Physicians of the night
The who, what and why of nocturnists
From the December ACP Hospitalist, copyright © 2008 by the American College of Physicians
By Stacey Butterfield
“What kind of nut wants to work just at night?” asked John R. Nelson, FACP, medical director of the hospitalist program at Overlake Hospital in Bellevue, Wash.
His joking question is seriously on the minds of many hospitalist leaders lately. Studies showing disparities between day and night care, as well as new guidelines and public pressure, are pushing hospital administrators and hospitalist practices to offer 24/7 care. Meanwhile, continuing workforce shortages mean that hospitalists can be choosy about their schedules, and many of them prefer to work only days.
Given this difficult situation, the good news is that quite a few “nuts” are willing to work at night, under the right circumstances. A few years ago, the word nocturnist didn’t even exist. In a Society of Hospital Medicine 2007-08 survey, however, 6% of hospitalists identified themselves as such.
Why do these doctors choose to be nocturnists? How does their work impact the quality and efficiency of patient care? And, perhaps most importantly, how can you get them to work for you? In recent interviews, a group of nocturnists and experts offered their takes on working the night shift.
Debate over value
The growth of nocturnist services is part of a larger trend toward 24/7 hospitalist care. While nocturnists are typically defined as doctors who work exclusively at night, many 24/7 programs are staffed by hospitalists who switch back and forth between nights and days. According to the SHM survey, 53% of hospitalist groups have a physician in the hospital, rather than on-call, to provide care during the night.
Multiple studies have shown that patient outcomes from stroke, myocardial infarction, and other events are worse at night, and hospitalists and administrators hope that putting more physicians on the floor will help correct those differences. “[Nocturnist coverage] is almost certainly going to be a piece of the puzzle in eliminating the disparity,” said David J. Shulkin, FACP, president and CEO of Beth Israel Medical Center in New York.
David J. Shulkin, FACP, works with a colleague during midnight rounds.
“It means that the work done at night will probably be more complete and more attentive than if you have some other system of night coverage,” agreed Dr. Nelson. Night coverage programs are also popular with consumers, as well as night nurses and the other physicians who are at home asleep, experts said.
“It’s attractive to hospitals to say they have someone onsite,” said Kenneth R. Epstein, FACP, a hospitalist consultant in Boulder, Colo. Dr. Epstein is one of few (or possibly the only) researchers to study the impact of round-the-clock hospitalist care. The problem with 24/7 programs, he said, is that there’s no evidence to show they affect the outcomes they are intended to target.
Using 2005 data from hospitalist practices owned by IPC The Hospitalist Company, a multistate private-practice hospitalist group, he compared practices with on-call and 24/7 set-ups on length of stay, mortality, readmission, patient satisfaction and quality indicators. “What we found was that there was absolutely no difference,” said Dr. Epstein. “Believe it or not, the only difference we found was a slight difference in mortality, but it actually favored the non-24/7.”
Dr. Epstein doesn’t have an explanation for the findings, but he suspects it might indicate that boosting nurse staffing could be the most cost-effective solution to the nighttime disparity problem. “As important as physicians like to believe they are, the reality is a lot of the difference in care is provided by the quality of nursing and the quality of support staff,” he said.
Drs. Shulkin and Nelson both acknowledged the lack of evidence, but are convinced that having physicians in the hospital at night is the way to go. “It would be pretty hard to make the case that care would get much worse, so it’s not risky to patients,” said Dr. Nelson. “The only risk is to your business operations. We all the time make a lot of choices about business risk without research data.”
Not even Dr. Epstein expects the push toward round-the-clock coverage to abate. “I think 24/7 coverage is here to stay because of market forces,” he said. “I’m not arguing to get rid of nighttime coverage.”
There when needed
Practicing nocturnists are convinced of the benefits of their model, anecdotally and logically.
“I can’t count the number of times when if I weren’t there, if someone weren’t there, there would have been a bad outcome. It’s easier for a nurse to call a nocturnist,” said Arash Nadershahi, MD, a nocturnist at Overlake Hospital.
Edward S. Chun, ACP Member, a nocturnist in Bellevue, Wash.
Once they’ve been summoned, nocturnists are faster, and more likely, to come check out a patient’s problem, according to Edward S. Chun, ACP Member, another Overlake nocturnist. “If you’re at home, you’re not going to come in. You may temporize until the morning,” he said.
One way in which nocturnists clearly assist their patients and colleagues—both other hospitalists and emergency physicians—is by working up admissions. “If someone comes in in the middle of the night, the [on-call physician] asks the ER to put in hold orders. When you have a night person there, you don’t do that as often. So you’re seeing patients sooner, thereby reducing risk,” said Matthew Gembala, MD, a nocturnist who works for IPC at Tucson Medical Center.
Dr. Shulkin sees nighttime admissions as a major justification for nocturnist coverage. “The real issue is, is it appropriate to have your patient admitted without an attending physician being available?” he asked. “If you do not have a physician who is able to really look at and spend time with the patient on admission, I think that is a real missed opportunity.”
Of course, a hospitalist service could have physicians on site to admit and care for patients 24/7 without hiring nocturnists, and many do. But nocturnists and experts see additional advantages to the nocturnist model.
One is greater familiarity with the night operations of the hospital. “You can specialize in putting out fires at night. You get to know your night staff, your night staff gets to know you,” said Dr. Gembala.
“I can tell when a particular ward calls me—how much do I trust them to just give them instructions? Or is that a weaker ward, and I need to just go and be there?” he explained. That knowledge and experience has an impact on patients, according to Thadeo G. Catacutan, ACP Member, a nocturnist at the Cleveland Clinic. “If you have regular people being fielded, the variation in care is minimized,” he said.
At Beth Israel, particular efforts have been made to cement the relationships and teamwork of night staff. “When staffing is reduced, there’s a greater need to work as a cohesive hospital rather than silos,” said Dr. Shulkin. “We’ve just been pulling the people who work at night together into informal, almost social gatherings to get to know each other.”
Nocturnists may also suffer less from the sleep deprivation and resulting problems that plague physicians on rotating shifts because they get used to working at night and sleeping during the day, the night doctors said.
Reports from non-nocturnists working the night shift seem to confirm these suppositions. When Dr. Nadershahi first began working as a nocturnist, the daytime hospitalists in his practice covered his weeks off. “I’d come back to horror stories of how stressful it was. One partner would be in tears after the third admission. There’s something to say for being in tune with it,” he said.
Aman D. Sabharwal, MD, a hospitalist with the University of Miami-Jackson Memorial Hospital, summed up the benefits of nocturnist programs this way: “I think it provided a better flow, a better quality of care, and it was less hassle for the daytime doctors.”
Not all roses
There’s a reason Dr. Sabharwal spoke in the past tense, though. Although he was one of the first to document the nocturnist trend, in a first-person piece in The Hospitalist in 2005, his hospital has since given up on its nocturnist program.
The problem was recruitment. “Even with a significant salary differential, there was no interest from anybody,” Dr. Sabharwal said. He understands his colleagues’ reluctance, as his sleep schedule is still suffering the consequences of working as a nocturnist. “I haven’t worked nights in a year and a half and I’m still not back to normal.”
Nocturnists concede that their sleep schedule is less than ideal and may limit their tenure in the position. “I think the major factor would be the aging process. I’m not sure how my body will react five or seven years down the road,” said Dr. Catacutan.
Some people can handle working nights for the long term, said Dr. Nelson, who knows a couple of nocturnists who have been on the job for 12 or 14 years. But he doesn’t ask that much of his new hires. “I tell them if you’re going to take this job, I want you to do it for two years.”
In some cases, physicians commit to the job to get their foot in the door of a practice that’s not currently hiring daytime physicians. Dr. Chun did that, when his wife wanted to relocate, but he’s since passed up opportunities to move from nights to days. “It’s a golden cage in some ways,” he said.
Having so much free time during the day is an irresistible lure for many of the nocturnists. Their off-hour priorities are varied—taking care of kids and conducting research were common motivations; racing motorcycles and running for political office were more unusual ones.
The tasks of the job also have a unique appeal. At night, there are no discharges and no patients’ families, and some nocturnists like that.
“It makes it simpler,” said Dr. Chun. “For me, it’s a little bit more intellectually stimulating. It’s pure problem solving and not so much the social issues of discharge.”
There is also less hospital staff around, which has both its advantages and disadvantages. “There’s less buzzing. There are fewer demands from nursing staff. You’re not being tugged in multiple ways at once,” said Dr. Nadershahi.
Dr. Gembala relishes the independence of working on a skeleton crew. “When something bad goes down, I don’t mind not having 100 different opinions there. It’s just me and the night staff and we take care of it.”
But it can be a lonely job, he and other nocturnists admitted. “I can go into the doctor’s lounge and most people won’t even know who I am,” said Dr. Chun.
A happy nocturnist
Isolated nocturnists can easily turn into frustrated—and then former—nocturnists, so it’s in administrators’ best interest to keep them in the loop, experts said.
“To have a happy nocturnist, your liaison between the hospital and the group needs to be proactive to encourage our feedback,” said Dr. Gembala. Recurrent problems, like a ward that pages every five minutes for something minor, can fester for a long time if no one checks in with the nocturnist. “As people who are sleeping during the day, we are not proactive. We tend to be the loner types,” he said.
Pay and time off appear to be the other keys to keeping nocturnists. Some nocturnists get two weeks off for every week on, others nine days off for five days on, but almost no one can handle a full-time schedule during the night, the experts said. They also get a salary bump.
"It not only messes with your sleep and your sanity to flip day to night, the night work person doesn't have as much opportunity to [earn a] bonus."
“It not only messes with your sleep and your sanity to flip day to night, the night work person doesn’t have as much opportunity to [earn a] bonus. You earn a lot more money by doing follow-up visits,” said Dr. Gembala.
Typically, other hospitalists are happy to make up the difference for their nocturnists. “Twelve hours of covering your colleagues’ problems—that is worth something,” said Dr. Gembala.
The ideal, for an administrator, is to find a balance where nocturnist and day jobs have different, but equal appeals, said Dr. Nelson. “For any given member of the group, it’s kind of a hard choice to be a day or a night doctor. After a busy day, we’re all grousing ‘I’m going to be a night doctor.’” And after a tough week of nights, the nocturnists are thinking about switching to days, he said.
That’s just the situation in which Dr. Nadershahi finds himself. “Every time I think maybe I’ve had enough, they do something that makes it more acceptable. They keep roping me back in.”
Nocturnist or nocternist?
John R. Nelson, FACP, is on a one-man crusade that even he admits is quixotic. He believes that he may have coined the term nocturnist. “I started using it in talks as a joke. Now it’s become a standard part of the vocabulary,” he said.
The problem is that everyone else is spelling his word incorrectly. “To spell it with a ‘u,’ it means someone who loves the night or someone who loves nocturnes—night music. I spell it ‘nocternist’ to make it a combination of nocturnal and internist,” he explained.
Sadly, his crusade seems to be a losing one. A Google search for nocturnist pulls up 11,000 hits compared to just four for nocternist.
“I’m having so much fun trying to persuade everyone of my way of spelling it, even if it is still really rare,” said Dr. Nelson.
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