Pulse
Night Shift Newcomers
As some hospitalists find working the night shift fits their lifestyle, hospitals are weighing
the pros and cons of the nocturnist movement.
Nine years into his career as an internal medicine physician, Eric Salata, M.D., realized something he hadn’t known about himself: he really liked working nights. A hospitalist at Mercy Hospital in Coon Rapids with occasional overnight on-call responsibilities, he found the adrenaline rush of the night shift exhilarating. “Things are definitely stranger during the night,” he says. “It’s very erratic and unpredictable.” As the sole physician tending to patients admitted during the night, he adds, “It’s also very rewarding.” When he took a new position a year ago with United Hospital in St. Paul and Woodwinds in Woodbury, he signed on as a nocturnist, the newest job in medicine.
In fact, dedicated night-shifters like Salata are becoming a hot commodity in many places. According to the Society of Hospital Medicine, the number of hospitals nationwide employing nocturnists surged from 700 in 2003 to nearly 1,200 in 2007. More and more, institutions are looking at safety and quality measures and tabulating the number of emergencies that crop up during the wee hours when hospital staffing is thin. Having hospitalists on hand who specialize in nighttime care—as opposed to residents, moonlighters, or weary practitioners who’ve shifted their sleep cycles to serve an on-call schedule—is one solution that’s been brewing for nearly a decade and is finally taking hold.
Nocturnists have become popular on both coasts, and hospitals are willing to pay extra to employ them, notes Burke Kealey, M.D., head of the practice analysis committee for the Society of Hospital Medicine and who reviews programs nationwide. Because nocturnists see fewer patients, he says, they earn about 40 percent more per patient encounter than hospitalists. However, nocturnists’ salaries tend to be lower ($174,400 versus $193,000 for a hospitalist, according to the society) because they work fewer hours.
The Job No One Wants
The trouble, as several hospitals in Minnesota have discovered, is that few people want the job. Kealey, who also leads HealthPartners Medical Group’s hospitalist program, which serves Regions, North Memorial, and Mercy hospitals, was part of the team that initiated HealthPartners’ fellowship program in hospital medicine a decade ago. Of the 70 hospitalists currently practicing at Regions, two are nocturnists. “It’s a small percentage of my group,” he says, “but a high percentage compared to most groups. It’s hard to find people who want to work all night.” Regions itself went through a long search to find nocturnists to join its staff five years ago. “We had an ad in some of the major journals going on two years without a single response,” Kealey recalls, “and we eventually just took the ad away.” In time, they recruited from within, when two physicians on staff happened to want to shift their schedules.
Such frustrating searches are familiar to Kristin Eberth, a recruiter at St. Luke’s Hospital in Duluth, which has three nocturnists on staff and has been trying for more than a year to hire two more. Print and online ads and even search firms are turning up few physicians who want the graveyard shift. When she broaches the idea with physicians seeking hospitalist positions, they are “initially scared off by the idea,” she says. Most see the night shift as an inconvenience.
According to Salata, however, the inverted schedule confers a wide range of benefits. He typically works eight 12-hour shifts per month, beginning at 7 p.m. or 8 p.m. He finds that his nocturnist shift tends to end promptly when he turns his cases over to the hospitalists who come on duty in the morning. In contrast, when daytime hospitalists hand cases over to a single nightshifter, they might find themselves spending hours catching up on paperwork and other chores they didn’t finish during the day. When Salata goes home, he’s ready to sleep or run errands. “That’s one of the nice things,” he says. “If you’re not working during the day, you do have the option of getting stuff done.” The job suits his family life, too. His wife, a nurse practitioner, also works many evenings so their schedules coincide, and the long blocks of time off enable him to spend quality time with his 13-year-old daughter.
At the same time, he notes, he’s found he is capable of handling an altered sleep schedule. “I’m the type of person who can sleep anywhere and sleep well,” he acknowledges. “I think it takes that. If someone’s a very finicky sleeper, it’s probably not the best thing to do. But I can sleep during the day, get a solid eight, and then get up and be fine.”
At Fairview Southdale in Edina, lead hospitalist Seema Maddali, M.D., has her eye out for the right candidate for a nocturnist job. “Absolutely, I am looking,” she says. She notes that hiring a nocturnist would take the pressure off staff who now have a rigorous on-call schedule. “Ideally, a lot of us would like to give up the night shift because it does interfere with our sleep cycle.… The burn-out rate would be a lot lower,” she says. “The retention rate would be higher.”
Maddali speculates that nocturnists may be harder to come by in Minnesota than on either coast because the cost of living in the Midwest is not as high. On the coasts physicians might be more driven to work the off-kilter hours because of the higher pay or to avoid childcare costs. Further, she adds, because training programs in general are turning out fewer physicians, newly minted doctors aren’t competing as heavily for positions as they once were, so there’s less of a reason for them to consider the unusual hours.
Hospitals Wary
Even as hospitals recognize the potential benefits of nocturnists, some are circumspect as they look to hire. “It has to be the right person,” Maddali insists. The night shift requires a physician to work autonomously, with fewer specialists to consult and a smaller auxiliary staff on hand. The nocturnist also may be the only one supervising residents and medical students at night. Kealey concurs that nocturnists must be skilled at multitasking, dealing with surges of patients, and managing multiple emergencies at once. “Often they are the code team or the rapid response team, so they need to have their ACLS skills up to date,” he adds. Ultimately, they become the point person for the emergency room and the contact for referring physicians. “They’re the one number that will be called for new admissions,” he says.
Some are waiting to see how the nocturnist trend evolves. Jo Ann Wood, M.D., lead hospitalist at the University of Minnesota Medical Center, Fairview, says the hospital is considering the idea of hiring nocturnists. “It’s something we’ve certainly been discussing,” she says. “There is a potential advantage with regard to safety because having a nocturnist present would enable us to provide extra support to our residents.” Even so, changing established practices—in this case, allowing a nocturnist to make decisions in the place of subspecialists—will take time. “If we start to see marked quality improvements as a result of the nocturnists at Fairview Southdale, it will make it easier to consider making that sort of a change here.”—Kate Ledger