalist