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Duty after Dark


 

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

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.

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.

Where to Find Them

People often tell me they’d love to add nocturnists to their practice but can’t imagine where they could find people willing to do the work.

There are many potential nocturnists who might be available, including hospitalists in your practice. You just have to ensure they have a better “juice-to-squeeze ratio” than others in the practice. Usually this means offering them some combination of more pay and/or less work than others in your practice. Many people are attracted to hospitalist work because they want an interesting job that provides a lot of time off. By having nocturnists work less than others in the practice, they can have more time to pursue other interests.

There is no perfect way to gauge the appropriate adjustments in workload and compensation that will attract people to a nocturnist position in your practice. Estimate what seems equitable and see if any of your doctors would be willing to become a dedicated nocturnist. If none find the deal attractive enough to consider seriously, the chances are a new doctor you try to recruit will come to the same conclusion.

While a good “juice-to-squeeze ratio” is most important in attracting nocturnists, you could also consider a nocturnist recruitment ad that screams at the top “Never work another day in your life!” That might attract a lot of attention amid competing ads that describe the wonderful schools, quality of life, and proximity to shopping, lakes, and recreation other positions offer.

How to Pay Them

Where can you find the money to pay the nocturnist well for doing less work than his or her daytime counterparts? Most practices can appeal to their “sponsoring” hospital for more money to support this valuable component of the practice. If doctors in the practice want to be relieved of night work badly enough, they might give up some salary that can be put toward the nocturnist position.

Ask your hospital to match the contribution the doctors make. For example, each of the eight doctors in the practice might accept a $5,000 reduction in annual compensation to be relieved of all night shifts. That $40,000 could be matched 100% by the hospital for a total of $80,000. Each of two nocturnists hired by the group could split that $80,000 so they could be paid the same salary as the day doctors plus $40,000.

The Long View

Nearly everyone tires of working the night shift eventually—even if it does mean less work and more pay. Two to five years of working solely as a nocturnist might be as long as most people can do it, so plan for relatively frequent turnover. But I know of several hospitalists who have worked only at night for more than 10 years, provide excellent patient care, and seem quite happy to continue working nights. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. He is also part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.