Twenty-four-hour coverage is standard practice for all successful hospitalist groups. At Lehigh Valley Hospital in Allentown, Pa., the hospitalist group features 17 FTEs that split time in a traditional seven-on/seven-off schedule. Five doctors per week round on units seeing patients; one works triage/admitting in the morning and sees some follow-ups in the afternoon; and one works a middle shift for admissions, consults, and ICU transfers.
The foundation of this coverage comes at night. We employ an overnight doctor—a nocturnist—every day of the year. This doctor’s sole responsibility is to cover night admissions, rapid responses, floor calls, and transfers.
Change Is Necessary, Difficult
Lehigh Valley’s change to a nocturnist model came about when members of the group asked for it. We needed to put a model in place that could help the group, improve morale, and improve our care at night. Of all of our shifts, nobody wanted to work overnight. Each clinician was working about four weeks of nights per year, and we started to notice that our new hires from residency were the only ones truly capable of handling the sleep challenges—or, more truthfully, our veteran hospitalists were having difficulty with the nights.
For such a large group, having a nocturnist makes sense. However, there are a few issues to contend with in hiring a nocturnist. Most notably, nocturnists are hard to come by. It takes a special type of person to come in and work the opposite schedule from everyone else. Nocturnists are typically alone in the hospital and don’t always have the support of other hospitalists when times get tough. They usually are at the mercy of other stakeholders. Namely, they are at the mercy of the ED. If the ED is busy, then so is the nocturnist. That special type of person knows the balance and becomes a specialist in ED dynamics, as well as in ED night staffing.
Nocturnists are expensive; we looked at MGMA and SHM data and realized that we would have to pay a 20% to 50% premium if we wanted to employ a true seven-on nocturnist. And if we wanted all nights covered, we would have to hire two of these doctors.
Another point of contention is the buy-in from administration. CEOs and CMOs often don’t understand the need to pay for a nocturnist, and more often than not, they fail to see the need to have a nocturnist employed in the first place.
Finally, in the event of sick time, holidays, or vacation time, the hospitalist team is at the mercy of the nocturnist in terms of necessitating coverage.
Internal Solution=Perfect Remedy
In addition to the aforementioned concerns, I recently experienced a “what’s most important to me?” moment at work with the expectation of my first child. I planned on returning to work after my maternity leave, but I was reassessing just exactly how much I wanted to come back to work. It was in this setting that I began to brainstorm ways to help the group with our concerns regarding working nights, as well as my own feelings of being torn with such a grueling schedule while having a new baby at home.
Then the solution hit me: a new nocturnist model.
After long discussions with the group and group leadership, we found, not surprisingly, there were a good number of people who valued time more than money. I fell into the category of desiring more time away over a premium salary. We also found two others like me who fit this same category. None of us were considered “nocturnists” up to this point, and none of us would have gone for the idea of being seven-on/seven-off nocturnists, either. So we needed a new plan.
And with a little brainstorming and schedule-wrenching, the new nocturnist was born at Lehigh Valley. We are a group of 17. By taking the three willing participants out of the pool of 17 hospitalists and asking them to exclusively work nights, rotating in a one-week-on, two-weeks-off rotation, we were able to still leave 14 doctors to run the day shifts. The daytime hospitalists would no longer have to work nights, drastically improving their quality of work life.
This was a huge step forward for our group. It was a morale boost for the daytime doctors and actually allowed the group to save money. We were looking for doctors 18 and 19, and instead found internal solutions to our night problems. The schedule fit together like a patchwork quilt.
In exchange for two weeks off, the three nocturnists agreed to no additional vacation time. Our salaries stayed the same, too. So from a budgetary standpoint, nothing changed. From a quality-of-life standpoint, everyone was happy. My nocturnist colleagues and I were happy to exchange working nights every third week for the same salary in exchange for more days off.
The new schedule even allowed the group to eliminate the middle shift, creating an additional hospitalist available for daytime rounding. And having three nocturnists creates a pool of night doctors who are readily available to cover each other’s sick or personal time.
In all fairness, this new model was not an easy sell to administration. But as the group became more stable and morale increased, we, as members of the group, relied on this stability. We also noticed an increase in recruitment. Veterans and rookies wanted to start in a practice that had its nights covered. Ultimately, increasing our daytime capacity increased our inpatient encounters, and by increasing recruitment and retaining our current staff, our administration saw the benefits.
Employing a team of nocturnists maintains group stability, is cost-effective, helps with retention, boosts morale, and is attractive new recruits. Hospitalist programs that are struggling with staffing should consider a similar approach—and remember that they might be able to change everyday life without changing the ever-important bottom line.
Dr. Verdetti-Healy is a nocturnist at Lehigh Valley Hospital in Allentown, Pa.
Daniel Bitetto, MD, SFHM, chief of the section of hospital medicine at Lehigh Valley Hospital in Allentown, Pa., contributed to this report.