Published in the October 2006 issue of Today’s Hospitalist
Earlier this year, Brian J. Bossard, MD, marked a first in his long career as a hospitalist: He placed an ad for a nocturnist, a hospitalist who works exclusively at night.
Related article: Nocturnist update: Soaring volumes can mean trouble at night
While Dr. Bossard has worked in hospital medicine since 1993 and founded the hospitalist practice at BryanLGH Medical Center in Lincoln, Neb., he had never seen the need to hire a nocturnist “until now. His 16-physician group has provided 24/7coverage since 2002, and there has been little physician grumbling about working nights. Each member of Inpatient Physician Associates covers no more than two nights in a row, putting in just one week of nights over a seven-week period.
“Larger periods of time off were very important to me.”
~ Shannon Bryan, MD
Swedish Medical Center
So why did the group decide to take the plunge and search for a dedicated physician to cover nights? Dr. Bossard, the group’s medical director, says that for him and his colleagues, the decision was all about ensuring the group’s longevity.
Check our latest (2014) articles on all aspects of hospitalist practice management, from productivity metrics to scheduling strategies and paperwork reduction.
“As our 30-somethings turn into 40-somethings and turn 50,” he asks, “are they going to be interested in spending the same number of nights in the hospital? We’re trying to set up a program that encourages long-term commitment.”
The group is far from alone. A growing number of hospitalist groups, often at hospitals that have no housestaff presence, are turning to nocturnists for exactly those reasons. Hospitalists hope that by bringing a nocturnist onboard, they will take pressure off the rest of the group, letting them work fewer nights and providing more flexibility in scheduling.
But hospitalist groups experimenting with nocturnists are also learning some tough lessons about recruiting and retaining these physicians. For one, it can be difficult “and expensive “to find the right kind of physician who wants to spend only nights in the hospital. And as patient loads in the nighttime hours keep getting heavier, the real challenge may be keeping nocturnists once you find them.
The tipping point
At what point are hospitalist groups considering adding nocturnist coverage? Groups that have gone that route say the tipping point typically comes as patient volume soars, often because of contracts with hospitals and primary care physicians.
Some programs add nighttime coverage when the daily census tops between 50 and 70 patients. Others take a close look at the number of nighttime admissions, adding coverage when those start adding up to between 10 and 14.
Presbyterian Inpatient Care Physicians (PICS) in Charlotte, N.C., moved to cover nights when the group had five different day teams in place. Within several months, some members began to balk at working the graveyard shift “and the group started recruiting nocturnists.
“Most of the crew started resenting nights,” says PICS medical director George K. Davis, MD, who has had two nocturnists on his 38-member team for almost two years. (The program recently hired two nocturnist PAs.)
Since the PICS program ramped up to five day teams with nocturnists in 2004, the rest of the group has had no night responsibilities “although once every several months, they each cover a seven-day consult shift that runs from 2 p.m. to 11 p.m. With nocturnists, Dr. Davis estimates that shift responsibilities for the rest of the group dropped from 46 night shifts per year to 26 evening shifts a year.
At other hospitals, programs that start off with 24/7coverage bring in nocturnists from the start. That was the thinking behind the adult hospitalist group at Swedish Medical Center in Seattle, which launched in 2000.
“I had been a hospitalist for four years, and I had done the overnights, and the 24- and 36-hour shifts myself,” says Per Danielsson, MD, the group’s medical director. “I knew it wasn’t sustainable for the majority of people.”
While he was committed to hiring nocturnists from the start, Dr. Danielsson was surprised when his first two hospitalist hires jumped at the opportunity to work only nights. Both are still there six years later, and the group has added three more nocturnists to the roster of 29 hospitalists who cover three hospitals.
Benefits of nighttime coverage
If you think that hiring a nocturnist will absolve you from ever having to work nights again, think again. As experts are quick to point out, bringing nocturnists on board only goes part of the way to solve the puzzle of night coverage.
Both Drs. Davis and Danielsson say they make liberal use of moonlighters to round out nocturnists’ coverage, including fellows from the University of Washington “in Dr. Danielsson’s case “and other hospitalists during their time off. Dr. Davis, in fact, wants to recruit two more nocturnists so he can stop using moonlighters for the swing and graveyard shifts.
While nocturnists may not be a panacea for hospitalists’ scheduling problems, groups nonetheless say that fewer night shifts for the rest of the team translate into less burnout and more job satisfaction. Allowing daytime hospitalists to cover more day shifts can improve patient continuity and make hospitalists that much more efficient working with hospital staff during the day.
And nocturnists help their daytime colleagues avoid “this whole bolus of patients who came in, that they have to sort through before they get on with their day,” said Martin Buser, MPH, a partner in Hospitalist Management Resources LLC in Del Mar, Calif. “Nocturnists are incredibly valuable from that standpoint.”
For BryanLGH’s Dr. Bossard, hiring a nocturnist will help support another of his group’s strategic goals: more flexible scheduling. The program recently began offering hospitalists the option to work only part time or to not cover nights at all, a goal that will be easier to reach with a nocturnist.
At the same time, he’s aware that flexibility and stability depend on recruiting right. “We’re really looking for the person who embraces that life,” he says, “not necessarily someone who’s going to do it for the short term.”
Finding the right match
Finding a nocturnist who will work out over the long run requires understanding the mindset of physicians willing to work the graveyard shift.
“There has to be some tolerance for nighttime work and an ability to sleep during the day,” Dr. Danielsson explains. “Otherwise it’s miserable.”
Motivation is another key for nocturnists. Many of these physicians work nights to spend more time with young families, going off to work when their children go to bed and sleeping while the children are in school.
There are also plenty of perks for physicians working nights, including a premium in pay. According to Merritt Hawkins and Associates, a national recruiting firm, the average nocturnist salary is hitting $200,000, significantly higher than the $175,000 that daytime hospitalists earn on average.
And while nocturnists’ hours may be difficult, they tend to be short. The nocturnists at PICS, for example, work only eight-hour shifts, but are paid the same as their colleagues who work 12-hour shifts.
At Swedish Medical, nocturnists likewise work two thirds the number of hours as their daytime counterparts. While that translates into more time off, the group’s nocturnists also enjoy a higher salary.
“I didn’t mind working very hard while I work or working long stretches,” says Shannon Bryan, MD, MPH, one of Dr. Danielsson’s two original nocturnist hires. “But larger periods of time off were very important to me.”
Because nocturnists are working fewer hours at a higher pay scale, there are concerns about whether nighttime coverage is worth the cost.
According to Dr. Bossard, working nights is generally only 50 percent as productive (measured in relative value units) as daytime coverage, because hospitalists during the day can capture many more subsequent visit charges. That means that hospitals have to subsidize nighttime coverage to an even greater extent “estimates run to 70 percent “than for their daytime colleagues.
As Dr. Bossard points out, however, by not having to wait until 7 a.m. to admit and work up patients, night coverage can shave off hours in length of stay and enhance patient safety, which “easily pay for nighttime coverage.”
And according to Mr. Buser, “The real cost savings are that nocturnists take all the codes, play the role of the rapid response team physician “and free up the emergency room doctor from having to leave the ER and run upstairs.”
While nocturnists may not generate as much revenue as their daytime counterparts, that doesn’t mean they don’t get brutally busy. At Dr. Danielsson’s practice at Swedish Medical, the nocturnists often face such a heavy load early in their shift that the program has started a swing shift that lasts until 11p.m. or midnight to beef up their support.
Still, Dr. Danielsson says, when you hire nocturnists, you have to accept the fact that some nights will be busy, and others will be quiet. “Some nights you’ll do one admission,” he explains, “while it will be 13 or 14 on others.”
And while some groups may be tempted to give their nocturnists additional duties to keep them busy when patient loads are light, that may not be a good idea. At PICS, for example, Dr. Davis says that nocturnists can occasionally do an early preoperative evaluation for orthopedic patients having very early surgery. But they are often too busy to consider adding other duties to their shift.
Supply and demand concerns
One of the downsides of working with nocturnists is the limited supply of physicians willing to work nights.
When Sanjiv Panwala, MD, was looking for work as a nocturnist three years ago, he says hospitalist groups were bending over backward to accommodate him. “More people are trying to get nocturnists,” says Dr. Panwala, now one of two nocturnists at Providence St. Vincent Medical Center in Portland, Ore., “but there just aren’t enough people willing to do it.”
Dr. Panwala started working three nights out of seven, in 12-hour shifts, but he quickly found that three nights a week were not sustainable for the long term. After one year, he cut back to part time, working only two nights a week. However, over the next few months, he plans to begin splitting his shifts between night and day.
He’s making the change in part because the pace and volume of the nocturnist shift has grown. “When I initially started, the night duties were not quite as difficult,” Dr. Panwala explains. As coverage of primary care practices has grown and additional responsibilities have been added to the night shift, “It becomes not doable in the long term. Because there’s nobody else to help you, a busy night can really turn into a very stressful situation.”
Dr. Panwala thinks his experience shows why hospitalist programs have to balance their use of nocturnists against their continued growth. He also says he believes the nocturnist model works best for moderately-sized services.
But with no end in sight to the growth of hospital medicine, the need to recruit nocturnists will only become more competitive. That’s why Swedish Medical’s Dr. Danielsson says that hospitalist groups interested in nocturnists must be prepared to be accommodating.
“If you’re going to retain nocturnists,” he says, “the key is to make it a sweet decision.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
After the sun goes down: a look at the life of a nocturnist
Ask nocturnists Shannon Bryan, MD, and Sanjiv Panwala, MD, why they chose to work nights, and they give the same answer: family.
“Even on the weeks I work, I get to see my family more as opposed to a day job,” says Dr. Bryan. She estimates that she spends as much as four hours a day with her toddler daughter, even when she’s pulling her seven-on, seven-off shift.
The same is true for Dr. Panwala. When his children were younger, he says, they didn’t even realize that he went to work. Now that they are in grade school, he sets his alarm on the days that he works to pick them up after school.
“Nights really work for family,” he notes, “if you can burn the candle at both ends.”
Admitters vs. rounders
Along with typically earning more money for working fewer hours, nocturnists enjoy other aspects of the night shift.
For one, Dr. Panwala says, there’s more camaraderie. “I have more fun with people at night than during the day,” he says. Nights are “a bit more relaxed, there aren’t as many ears around or as many rules and regulations. You’re able to interact a little more freely.”
Dr. Bryan likes not having patients to round on, so “you start fresh every night.” She also likes the variety of admissions, codes and cross coverage, and patients’ greater acuity.
Dr. Panwala echoes that sentiment. “I definitely enjoy being an admitter much more than a rounder,” he says, pointing out that working the days often means having to follow someone else’s medical plan for the patient.
“At night, it’s just pure medicine, it’s pure management of medical issues, and that’s the fun part of medicine for me. You make a lot more decisions independently than you would during the day.”
A sense of isolation
That doesn’t mean the schedule doesn’t have downsides. The biggest minus for Dr. Bryan is sleep. Every week she has to flip her sleep cycle from going to bed at 9 a.m. and waking up at 4 p.m. to sleeping at night during her weeks off.
“I certainly have my darkened room and my fan and ear plugs, but it messes up my sleep cycle,” she says. “It’s now harder for me to sleep at night.”
And while Dr. Bryan enjoys the shift’s variety, she misses patient continuity. “The day hospitalists follow patients through their whole hospital course,” she notes. “We just see patients for an hour when they come in and never see them again unless something comes up or we get a chance to see a chart.”
And although Dr. Panwala appreciates the independence of being a one-physician show, flying solo can be stressful. “All it takes is one or two admissions simultaneously and one issue on the floor, and all of a sudden you’re stretched very thin,” he says.
There is another downside. “Other than sign-out, you don’t interact with the people in your group on a daily basis,” Dr. Panwala says. While he now enjoys the friendship of most of the staff in the emergency department, “after a couple of years, you feel almost like an outsider to your own hospitalist group.”