Nocturnist Job change, what can I do?

[ItsDistended]

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So I accepted a nocturnist position about a year ago at a small rural hospital. It was a really good job at first it was a 30 bed hospital with a hard cap on admissions. I had worked there PRN previously and for literally years night shift was 0-3 admits with 30 bed cross cover. it was dreamy. and this was the job I accepted with a 2 year contract. There are 2 day rounders as well. I moved to a new state for the job. 6 months into my contract the main ortho doc leaves and so they lose a ton of elective ortho admits and instead replace them wtih ER admits. It was a big shift in the patient population from elective ortho cases with good health to ER crackheads and decompensating cirrhotics. Starting at about 6 months with the departure of the surgeon my job description suddenly changed to consistently ER 4-5 admits nightly and still 30 bed cross cover. Still a good gig in my eyes. The er typically just admits non stop until we are capped so I finish my admits around 11-12 and lie down and can still get on a good night 3-4 hours sleep. My contract is for ~300k base pay with potential RVU if I admit over like 10 admits a night, so no RVU bonus. The nocturnist has never since I worked there ever come close to approaching the 4300 RVUs necessary to generate any kind of bonus and I told administration that if the nocturnist is admitting that many patients on a shift it is no longer a good nocturnist position and I wouldnt be interested in that scenario. When I started I never was told I would have to do 7on 7 off either and I have requested multiple times to not have more than 4 in a row and was told that because the other night doc wants 7on/7off I kind of have to also work that schedule. 7on 7off is fine when you can still get 3-4 hours of sleep a night. My shifts are 7p -7am and I have to work 12 per month for 1.0 fte nocturnist as opposed to the day docs who work 14 days and like 1 night per month. But the day docs are making at least 400K as they have higher census but a fair amount of mundane ortho consults during the day that are easy RVU generators.
It was announced last month that the hospital is opening two new wings and expanding the census to around 40-45 from 32. They are opening more ICU beds as well. They are hiring a new daytime hospitalist so they will have 3 days docs covering around 40-45 beds(not certain yet). I assume there will still be a cap but Im very worried that with the new expansion my nights are going to completely change. If the day team is capped that averages around 13-14 patients per doc which in my experience is super easy. I worry if each doc discharges 3-4 pts per day and the ER just calls until I have to tell them we are capped they are going to push me to admit like 10+ patients each night. This hospital is part of a large corporate system and it is the only outlier in that it is far out in the rural areas where they cant get docs often but the other hospitals they abuse their night docs and chronically have night jobs available from just hiring and chewing through nocturnists.
Im going to look at my contract and see if my job description specifically notes that I am covering a 32 bed hospital and can argue that opening up two new wings constitutes a change in my contract. I signed up for 2 years of this and frankly if my job goes from admitting 0-3 patients per night with 30 bed cross cover, and that was what was sold to me and now im being asked to cover 33% more beds and admit 3-4x as many patients im not really okay with that level of stress. Thats not a sustainable job. would leaving be a breach of contract typically? Have other people encountered this? Am I being unrealistic in thinking admitting 8-10 per night is starting to be a sucky job with cross cover? And all the while being forced to work 7on 7off 12 hour shifts at night?

 

[ItsDistended]

also the hospital has open ICU with me being the only doc aside from the er doc in house at night. I dont do procedures but am responsible for ICU, codes, RRT. General surgery is on call but essentially dumps on me to do even their most basic lap chole admits at night, same with GI and ortho. they have no cardiology or really any subspeciality support (aside from a higly money oriented gastroenterologist) but are pushing us to admit sicker and sicker "general medical patients".

 

[anonperson]

also the hospital has open ICU with me being the only doc aside from the er doc in house at night. I dont do procedures but am responsible for ICU, codes, RRT. General surgery is on call but essentially dumps on me to do even their most basic lap chole admits at night, same with GI and ortho. they have no cardiology or really any subspeciality support (aside from a higly money oriented gastroenterologist) but are pushing us to admit sicker and sicker "general medical patients".

You work nights

You make less than the day time physicians

You have to cover the unit with minimal support

Strike 1
Strike 2
Strike 3

Regarding leaving, your contract will list those terms. It is typically listed under the section on leaving with or without cause.

Usually there is a notification period of anywhere from 30 to 90 days.

 

[ItsDistended]

You work nights

You make less than the day time physicians

You have to cover the unit with minimal support

Strike 1
Strike 2
Strike 3

Regarding leaving, your contract will list those terms. It is typically listed under the section on leaving with or without cause.

Usually there is a notification period of anywhere from 30 to 90 days.

when I took the job it was literally 0-3 admits nightly with minimal cross cover. I remember the site lead asked me if I was going to get a day job to keep me busy. I made a case that regardless of how busy nights are I shouldnt be making 50-100k less than the day team to be up a good chunk fo the nights. They refused to budge saying they have the same RVU structure for all their nocturnists.
If it was still 0-3 admits would you still feel it is a poor job? I was at times getting 5-5.5 hours sleep at night the first months there before the ortho surgeon left. Now it is very, very different. fighting with the ER about why I cant take the decompensating cirrhotic patient with a sodium of 114 on 2 pressors in renal failure at a hospital that has almost no critical care during the day, no nephro, nothing except a gi doc who will scope anything with a pulse and then run the other way.

 

[ItsDistended]

You work nights

You make less than the day time physicians

You have to cover the unit with minimal support

Strike 1
Strike 2
Strike 3

Regarding leaving, your contract will list those terms. It is typically listed under the section on leaving with or without cause.

Usually there is a notification period of anywhere from 30 to 90 days.

would the change in the workload and opening new wings constitute a breach of contract for cause?

 

[dozitgetchahi]

would the change in the workload and opening new wings constitute a breach of contract for cause?

Depends on what your contract says.

If your contract defines a specific workload (number of patients admitted, number of beds cross covered, etc etc) and they just exceeded that, then yes, maybe.

My guess is that it probably doesn’t.

Look at your contract and see what (if any) penalties are there for leaving. Virtually every contract is going to have an “out”, usually with something like 90 days notice. There may or may not be a “penalty” for this (they may not cover your tail if you leave before a certain time, or you may have to pay back part of a sign on bonus, or whatever).

EDIT: also, what kind of hospital pays the hospitalists working nights *less* than the daytime docs? Wtf? That alone is reason to leave.

 

[anonperson]

when I took the job it was literally 0-3 admits nightly with minimal cross cover. I remember the site lead asked me if I was going to get a day job to keep me busy. I made a case that regardless of how busy nights are I shouldnt be making 50-100k less than the day team to be up a good chunk fo the nights. They refused to budge saying they have the same RVU structure for all their nocturnists.
If it was still 0-3 admits would you still feel it is a poor job? I was at times getting 5-5.5 hours sleep at night the first months there before the ortho surgeon left. Now it is very, very different. fighting with the ER about why I cant take the decompensating cirrhotic patient with a sodium of 114 on 2 pressors in renal failure at a hospital that has almost no critical care during the day, no nephro, nothing except a gi doc who will scope anything with a pulse and then run the other way.

Night shift work is associated with an increased risk of heart attack, stroke, and cancer.

That is worth a significant premium in my eyes.

Just a mild disruption in your circadian rhythm is enough to cause issues.

I used to do 24 hour shifts as an OB GYN but my employer completely devalued the call work which was significant. I left that job and haven't looked back. More and more physicians are doing the same.

 

[ItsDistended]

EDIT: also, what kind of hospital pays the hospitalists working nights *less* than the daytime docs? Wtf? No shift differential? That alone is reason to leave.

I work 12 nights instead of the day teams 15 shifts so they call that a differential. We all make the same base pay, its just that days easily make more RVUs so they are making a nice big bonus while nights are less busy and we arent nuts about billing cross cover so we never meet the threshold. I agree completely its not okay that I am making 50-100k less, I was okay with it when I could get 4-5 hours sleep but now that nights are much more busy it feels like we are being treated as less valuable members of the team.

I was thinking of a funny analogy and thought it would be like asking surgeons taking night call to perform elective surgeries and have booked overnight ORs while on night call to generate RVUs to ensure they are "earning their keep" like the surgeons working the days. it sounds ridiculous that night docs should be paid on the same model of generating RVUs. admitting patients is only half of what we do its as though covering the hospital isnt a valuable service.

 

[dozitgetchahi]

I work 12 nights instead of the day teams 15 shifts so they call that a differential. We all make the same base pay, its just that days easily make more RVUs so they are making a nice big bonus while nights are less busy and we arent nuts about billing cross cover so we never meet the threshold. I agree completely its not okay that I am making 50-100k less, I was okay with it when I could get 4-5 hours sleep but now that nights are much more busy it feels like we are being treated as less valuable members of the team.

I was thinking of a funny analogy and thought it would be like asking surgeons taking night call to perform elective surgeries and have booked overnight ORs while on night call to generate RVUs to ensure they are "earning their keep" like the surgeons working the days. it sounds ridiculous that night docs should be paid on the same model of generating RVUs. admitting patients is only half of what we do its as though covering the hospital isnt a valuable service.

This is nuts. Just leave this job.

 

[collegestud2013]

I work 12 nights instead of the day teams 15 shifts so they call that a differential. We all make the same base pay, its just that days easily make more RVUs so they are making a nice big bonus while nights are less busy and we arent nuts about billing cross cover so we never meet the threshold. I agree completely its not okay that I am making 50-100k less, I was okay with it when I could get 4-5 hours sleep but now that nights are much more busy it feels like we are being treated as less valuable members of the team.

I was thinking of a funny analogy and thought it would be like asking surgeons taking night call to perform elective surgeries and have booked overnight ORs while on night call to generate RVUs to ensure they are "earning their keep" like the surgeons working the days. it sounds ridiculous that night docs should be paid on the same model of generating RVUs. admitting patients is only half of what we do its as though covering the hospital isnt a valuable service.

With the new volumes you are describing, it's probably still minimally doable for single coverage, though not cush like before and not be sustainable in the long run. Regardless, with these volumes you should at least have 1 PA or NP with you at night to help with cross coverage and some of the admissions. Otherwise agree that it was not be sustainable for very long for any nocturnist and there will just be a lot of turnover. Also, low $300ks is low for full-time nocturnist pay; with 12 twelve-hour shifts per month, that comes out to ~$174 per hour which is a bit low for nocturnist pay in 2024. And especially low considering it's a single coverage at a rural hospital that, as expected, has a hard time recruiting nocturnists.

As for the daytime hospitalists making close to $400k, would have to look at the volumes they're seeing to make that amount. It their base is the same $300k as you, to make an extra $100k in RVUs would likely involve seeing a lot of volume (though would depend on the specific RVU structure) and likely working extra shifts on addition to the 15 per month, so it may not be a good of a deal as it seems for them once you count the total number of hours they are working.

I would only stay if they can either raise your base pay or lower the RVU threshold, AND they get you a PA/NP to help at night. Nocturnists who are paid based on RVUs should not have the same RVU threshold as daytime docs, as it will be harder to reach the threshold not only because you are working less shifts per month, but with the new wRVU weights by CMS that started in 2023, H&Ps are now worth less than before while follow-ups and discharges are worth more wRVUs. To reach 4300 wRVUs per year doing 12 shifts per month, with the current Level 3 H&P (the most commonly billed level for H&Ps) being worth 3.50 wRUVs, you would need to average 8.5-9 admissions per night just to reach the threshold. Cross coverage work at night unfortunately is one of those things that hospitals often don't value as it is seem as a necessary business expense keep the hospital running (but does not generate any additional money or RVUs in the majority of cases).
They probably didn't breach your contract unless they wrote a hard cap in your contract to begin with. Most hospitalist contracts won't have these hard caps so the facility has more flexibility when the census fluctuates.

In theory, you should have a good amount of leverage considering nocturnist in a rural hospital will not be easy to recruit. Of course it's possible that admin still won't care.

 

[ItsDistended]

With the new volumes you are describing, it's probably still minimally doable for single coverage, though not cush like before and not be sustainable in the long run. Regardless, with these volumes you should at least have 1 PA or NP with you at night to help with cross coverage and some of the admissions. Otherwise agree that it was not be sustainable for very long for any nocturnist and there will just be a lot of turnover. Also, low $300ks is low for full-time nocturnist pay; with 12 twelve-hour shifts per month, that comes out to ~$174 per hour which is a bit low for nocturnist pay in 2024. And especially low considering it's a single coverage at a rural hospital that, as expected, has a hard time recruiting nocturnists.

As for the daytime hospitalists making close to $400k, would have to look at the volumes they're seeing to make that amount. It their base is the same $300k as you, to make an extra $100k in RVUs would likely involve seeing a lot of volume (though would depend on the specific RVU structure) and likely working extra shifts on addition to the 15 per month, so it may not be a good of a deal as it seems for them once you count the total number of hours they are working.

I would only stay if they can either raise your base pay or lower the RVU threshold, AND they get you a PA/NP to help at night. Nocturnists who are paid based on RVUs should not have the same RVU threshold as daytime docs, as it will be harder to reach the threshold not only because you are working less shifts per month, but with the new wRVU weights by CMS that started in 2023, H&Ps are now worth less than before while follow-ups and discharges are worth more wRVUs. To reach 4300 wRVUs per year doing 12 shifts per month, with the current Level 3 H&P (the most commonly billed level for H&Ps) being worth 3.50 wRUVs, you would need to average 8.5-9 admissions per night just to reach the threshold. Cross coverage work at night unfortunately is one of those things that hospitals often don't value as it is seem as a necessary business expense keep the hospital running (but does not generate any additional money or RVUs in the majority of cases).
They probably didn't breach your contract unless they wrote a hard cap in your contract to begin with. Most hospitalist contracts won't have these hard caps so the facility has more flexibility when the census fluctuates.

In theory, you should have a good amount of leverage considering nocturnist in a rural hospital will not be easy to recruit. Of course it's possible that admin still won't care.

the day team does a lot of elective ortho consults to generate and fluff the RVUs. probably 3 per doc per day, mon-fri. At my old job those were covered by our PA solely. The day team have a higher threshold to generate a bonus but the issue I expressed is even the lower RVU threshold for night docs has never been enough for any nocturnist to actually get a bonus in the last 7 years, so they are creating an artificially high RVU threshold that they know the night docs will never reach. It didnt bother me when I was doing 0-3 admits nightly and getting maybe 10-15 cross cover calls a night and could often get some good sleep, but thats all changed now. Frankly if I started admitting the numbers needed to hit my RVU to bonus it would be a terrible, awful, unsustainable job for even a short time. Meanwhile the day team can easily hit thresholds and leave on time. I maintain that a "good" nocturnist job is one that ANY hospitalist would be able and willing to do long term, not one that admin pretends is good only because the nocturnist is some kind of vampire workhorse or something, and I honestly dont think such a thing currently exists. anywhere.

 

[glorifiedresident]

Well it was fun while the party lasted. Only you can decide if it's worth sticking around.

 

[tantacles]

Eyyyyy lookie there! Another hospital decides to screw over its nocturnists. Surprise, surprise!

 

[dozitgetchahi]

Eyyyyy lookie there! Another hospital decides to screw over its nocturnists. Surprise, surprise!

Yep.

I’ve always heard that one of the selling points of nocturnist work is the fact that you don’t have to deal with admin or the other daytime BS (rounding with pharmacist/social work/etc etc). However, the flip side is that the folks working the nighttime hours are largely going to be invisible to admin and everyone else at the hospital. Admin etc is always going to care more for the people there during the day that they interact with (daytime hospitalists) vs nocturnists.

I have several family members who are nurses who work nights, and they say it’s the same dynamic. They’re invisible to admin.

 

[ReviewOfSystems]

Career nocturnist. Turn in your notice now. Dont pass go. I feel like I could have written this same post a few years ago. Your first mistake was accepting less money than the day shift. They sell you one thing and all bright eyed and bushy tailed you accept. But if it sounds too good to be true, it is. Night admits are going to increase. Cross cover will increase. More patients and sicker means more codes/rapids and thus more ICU patients or even transfers that you guessed it- are your responsiblity. One of the admits that comes after the cap is going to have a critical event, then they will eliminate the cap. Then they will force you to do 7 on and threaten your job if you dont comply. And still no RVU/bonus for more work. Your contract will not protect you from any of this.

 

[Entadus]

Amazing that you would continue to accept this abuse. Walk away and don't look back.