Into the Night


The halls are quiet, the lights dimmed, the incessant ringing of telephones has fallen silent, patients slumber in their rooms, nurses sit and chart, waiting for the inevitable patient call light to glow once again. Then it happens: the overhead announcement that slices through the night like a knife.

“Code blue, code blue!”

As the code team scurries to the room, they start the protocols. However, they are waiting for someone—the conductor of the symphony, if you will. Who will answer the call? Who will whisk down the hall to take the podium? Will that patient’s primary-care physician (PCP) come? The cardiologist, maybe the pulmonologist?

No, there is one person who walks the halls at night when all others are asleep (even the ED doctors, though awake, are consumed by crowded emergency rooms and cannot help). This person is the nocturnist.

What is a nocturnist, you ask? Well, among the many titles, job descriptions, and opportunities that being a hospitalist can entail, being a nocturnist is the one that shines in the dark of night when everyone else is fast asleep. A nocturnist is a hospitalist who works the night shift. As a resident, you might have nightmares about the many nights you’ve worked, the assembly line of patients, procedures, and cross-cover calls you’ve processed.

You are somewhat of a rock star. It’s evident by the fact that most nocturnists are paid a 10% to 20% shift differential. In layman’s terms, you get paid more money than everyone else.

Nocturnists are the lone wolves of the night. They wear many hats and encounter a milieu of incessant admissions, more cross-cover calls than you can swing at, more grumpy, sleepy consultant phone exchanges than you would like, and endure the chronic fatigue of a person 20 years older than their actual age. But deep down in the muck of it all, there is something about the night shift that keeps a nocturnist coming back night after night.

Nocturnist in Charge

Working as a nocturnist is the last, purest form of practicing medicine. This position affords you the perfect opportunity to get back to the patient-doctor relationship because you are not rounding on other patients, juggling staff meetings, or battling a slew of other staff pining for your patient (i.e. case workers, physical therapists, consultants, etc.). Therefore, you can spend an adequate amount of time getting to know your patient without feeling rushed.

As far as admissions are concerned, there still are those days when you feel you need more hours in a day and two extra hands to take on the flood, but as the physician in charge, you have the ability to better triage these patients and defer to a specialist if needed. It’s not like those residency days of admitting whatever they call you for.

In addition, you have the opportunity to really hone your medical skills and procedural skills, because you are the specialist at 3 a.m. There will be times when you have to make decisions without the luxury of an immediate consultation; that has its pros and cons, but it definitely makes for an exciting Friday night. Consequently, you usually are the first point of contact for the nursing staff at night, so you have the ability to formulate relationships with nurses like no other physician can, because you are there with them, side by side, handling all the emergent (and often nonemergent) cross-cover calls. The nurses learn to trust you and you them, and there is a sense of camaraderie that forms from that trust.

Night-Shift Benefits

If you are still not convinced that the nocturnist world is for you—though you will be able to spend more time and have a more meaningful relationship with patients, nursing staff, and be the hero to every consultant and PCP you allow to sleep through the night—then I must reveal that the real cherry on top is actually green. Since you are working the least desired shift in your HM group, you are somewhat of a rock star. No one wants you to be unhappy, because they really want you to keep working the night shift. It’s evident by the fact that most nocturnists are paid a 10% to 20% shift differential, according to In layman’s terms, you get paid more money than everyone else.

You have the opportunity to really hone your medical and procedural skills because you are the specialist at 3 a.m.

Another benefit is that nocturnist shifts range from eight to 12 hours; some even allow you to take call from home, so you can find a position that fits your schedule. The average number of monthly shifts usually is fewer than those working the day shift (10 to 14 shifts compared with 14 to 18 shifts) on average.

Depending on what type of hospital you choose (rural or urban, community or academic), you can have a wide range of nightly responsibilities. Some nocturnists perform as many procedures as they like; others choose to perform no procedures. Patient caps might exist on the number of patients you can admit during a shift. And working as a nocturnist can afford you a terrific lifestyle, because there is an a la carte menu of hospitalist groups, shifts, and practice lifestyles to choose from. And everybody in HM knows that everyone is looking for a nocturnist, so the availability of job offers is never a problem.

Nevertheless, with more money and choices comes more responsibility. As a nocturnist, you have to be flexible and creative in order to stay informed, as you will find it challenging to make all the staff meetings. Ask your group to schedule important group meetings early, so that you can stay after your shift and attend. Sometimes you just have to dig in and stay for those later meetings, if need be. (Sleeping in the call room until your next shift makes you somewhat of a martyr.) And remind your medical director to email you any important information you might have missed.

Even though you won’t be around during the day, you must stay abreast of quality initiatives (CHF, AMI, etc.). Beware of charting requirements, which can change from day to day.

If you are looking for an exciting way of life, and the ability to practice pure medicine after residency, you might want to get “into the night” and consider an HM career as a nocturnist. TH

Dr. Cunningham has been a hospitalist since 2004 and a nocturnist the past three years at Hamilton Medical Center, a community hospital in Dalton, Ga., and locum tenens in the Tennessee area.

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