Hospitalist considering nocturnist position please help?

[Fococoroco22]

Hi - Been a while.

TLDR: Take Nocturnist position in My home city [details below] vs wait for California license to come in and see if I can find a gig in LA. Long term relationship ended 9m ago and extremely low likelihood of compatible partner where Im currently living. Also maybe in midlife existential crisis, albeit one that has led to tremendous personal growth.

Main:
Have been practicing as a hospitalist for a little over 3y and about 9m ago joined a concierge group as well.
Living in an older community. Im 40. For personal reasons I'm looking to move.
I truly appreciate what I have now, great neighbors and an easy job though one I cant see doing indefinitely HERE. However, I want to move forward, I feel a driving need to move forward but have some fear.

Currently I'm being offered a nocturnist job. the med director: 285k base + 50k bonuses easy to get [supposedly]. 7on/7off. 8pm to 6am. 8-10 admits a night. Supposedly minimal floor call but need to specify further.


The questions/issues Im struggling with:

I strongly suspect nocturnist medicine is much more my style clinically than Day rounding [much less admin/social bs]. BUT I have no experience switching between night and day cycle- not since residency at least and those were often random 24h shifts, murderous.

Apologies in advance if these are a mix of existential and logical questions. I'm working on it.

1. Most Concerned that due to night to day switching work-life balance will not be possible— Preventing me from dating and establishing a meaningful relationship and community.

2. Concerned I dont know how to safely, effectively and sustainably switch between nights and days without causing harm to my health. Im 40.

3. Lastly, I wonder, esoterically/annoyingly, if California is spiritually, intellectually and culturally more expansive than Miami and therefore may help foster more personal growth and romantic connection opportunities.

So, should I wait where Im at until my California license comes thru in the next few months and find a job there -- my cousins, who Im close with are all in LA.

I know its much more expensive and of course thats an issue but at this stage in my life my primary concern is continued self growth [which can of course occur anywhere], building more connection to community and cultivating a real and long term relationship.

I appreciate the time of my fellow doctors. Apologies for kind of dumping this non clinical issue on here. I have to make a call within the week. I have been working hard to clear my head and make a strong call but I'm feeling a bit vulnerable here.

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[dozitgetchahi]

You have a job as a concierge doctor (what some would call the holy grail of general internal medicine) and want to switch that to be a nocturnist in one of the most expensive COL areas of the country?

More and more data keeps coming out about just how bad shift work and night shifts are for your general health and wellness. When I got done with residency, one of my priorities was to never have to take call shifts or night shifts ever again - it disrupts so much of your life. I did rheumatology and was able to date normally as an attending - living a normal lifestyle as a doctor has been great. I’d never switch back. Dating would have been a lot harder that way. But YMMV.

Also, COL is important. You’re considering moving to two of the most oversaturated medical markets in the country - areas where doctors unfortunately often get paid and treated like garbage because there’s such an oversupply of them. Getting paid worse to live in a massively more expensive area isn’t pleasant, and neither is dealing with institutions who don’t care how they treat you because they think they can just pick up another doctor in a week if you leave - been there, done that and I will never do it again.

How far do you live from Miami now? Can you date there and drive back and forth?

 

[Fococoroco22]

Hi I live 2h away from Miami. Doesnt seem that far but going back and forth every weekend creates this weird sense of non-presence in either location. Has been tough getting away with enough regularity to really date well. You lose the little daily or weekly touches like lunch or drinks during the week etc. WHich I would too of course with nights-- just would hope during my off week I could make up for it.

Yeah its all great here -- easy living, just no partner. I have to rely on magical thinking instead of action : When Im ready she will come etc.

Alternatively I just had a thought that perhaps I could renegotiate my contract coming due in Jan to give me a 4d work week.
Any suggestions on negotiation. Currently making 250k.

Yes if someone asked me if the main impetus to leave is emotional Id have to say yes. I want to get away from the place that reminds me of lost love. What would a more enlightened mind do? Probably sit still and grow thru the loneliness and wait for something else to align? OR they would go out and struggle to create a different life?

I fully appreciate that professionally I've lucked out -- randomly choosing a living space with great neighbors and being found by this concierge job. Even meeting my previous partner was luck. But I lost the girl and now its been 9months and Im still pretty wrecked. SO I was hoping that a radical change would help re-align, restart and help me move forward with my life.

 

[Lucky1993]

How much is your current salary? Would you be taking a hefty paycut?

 

[Fococoroco22]

Current salary 250k, no health ins , 401k with match comes with about 10k/y. Gross. ONCE I get 42 patients or so Ill be paying for myself and then my salary can grow or can talk about buying in.
BUT growth is slow. Over last 10months maybe 7-8 patients. So less than 1 per month. Even at 1 per month which doesnt seem likely it'd be years before Im at a place of growth.

I think I want to see how I can try to negotiate a 4d work week. That way Ill be able to more reasonably establish a presence back home in Miami and date in a way that provides my future partner some consistency.

Nocturnist gig 285k + 50K bonuses that are supposedly easy to meet -- notes done, orders in, no meetings etc. Ill assume ill make around 300-330k/y as nocturnist. BUT at what cost to my physical and social health? I just dont know and cant get a clear picture.

I Dislike that I cant simply make this a logical decision. Rather Im making this a spiritual or existential thing ie: Losing something that I appreciate for what it is -- the concierge gig, the great neighbors.
Frankly thats how I lost the girl--Didnt fully appreciate what I had, kept going back home to miami on weekends to see family and go diving bcs I felt I needed to recover and find peace. But one of the lessons was that peace doesnt come from doing things it comes from who you have in your life, who you do those things with and appreciating to the fullest what is in front of you and in your life at any given moment.

I see the gifts Ive lucked into here. But because Im not a monk I am having trouble KNOWING what the best most aligned thing to do next is.

Therapy, rabbi discussions etc arent enough. A broken heart makes it hard to think clearly. Not feeling sorry for myself. Just know that Im not as clear as I could be. I know I'm likely not thinking about things in the most logical or rational or spiritually aligned way.

 

[dozitgetchahi]

Current salary 250k, no health ins , 401k with match comes with about 10k/y. Gross. ONCE I get 42 patients or so Ill be paying for myself and then my salary can grow or can talk about buying in.
BUT growth is slow. Over last 10months maybe 7-8 patients. So less than 1 per month. Even at 1 per month which doesnt seem likely it'd be years before Im at a place of growth.

I think I want to see how I can try to negotiate a 4d work week. That way Ill be able to more reasonably establish a presence back home in Miami and date in a way that provides my future partner some consistency.

Nocturnist gig 285k + 50K bonuses that are supposedly easy to meet -- notes done, orders in, no meetings etc. Ill assume ill make around 300-330k/y as nocturnist. BUT at what cost to my physical and social health? I just dont know and cant get a clear picture.

I Dislike that I cant simply make this a logical decision. Rather Im making this a spiritual or existential thing ie: Losing something that I appreciate for what it is -- the concierge gig, the great neighbors.
Frankly thats how I lost the girl--Didnt fully appreciate what I had, kept going back home to miami on weekends to see family and go diving bcs I felt I needed to recover and find peace. But one of the lessons was that peace doesnt come from doing things it comes from who you have in your life, who you do those things with and appreciating to the fullest what is in front of you and in your life at any given moment.

I see the gifts Ive lucked into here. But because Im not a monk I am having trouble KNOWING what the best most aligned thing to do next is.

Therapy, rabbi discussions etc arent enough. A broken heart makes it hard to think clearly. Not feeling sorry for myself. Just know that Im not as clear as I could be. I know I'm likely not thinking about things in the most logical or rational or spiritually aligned way.

I think you may be reading too much into all of this.

Let me share a story.

I am on my second marriage. The first marriage was largely a casualty of medical training. It started falling apart by the end of IM residency.

I know exactly how you feel, because I felt that way throughout the duration of rheumatology fellowship - horny, a bit lonely, strongly interested in dating but somehow being too busy to really be able to do so. Feeling like life had been turned upside down because of the end of a relationship. It was a distraction, and stressful.

If I could give you some basic tips, it’s these:

- Just go date. Meet women, go on fun dates, talk. You likely need to loosen up on the cultural and religious limitations you have set for yourself. I’ll give you another example here - I am the son of very conservative parents. First wife was basically “straight laced”. Current wife is a wonderful short haired, liberal, bisexual. Is this whom I envisioned marrying growing up? No! Is it whim my parents thought I should marry? No! Is she a wonderful person and great match? YES! During my dating phase after marriage number one, I dated all sorts of women from all sorts of races, creeds, and walks of life and the experience was wonderful. There are likely a lot of women out there whom would be great for you - don’t rule out huge swaths of them just because of their religion, or culture.

- Find a woman who meshes with you and your lifestyle. There are women who are divers. If that matters to you, find one. If you want to spend your weekends diving, do that. Find someone who wants to do it too. Visiting family and diving aren’t necessarily bad ways of spending your time. It’s not like you were going out to blow your paychecks at the strip club.

- I don’t think being a nocturnist is a good idea. It’s going to make dating hard. It’s going to make you miserable. I didn’t date during IM residency because I felt like garbage all the time and never felt I could put out the right vibes to mesh with someone. I think you’d feel the same here.

- Beware sometimes of what you hear from spiritual advisors, therapists etc. Sometimes their advice can be good, sometimes not so good. You have to be the “captain of your soul”, as the old poem put it. At some point you have to shift gears and go into action. I have several orthodox Jewish friends, and one thing I’ve noticed is that they seem to put a massive amount of stock in what their rabbis tell them - to the extent that the rabbi sometimes becomes some sort of micromanager in their lives. When I was a fellow, I saw some orthodox Jewish patients who wanted us to call their rabbis to talk over the medical decisions with them. I think that’s nuts, and I say that with all due respect to peoples’ religious preferences. Who do you want to date? Where do you want to live? How do you want to live? If none of these other people in your life had an opinion, what would you do? Where did you grow up, and where do you dream of living? I’m feeling you on the desire to break away and go somewhere else - sometimes it’s what you have to do to define yourself. If the money situation doesn’t bother you much, you could go to LA…but there’s also a lot of other communities out there with a significant Jewish population. Sometimes there’s a logical way of doing things, and sometimes you just need to pick a place and go give it a shot. It may take several tries to get it right, so the sooner you start moving towards the target, the better. Look around.

 

[chessknt]

From a $ perspective both of those jobs are crap and your current one sounds like it is too depending on how much you are working. Nocturnist definitely isnt going to help your social situation and would be a really bad move in that regard and will probably be bad for your emotional and physical health. It sounds like you are having an existential crisis--commit to going to therapy for a few months before making any big changes, talk through this loss with someone in a confidential setting and figure out what your feelings are and healthy ways to process that and how to move forward. Running away to go find love in the big city sounds romantic but I am not sure you are thinking too clearly. You have to work on yourself and your own state of mind before planning on entering a relationship if you want it to work out.

 

[Fococoroco22]

Many thanks for the wisdom and insight. Many thanks.

 

[ReviewOfSystems]

As a career noctunist I would say do what you are pulled to do because of what YOU want. Everyone looks at me like I have 3 heads when I say I like and prefer nights. But I was so miserable working days that it negatively affected every aspect of my life. I cant wake up early with ease, 7a-7p eats my whole day and working days I'd come straight home and sleep, I was lucky if I ate and showered prior. I never saw the sun, worked every other weekend, never got anything done personally 14 days out of each month, and had to deal with day shift BS on top of all that. My life is 10x better for working nights, and it positively bleeds into my personal life. My future partner must fit into that (dating is hard no matter what your working schedule is) and socialization is a challenge, but I'm 31 not 20 something, a quieter life is nicer.

 

[gutonc]

As a career noctunist I would say do what you are pulled to do because of what YOU want.

This is pretty much the answer to every single "what should I do for a career?" question asked on SDN.

 

[NITRAS]

I feel that exclusively night doctors lose their longitudinal medical skills because so much of their management gets deferred to the day doctors.

Lots of people are ok with that. I am doing more of the “admission only work” (during the day only thank God!), and I feel my skills have atrophied somewhat.

 

[ReviewOfSystems]

This is pretty much the answer to every single "what should I do for a career?" question asked on SDN.

I mean its just that simple.

 

[ReviewOfSystems]

I feel that exclusively night doctors lose their longitudinal medical skills because so much of their management gets deferred to the day doctors.

Lots of people are ok with that. I am doing more of the “admission only work” (during the day only thank God!), and I feel my skills have atrophied somewhat.

This is kind of true. Which is why I bookmark all of my admits and read up on their hospital course (the interesting ones at least) to see if they go how I expected them to. And they usually do. But other than that, I dont care. I know what I need to in order to perform MY job. I will study again for real when boards time comes back around.

 

[sloh]

dating is hard no matter what your working schedule is)

Yeah but harder working nights

 

[wamcp]

Age 40? Switching to a full time nocturnist job? For 99% of the population that’s a “no way dawg”

I’m in my early thirties and I can’t see myself still doing noctrunist in my fifties.

 

[ReviewOfSystems]

Yeah but harder working nights

For me it was harder when I was on days.

 

[chessknt]

For me it was harder when I was on days.

How?

 

[BicepsTriceps]

If nights are only admissions without cross coverage (or APN to cross cover and only calls you for difficult/ rapid responses where you can actually bill CC and make extra RVUs) I'd jump to it in a heart beat.

It's those damn pages every 5-15 minutes for the stupidest reasons ever that would drive me absolutely insane doing nights.

Nope.

Only other way I'll consider it if 5 on 10 off or 7 on 14 off. I think nights should be full time like this. Otherwise it's bad.

 

[Señor S]

Mid-30s, not a nocturnist but do a decent amount of nights as part of my job...for me nights are a killer. Absolutely wipe me out even if they are slow (and they certainly can be). Just brutal, and I generally don't do more than 3 at a stretch. 7 nights in a row sounds like my idea of hell. I can't imagine an older person doing that kind of schedule, consistently, for years.

 

[ReviewOfSystems]

Mid-30s, not a nocturnist but do a decent amount of nights as part of my job...for me nights are a killer. Absolutely wipe me out even if they are slow (and they certainly can be). Just brutal, and I generally don't do more than 3 at a stretch. 7 nights in a row sounds like my idea of hell. I can't imagine an older person doing that kind of schedule, consistently, for years.

It's more brutal if u do days and nights.

 

[sloh]

Night shifts are detrimental to health even if the person only does nights without flip flopping between days and nights

 

[collegestud2013]

Hi - Been a while.

TLDR: Take Nocturnist position in My home city [details below] vs wait for California license to come in and see if I can find a gig in LA. Long term relationship ended 9m ago and extremely low likelihood of compatible partner where Im currently living. Also maybe in midlife existential crisis, albeit one that has led to tremendous personal growth.

Main:
Have been practicing as a hospitalist for a little over 3y and about 9m ago joined a concierge group as well.
Living in an older community. Im 40. For personal reasons I'm looking to move.
I truly appreciate what I have now, great neighbors and an easy job though one I cant see doing indefinitely HERE. However, I want to move forward, I feel a driving need to move forward but have some fear.

Currently I'm being offered a nocturnist job. the med director: 285k base + 50k bonuses easy to get [supposedly]. 7on/7off. 8pm to 6am. 8-10 admits a night. Supposedly minimal floor call but need to specify further.


The questions/issues Im struggling with:

I strongly suspect nocturnist medicine is much more my style clinically than Day rounding [much less admin/social bs]. BUT I have no experience switching between night and day cycle- not since residency at least and those were often random 24h shifts, murderous.

Apologies in advance if these are a mix of existential and logical questions. I'm working on it.

1. Most Concerned that due to night to day switching work-life balance will not be possible— Preventing me from dating and establishing a meaningful relationship and community.

2. Concerned I dont know how to safely, effectively and sustainably switch between nights and days without causing harm to my health. Im 40.

3. Lastly, I wonder, esoterically/annoyingly, if California is spiritually, intellectually and culturally more expansive than Miami and therefore may help foster more personal growth and romantic connection opportunities.

So, should I wait where Im at until my California license comes thru in the next few months and find a job there -- my cousins, who Im close with are all in LA.

I know its much more expensive and of course thats an issue but at this stage in my life my primary concern is continued self growth [which can of course occur anywhere], building more connection to community and cultivating a real and long term relationship.

I appreciate the time of my fellow doctors. Apologies for kind of dumping this non clinical issue on here. I have to make a call within the week. I have been working hard to clear my head and make a strong call but I'm feeling a bit vulnerable here.

Pay comes out to be $156 to $184 per hour pending on how much of the $50k bonus you get, and assuming 182 10-hr shifts per year. Unless you get most or all of the $50k bonus, pay is otherwise low for nocturnist job, especially for high COL area. Night shifts are higher liability since you can be responsible cross-covering for patients who might crash at night, even if it was because the daytime person did not properly manage the patient. Also, not to mention effect on health and sleep schedule. I personally wouldn't do it for at LEAST $180 per hour. And even then, you should have at least a PA/NP with you for most of the night to help rotate in on admissions and cross coverage. That pay might be more reasonable if it's a day shift only job but doesn't seem competitive for nights. The only good part of the nocturnist job from what you've posted is the 10 hr shifts (instead of the usual 12 hrs 7PM to 7AM).

If the $50k are in quality bonuses (and not RVU), the employer could write then so they are very difficult to get the full amount. I'm not a fan of having that much of my pay being tied to arbitrary measures that the employer can easily change. I would prefer an RVU-based bonus structure instead so you get compensated more objectively when it gets busy.

 

[ReviewOfSystems]

Night shifts are detrimental to health even if the person only does nights without flip flopping

To each his own. Couldnt pay me to work days ever again.

 

[Fococoroco22]

I asked the program director about unpaid leave— I miss going on medical missions or longer vacations with family. He said it would be an administrative problem now and could not approve. That gives the impression of being locked into a 7/7 indefinitely. That sucks. Or are my expectations and attitude off? Is there a way around that? I need real time off not just a week to recover. It’s an important aspect of my work life balance.

Except for that issue, I was actually getting excited about the job. Still am hopeful it can magically work out. Bcs otherwise I’m stuck in the golden cage of my current gig.

I have another question , can anyone convince me that locums is the best way forward then? Considering freedom of scheduling and control over your life and finances to be a priority?

 

[NITRAS]

I’ve never done locums, but it sounds terrible. Half the struggle of a new place to figuring out the tiny nuances of how things are done differently at different institutions. At my institution, I call the trauma surgeons for the general surgery work. We never use nitroglycerin drips outside of the ICU, but ok for diltiazem or amiodarone drips. There are 4 cardiology services.

It just sounds like a total pain in the ass. You then add on variable nursing abilities and expectations, and that places can’t get full time coverage for a reason usually. It isn’t always because the locations isn’t a major city.

 

[dozitgetchahi]

I’ve never done locums, but it sounds terrible. Half the struggle of a new place to figuring out the tiny nuances of how things are done differently at different institutions. At my institution, I call the trauma surgeons for the general surgery work. We never use nitroglycerin drips outside of the ICU, but ok for diltiazem or amiodarone drips. There are 4 cardiology services.

It just sounds like a total pain in the ass. You then add on variable nursing abilities and expectations, and that places can’t get full time coverage for a reason usually. It isn’t always because the locations isn’t a major city.

Totally agree. I know some people seem to really love locums, but IMHO the worst and most unpleasant time at any job is just in the beginning where you’re trying to figure out how everything works at a new place and what to do. I couldn’t imagine always being in that phase whenever I go to work. Sounds very frustrating.

Also, you’ve hit the nail on the head wrt nursing staff and such. Most locums jobs are seemingly in the middle of nowhere, with understaffed units (and those that are there are unfortunately likely to be poorly trained, etc).

Plus, if **** hits the fan and it’s time to blame someone, who do you think is going under the bus? Someone from the home team, or the random locums guy who is here for 2 weeks?

 

[collegestud2013]

I asked the program director about unpaid leave— I miss going on medical missions or longer vacations with family. He said it would be an administrative problem now and could not approve. That gives the impression of being locked into a 7/7 indefinitely. That sucks. Or are my expectations and attitude off? Is there a way around that? I need real time off not just a week to recover. It’s an important aspect of my work life balance.

Except for that issue, I was actually getting excited about the job. Still am hopeful it can magically work out. Bcs otherwise I’m stuck in the golden cage of my current gig.

I have another question , can anyone convince me that locums is the best way forward then? Considering freedom of scheduling and control over your life and finances to be a priority?

A lot of places will let you block out a longer period of time if you're able to swap shifts with a colleague. For example if you swap with several people to cover one of your 7-day on stretches you could have 21 days off in a row. But of course would need to make it up by working extra during other parts of the year.

 

[collegestud2013]

I’ve never done locums, but it sounds terrible. Half the struggle of a new place to figuring out the tiny nuances of how things are done differently at different institutions. At my institution, I call the trauma surgeons for the general surgery work. We never use nitroglycerin drips outside of the ICU, but ok for diltiazem or amiodarone drips. There are 4 cardiology services.

It just sounds like a total pain in the ass. You then add on variable nursing abilities and expectations, and that places can’t get full time coverage for a reason usually. It isn’t always because the locations isn’t a major city.

Definitely common for locums, though also possible to see some hospitalists with PRN contracts with multiple local hospital systems (and paid on 1099 basis), so they don't have to travel very far and end up staying with a system they are familiar with. They can pick the shifts that fit their schedule as long they're available. Of course the downside is these don't pay quite as well as doing locums in a more rural area, and you're not guaranteed any number of shifts (and shifts tend to open up only when there's turnover of full time hospitalists, when there's a surge of patient census, or if someone is sick or on maternity leave).