Nocturnist subspecialty soars: The case for the night-owl doctor

Hospitals during the night have typically been thought of as the black hole of staffing and the voltage drop of communication, but a new subspecialty is reclaiming the night. Called nocturnists, or nighttime hospitalists, physicians devote their nighttime hours to monitoring inpatients to ensure their care.

The night used to be the butt of morbid jokes in which "you don't want to get sick during the off hours" for fear that the worst would happen. In traditional models, physicians at many institutions go home for the night, leaving the care of their patients in the hands of green physicians or nonphysician providers, such as physician assistants or nurses. Today though, nocturnists are turning that stereotype on its head. More institutions are electing to implement a nocturnist program in which dedicated hospitalists care for patients during the risky wee hours.

A Washington Post-Kaiser Health News article this week featured the rising subspecialty of nocturnists. Even though the concept has been around for several years, it's only now gaining traction across the country, as institutions are closely examining quality of care issues.

One of the drivers of the nocturnist movement is the often cited study, which, in not so many words, concluded: "Sick don't take a holiday." Researchers found that patients with in-hospital cardiac arrest were at greater risk of dying during nights and weekends compared to the day shift when survival rates were higher. Patients who experienced cardiac arrest between 11 p.m. and 7 a.m. had a 15 percent survival rate, compared 20 percent during the day.

The old model posed certain risks. At night, nonphysician providers sometimes must handle larger patient loads than they would otherwise during the day, making the risk even greater for someone to fall through the cracks. In addition, patients sometimes prefer the comfort in knowing that an MD or DO is in the room monitoring them.

Hospitalist thought leader John Nelson, MD, MHM, FACP, consultant at Nelson Flores Hospital Medicine Consultants, coined the term nocturnist and recommends that facilities strongly consider implementing such a program. For a small practice of fewer than six providers, primary care physicians can moonlight to help the hospitalists during the night, John Nelson wrote in an editorial (.pdf). For practices with six to eight providers, hospitalists might handle night coverage on their own. Medium to large-sized practices with eight to 10 providers should consider utilizing all hospitalists in the practice to rotate night coverage with schedules so they do not work the day before or the night after. For practices with more than 10 providers, it might be appropriate for certain hospitalists to work exclusively at night. These are general guidelines and not strict rules, according to Nelson.

There's much to consider in a nocturnist program, including politics of current staff, compensation, and nighttime stress. If you've made the decision to implement a nocturnist program, consider the following steps:

- Ask for volunteers from existing staff. You never know if someone on your staff is looking for a change, such as a parent who wants to spend time with his children during the day and would rather work at night.

- Offer appropriate compensation. Even with volunteers from existing staff, you'll likely have to sweeten the pot with more compensation (i.e., more money) or added benefits (e.g., more days off). The extras might incentivize someone to take the graveyard shift.

- Consider ways to offset the costs. Chances are the reason you are in the position that you don't already have an available nocturnist is that you can't afford one. If the physicians already covering the nighttime are eager enough to it give up, they may consider taking a small pay cut from their annual salary to essentially pay for a nocturnist to relieve them of the burden. In addition, the hospital may match that amount to sponsor the nocturnist's compensation.

- Watch out for burnout. Once you have nocturnists up and running, remember that even night owls need a break. Consistently working at night for years on end can wear on the body so keep an eye out for the mental, physical, and emotional state of your nocturnists. You can work with the physician wellness committee, if you have one at your institution, to ensure your nocturnists and hospitalists, in general, are happy and providing quality care.

Of course, quality of care is a no brainer, an absolute must for any organization. However, as hospital budgets are cut across the nation, many institutions are checking their spreadsheets and wallets to see if they can afford the much sought-after nocturnist. With a magnify glass up to quality these days, can we really afford not to? - Karen