By RENEE STOVSKY
Some studies indicate that nights and weekends may be riskier times for hospitalized patients. Lighter staffing and supervision may increase the likelihood of medical errors or that a patient's deteriorating health may go undiagnosed or treated.
In an effort to improve medical care and safety, and to ensure there aren't different standards of care on weekdays and weeknights, physicians and administrators have encouraged the increased use of nocturnists, a new breed of hospitalists, or inpatient care specialists. Nocturnists work nights to take care of hospital patients outside the emergency room.
"From our standpoint, it's an issue of stewardship," says Dr. T. Clifford Deveny, senior vice president for physician services and physician practice management at Catholic Health Initiatives, based in Englewood, Colo. "Nocturnists enable us to provide active, not passive, care on a 24/7 basis.
"Internal medicine residency programs started addressing the issue of inpatient management by clinicians 25 years ago," Deveny says. "This is a further refinement in integration of care." He estimates there are 40 hospitalist programs throughout the CHI system of 78 hospitals in 17 states. Several of those programs have formalized nocturnist practices within the last five years, he adds.
Mandatory downtime
"Since the late 1990s, there has been a progressive growth of division of responsibilities between outpatient physicians and inpatient physicians as it has become more difficult for primary doctors to split their time between the office and hospital," explains Dr. Carolyn Sites, senior medical director of the hospitalist program for Providence Medical Group in Portland, Ore. "Now, the concept of nocturnists has evolved for two reasons: to ensure safety in patient care and to improve quality of life for hospitalists, many of whom still handle night call."
In addition to widespread acceptance of hospitalists, two other factors are fueling the popularity of nocturnists, according to a Kaiser Health News report:
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Mandatory limits on work hours of interns and residents, who traditionally cared for patients at night in teaching hospitals
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A push by the federal government and other groups to improve hospital safety
Until 2003, when the Accreditation Council for Graduate Medical Education limited their schedules to 80 hours per week, the typical schedule for interns and residents was a 100-hour workweek, including some 36-hour stints without sleep. In the past decade, administrators have turned to hospitalists — and now nocturnists, too — to fill the gaps in house staff coverage.
Rapid response
More recently, the Joint Commission, which accredits hospitals, has set standards that have led to rapid response teams headed by doctors to care for patients whose conditions worsen. In addition, the Affordable Care Act requires Medicare payments to hospitals to reflect patient satisfaction scores as well. Hospitalists/nocturnists have been part of the staffing solution.
"When I began working as a hospitalist in 2002, straight out of my residency program, there were only three hospitalist programs in the state. Now most health care systems have them," recalls Dr. Brian Bean, head of the hospitalist group for CHI's St. Vincent Health System in Little Rock, Ark. "In fact, 10 years ago, there were only 3,500 certified hospitalists nationwide. The figure now is about 40,000."
Though a precise number is unavailable, it's estimated that 1,500 hospitals now employ at least one nocturnist as well, compared to 100 just a decade ago.
Becoming a nocturnist requires no special certification beyond that of a hospitalist, and many enjoy higher salaries and shorter work hours than their daytime counterparts. According to Merritt Hawkins & Associates, a national recruiting firm, the average nocturnist makes $200,000 a year — $25,000 more than a hospitalist — and often works 8-hour shifts instead of 12-hour days.
Nightlife
Yet recruiting and retaining nocturnists remains problematic.
Obviously, night shifts are distasteful to many doctors purely from a lifestyle standpoint. But the nature of the work is also far different from that of a daytime, hospital-based physician.
"During the day, hospitalists do some admitting but also round on patients, usually 10 to 15, in an organized fashion. There is also lots of coordination of care with specialists, social workers, home health providers and so on," says Bean. "At night, you are putting out fires. You have many more patients to cover, you deal with multiple admissions from the ER, and there is very little support from subspecialists."
That said, there are definitely doctors who not only tolerate, but thrive, under those circumstances.
Some, like Dr. Philip Garber, 55, are natural night owls. He is a nocturnist at FSCC Sponsored Ministries' Genesis-Good Samaritan Hospital in Zanesville, Ohio.
"This suits my internal clock; I am definitely not a morning person," says Garber, who divides nocturnist duties with Dr. Yamani Gunawardena, 43.
Aside from avoiding 5:30 a.m. wake-up calls (something Garber admits makes him "nauseous"), he also says he finds hospital work at night "more intellectually challenging."
"I see a much wider variety of illnesses — unusual cancers, neurological problems and so forth — that would normally be handled by specialists in the daytime," he says. "I also get thrown all kinds of admissions from the ER and must agree on diagnoses. At night, I usually have more time to digest the information and make adjustments."
For Gunawardena, who splits weeks, one on and one off with Garber, the lure is more than just the interesting mix of cases she sees and the independence she enjoys at night. As a recently divorced mother of three, ages 9 through 15, working as a nocturnist also fits her parenting schedule.
"I've been doing this since 2008, so even when I was married, I was able to go home early in the morning and see my kids off to school, then go to sleep and wake up at 3:30 in the afternoon when they returned. Then we would have three good hours together before I left for the hospital at night," she says. "Now, as a single parent, I am able to switch caretaking roles by the week with my ex-husband. It's a huge advantage."
Dr. Deborah Frost, of Providence Portland Medical Center, is parent to a 2 1/2-year-old, and while she appreciates being able to read bedtime stories to her son before she leaves for work at night, she says she's been a nocturnist for seven years mainly because she "just loves the work."
"The biggest advantage I see is that at night, it's all about patient care. I get to see people at their sickest when they come to the hospital, and then I get to make them feel better. There's lots more medical mystery — figuring out what's wrong and then getting treatment under way," she says.
Another advantage Frost appreciates is the chance to become "independent and confident in my skills."
"There is very little support at night from surgeons, cardiologists and other specialists who don't really like to be called unnecessarily at 2 a.m.," she says.
The disadvantage? "It can get a little lonely at times," Frost says, although now that she is sharing duties amongst three other nocturnists, there is some collegiality in the wee hours of the night.
Most important, however, is that as a nocturnist, she says she plays a part in making the hospital a safer place.
"Our service can run 140 to 160 people at any given point in time, and on average we admit 15 to 25 ER patients a night," says Frost. "You can't just park those people and cross your fingers until morning; you need to help them. That's what I get the chance to do."
Copyright © 2013 by the Catholic Health Association of the United States
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