A Mile in Their Shoes
Medical directors must balance a variety of factors when scheduling around-the-clock coverage. From day one, the hospitalist program at Albany Memorial Hospital in New York, where John Krisa, MD, is medical director, has been an in-house 24/7 program. Dr. Krisa’s group uses per diem physicians or fellows on their days off to cover most of the nights. The other hospitalists on the team do not escape occasional night duty, and they cover what is left after plugging in the moonlighters. This leaves from zero to five nights per month for each full-time hospitalist. Even the medical director covers night shifts, something Dr. Krisa thinks is valuable to his leadership.
“You, as the leader, still have to walk a mile in that other person’s shoes,” he says. “There are different challenges associated with both day and night shifts, so you have to appreciate what your colleagues are going through on the other shifts.”
Hospitalist Consultants’ Dr. Epstein agrees with that concept.
“Whenever medical directors have personal experience of how the system is working, they are better able to recommend and make changes,” he says.
It’s also valuable, Dr. Krisa explains, for the group leader to interact with ED staff and hear their concerns. Working night shifts helps avoid the night team versus day team schisms, which can lead to group disunity, he says.
Different Skill Set, Different Mindset?
The fact of the matter, though, is that pulling night shifts does not appeal to most established hospitalists. Sleep researchers have found that humans’ body clocks prefer office hours. Even if night-shift hours are consistent, those who work nights never really catch up on the sleep they need during the daytime.
Even so, some physicians embrace the graveyard shift. Working the night swing shift agrees with Dr. Marshbanks’ schedule. The hours are consistent, she works fewer shifts to qualify for FTE pay, and her shift is time-limited, as opposed to work-limited. She’s also filling a niche that others in her group eschew. “It’s a shift that most people with children don’t like because the hours are very disruptive to family life,” she says.
The workload at night is different. Instead of the routine rounding typical in day shifts, her work is more urgent. She does more admissions because she works the busiest ED hours, covers acute-stroke codes, and provides cross-cover. And, she says, night staff tends to be “a solid group, so we interact more on a regular basis, since there are fewer of us.”
The nocturnists at St. Rita’s Hospital are not held to the same meeting schedule as their daytime hospitalist colleagues, but they’re expected to read meeting minutes and to be responsible for any changes in guidelines or operational information, Dr. Humphrey says. Also stipulated in their hospitalist contracts is the requirement that they maintain competency in procedures, such as central-line placement and airway management.
What’s Better for Patients?
Experts have raised concerns that patient care can be compromised during off-hours, when staffing levels are reduced.1 The Leapfrog Group’s ICU Physician Safety (IPS) Standard argues for high-intensity ICU staffing to reduce patient mortality.2 A number of investigators have tried to determine whether patients admitted off-hours (weekends, nights, holidays) fare worse than those admitted during weekdays. Peter Cram, MD, MBA, acting director of the division of general internal medicine and associate professor of medicine at the Carver College of Medicine at the University of Iowa in Iowa City, found in a 2004 study that patients admitted to hospitals on weekends experienced slightly higher risk-adjusted mortality than did patients admitted on weekdays.3