Duty after Dark

John Nelson, MD, FACP

A colleague once told me his theory that we are all born with the capacity to work a predetermined number of night shifts.

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February 2008
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Think of this as a physiologic parameter similar to women being born with a fixed number of ova that can’t be replenished or increased after birth. While there seems to be significant variation in the number of night shifts each of us has to offer at the start of our career, it seems nearly everyone has a maximum number that is almost genetically determined. The only control we have is how quickly we use them up.

After careful consideration, I’ve realized I’ve used up all—or nearly all—my night shifts. And I have to admit it appears I was born with a fairly small number of night shifts in my genetic code.

I think every practice of more than about eight providers should seriously consider adding dedicated nocturnists. Most or all night shifts could be covered by the nocturnists, and the other docs in the practice wouldn’t have to rotate between day and night work. This can provide a substantial recruiting advantage and enhance career sustainability for the daytime hospitalists.

The way a hospitalist practice addresses night work can be critical to whether it offers a sustainable career for hospitalists and good care for patients. Night coverage for many non-teaching practices usually evolves based on the size of the practice. For example:

Small practices (on-call from home):

  • Fewer than six providers: Moonlighters (often local primary care physicians) are paid to help hospitalists with night coverage; or
  • Six to eight providers: Hospitalists handle call from home with minimal or no help from non-hospitalist moonlighters.

Medium to large practices (in-house coverage):

  • Eight to 10 providers: A hospitalist stays in-house all night. All members of the practice usually rotate responsibility for this coverage. The nocturnist on duty doesn’t work the day before or after a night shift; or
  • More than 10 providers: Dedicated nocturnists might work only, or almost exclusively, at night.

There are many reasonable approaches to night coverage, and I don’t intend to suggest a given practice evolve through the above steps as it grows. It would be reasonable to skip some steps or use different size thresholds when moving from one system to another. In my experience, small practices nearly always provide night coverage on-call from home because of low night-shift productivity. As the night shift gets busier, they usually switch to in-house coverage.

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