The Nocturnist Guide You Never Wanted But Are Getting Anyway. Also, like, AMA? I guess? If you really feel like it? Compliment compliment question?

tantacles

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Hey, all. I started a couple of weeks ago as a nocturnist at a community hospital in a large city, and for my own sake, I think it's important that I reflect upon the experiences that I've had. Everyone from my residency program is super tired of hearing about how much better nights are than days, so it's probably better for me to post my feelings here. At the click of a button, I can be ignored, which is probably best for some people.

My Background

Just for context. I did medical school at a low tier school in the midwest, and followed up with med-peds residency at a large academic center in the midwest. In retrospect, residency was an awful experience (no Stockholm Syndrome for me, thanks. I already ate.), but I got amazing training and loved my coworkers.

I was initially and still am interested in GI, but I now have no interest in doing fellowship as being a specialist is less important to me than living my best life now that I'm done with training. I didn't have the patience for any further delayed gratification. I ultimately decided to do only adult hospitalist medicine as I had no interest in doing a pediatric hospital medicine fellowship, which I consider to be a huge scam given the strength of my training and the fact that pediatric generalists tend to independently manage fewer problems rather than more (consult nephrology for just about all hypertension, for example) when compared to their adult hospitalist counterparts, and the focus in pediatrics skews more towards neonates, which I find cute but uninteresting, and the complex care population, which I am flatly not interested in anymore.

I ultimately elected to do nights for a few reasons. First, they pay better, and you work fewer shifts. Second, it is extremely rare that I am dealing with any social issues that are impeding discharge, meaning I can focus completely on providing excellent medical care. Third, all of the administrators are out of the hospital, meaning that I can do my job without worrying excessively about mundane frustrations like "Let's get all discharges done by 10 am" or "John doesn't have a ride. Can he stay until tomorrow?" or "This patient needs a prior auth for his necessary medication. Please get it done ASAP instead of helping your patients who actually need intervention today!"

My Job Specifics

My primary job is at an 80 bed hospital. I cover both the wards and the ICU, although there is an NP also covering the ICU who is expected to put in all orders and independently care for patients and go over the plan with me for any new patients or any acutely decompensating patients overnight. In terms of shifts, my 1.0 full time job consists of 10 night shifts per month. Compensation is in the 240,000-250,000 range when including billing.

I also have picked up several per-diem positions at other hospitals in my area, but I have not started working at any of them yet, so I don't have anything to say about them. Once my positions there actually start, I'll likely post an update with more tips. Plus, I'm only two weeks out, so I'm sure I'll have more to say 6 months and a year in.

But before I get to the important part of this post, let me just say the last two weeks were awesome. I worked 11 night shifts in 14 days, and I'm super happy with my job. I also just started a stretch of 2.5 weeks off, which feels amazing.

So here's the meat! The tips. The skinny. The Tea.

BEFORE you accept your job:

1. Find out what the nighttime duties are.

Do you have to cover the ICU? Is there any help at night if you get 10 admissions? What is the average number of admissions? How much cross cover is there? If you have to leave a couple of admissions for the morning team, how will that go down? How many nights are expected per month? Does the nocturnist do all procedures at night? Do they run codes? If a code happens, who intubates? These are all questions that should be ironed out before you accept your position. There are myriad more questions you should ask, but these are some of the more important ones.

2. Make sure your pay is appropriate.

Night shifts should, on average, pay about 1.5 times what a day person is being paid. If you have a friend who works where you're going, don't be shy about politely asking them if they can discreetly discuss salary and number of nights worked with you so that you can make sure the offer you are getting is appropriate. Harder to assess if you don't have a connection. My work's arrangement is that my base pay is the same as the day workers (they were transparent about this), but I work 2/3 the number of shifts as they day people (I do 120 per year and they do 180), and that makes sense for me as I can accept more work or not depending on how I feel.

3. Find out who makes the schedule and tell them what you need.

This may end up being something you do after you get your job, but I would at least ask what the night schedule looks like. I'm sure it works for some, but for me, I prefer not to do more than 3 nights at a time at this point. 4 would probably be ok occasionally in a scheduling crunch, and 5 perhaps to cover for a holiday or something. I have seen, however, some nocturnist jobs that are 7 on/7 off, and that kind of schedule just isn't sustainable for most people. So that should definitely be something you try to negotiate beforehand if possible. If someone who is not a nocturnist makes the schedule, you could even offer to take over some of the night scheduling if that's something you're interested in. Just realize that there is an advantage to being the only nocturnist at a specific shop as you'll likely have first priority over scheduling your shifts.

My suggestion is to try to get your shifts clumped into blocks. I, for example, generally work all of my shifts in a month over 14 days and then have the rest of the month off to decompress or take more work if I so please.

And then, once you start working:

1. Switch over your sleep schedule immediately

Sorry, but you're not going to get away with being awake during the day during a stretch of nights. Not only will it be difficult to switch back and forth, but if you're doing cross cover and admitting, switching between tasks can be incredibly taxing, and you need to be fully awake to provide effective care. And on that note:

2. Take every cross cover call seriously. Even the dumb ones. And pick your battles.

Part of being good at nights is getting the nursing staff to trust you. The best way to do that is to listen carefully when someone calls you. If what they are asking for is a reasonable request, put in an order. There is little point to fighting a nurse who asks for a sitter for a patient who has delirium, for example. If they don't need that sitter in the morning, the day team can take out the order (until they need a sitter the next night, of course).

And if there is something that you have to say no to, take a moment to explain yourself, and ask the nurse politely if they would pass it on to the day nurse. There's no need to make anyone feel bad. Most nurses are calling you because they have a concern about the patient, and they don't know if their concern can wait. The reason they don't know that their non-urgent concern can wait is that a nurse from the day shift, a physician, or an administrator (restraint order renewals? Come on.) probably yelled at them about not addressing something, and they adopted a personal policy that they just call.

3. Seek and destroy the pages and cross cover calls from nurses BEFORE they call you.

If I have time and am not getting hit hard with admissions, every night, I will physically round on the nurses in the med-surg and telemetry units 2-3 times to check in to see if there are any concerns. Often, I'm able to address 3-4 (or more!) pending issues this way. Regardless, though, my coming around often prompts the nurses to take a moment to think about if there's anything they need to address with me, and I find 5-10 minutes after that, I get an increased batch of calls and then a 1-2 hour period of relative peace, during which time I can catch up on notes or just rest (Nintendo Switch, anyone?). From what I've seen, most nurses appreciate this approach as they feel as if I care about their concerns, and this allows me to have more credibility when I have to say no to a nursing request or request something out of the ordinary.

4. Remember your role. Nights. And be creative if necessary.

The approach to nights has to be different than the approach for days. I consider it a big part of my job to help optimize patients' sleep to prevent delirium, help facilitate the plan of care of the day team and change the course if necessary, and allow daytime issues to remain daytime issues. One example that I am certain could stir up some controversy:

I had a patient overnight who had a hip replacement. The daytime nurses had removed the patient's foley per protocol, and the 6 hour post void residual at 9 pm was 600 mL. The nurse asked if I wanted her to straight catheterize the patient, and ultimately, I decided that replacing the foley overnight would be a wiser option. Why? Well, if we did a straight cath, I guarantee the nurse was going to bladder scan and likely straight cath the patient again at 3 am. My knowledge of people informed me that 3 am is a bad time to insert a foreign object into another human's urethra. So I instructed the nurse to place a temporary foley so the patient could sleep, and that we could remove it again at 6 am and do another voiding trial. Ultimately, I think the nurse appreciated this approach, and I felt it was ideal to just let the patient sleep. Voiding trials, in my opinion, should happen during the day.

5. Your day team will disagree with you and sometimes be annoyed with you, and that's ok!

Remember: Your job is to keep the patient's alive and to advance the plan as necessary. It is not to do the absolutely perfect thing every single second.

When someone gives you this feedback, take it, and be open to changing your practice if it happens again provided the intervention makes sense.

Kind of an embarrassing example that just happened recently: I had a markedly cachectic patient come in with C diff infection. Discharged from another hospital a week prior, didn't take his vanc, used heroin, you know. The standard stuff. Subsequent to my seeing him in the ED (which he never left prior to the end of my shift because bed issues), the patient developed marked hypoglycemia. He was still low after 2 amps of D50, and I said hey let's try another one and see if he comes up! When the day hospitalist came in the morning, I told him about the patient, and he asked if I would mind putting the patient on intravenous dextrose in addition to pushes of D50. And I was tired, so didn't really reflect on his feedback in that moment, but realized that I could have possibly changed the course of this patient's hypoglycemia had I just put him on fluids. He was still dry after 2 boluses anyway! Nothing to lose! Honestly, I think I was just tired after a long night and hadn't thought through different ways of managing this patient's hypoglycemia at 6 am, but still. Could have done better. Lifelong learning and all that (and honestly missing an easy way to improve this patient's care that made me feel stupid).


5. Recognize what you can't do

If things are really so busy that you couldn't admit every single patient assigned to you, first, recognize if this is just an issue with efficiency. However, if it isn't and there was actually just too much work for one person to do, nothing wrong with politely saying, "I worked fast and was busy all night, and I simply wasn't able to do 10/10 admissions because of the time they came." You can not do everything, and if you try to be everything to everyone, you could actually hurt a patient. Focus in on the patient you are dealing with in the moment, and take the time you need to get it right.

Well, I guess that's it for now. I'll be back. I mean, I'm always here anyway. I love nights. Happy to talk about how great they are, even when they suck.
 
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Awesome and informative post, thank you! What area of the country are you in? Also are you able to sleep at all during the night shifts? Thanks again!
 

tantacles

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Awesome and informative post, thank you! What area of the country are you in? Also are you able to sleep at all during the night shifts? Thanks again!

West coast.

And yes, occasionally, but as I alluded to, I try not to sleep on nights and truly be switched over so that I'm alert when I got that 1 call out of 50 that is actually important.

Edit: just to clarify, important in that it could significantly change the patient's course. Calls about pain are important; they are just not as important as the call about the patient with new onset dyspnea who isn't on DVT prophylaxis or the patient with new hypotension.
 
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Syndicate

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Do you feel nocturnist is something you can sustain long-term? Idk what your relationship/marital status is but do you think nocturnist, even if only 10 shifts/month, could be feasible with a full time working spouse and 1-2 young kids?
 
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West coast.

And yes, occasionally, but as I alluded to, I try not to sleep on nights and truly be switched over so that I'm alert when I got that 1 call out of 50 that is actually important.

Edit: just to clarify, important in that it could significantly change the patient's course. Calls about pain are important; they are just not as important as the call about the patient with new onset dyspnea who isn't on DVT prophylaxis or the patient with new hypotension.

That makes perfect sense. How many shifts per month will the per diem shifts add and what do you predict that will boost your salary to?
 
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tantacles

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Do you feel nocturnist is something you can sustain long-term? Idk what your relationship/marital status is but do you think nocturnist, even if only 10 shifts/month, could be feasible with a full time working spouse and 1-2 young kids?

I think I can, but who knows? I think many people find full time DAY hospitalist hard to sustain with children too. My partner is a pediatrician, and he and I plan to have children eventually. That being said, would I rather work 10 night shifts per month or 14 day shifts? I think scaling back to 10 night shifts per month will make it easier to care for my children, but no one can predict how it will go.

That being said, if my child is sick and has to stay home from school, as a nocturnist, I don't have to take any time off to make that happen, which is a huge advantage.
 
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Prehealth1011

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Sorry if you've already answered these
1) At what point of residency did you know you're not gonna pursue fellowships? I ask because for GI/Cards etc. don't you kind of have to be on top of things from day 1?
2) When did you start receiving job offers?
3) How many nocturnist shifts per month would equate to 300k/year in a closed ICU setting (i.e. no procedures, intubations, codes etc.)? Is it hard to find a closed ICU job vs open ICU?
4) Also dumb question, Is the reason why open ICU hospitalists make more because they're able to bill for the ICU stuff they're doing?

Thanks for this!
 
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chessknt

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I would add:

Assess how well staffed the day coverage is. This immediately and directly impacts you as the lone nocturnst because if the day staffing is poor and they are handing off 3-4 admits per night (yes this happened to me) and patients fall apart often during the night because they had shoddy plans in place or warning signs were ignored because their daytime providers were massively overloaded then your job is much much harder. This is much easier to do than assessing # of admits per night (which can be manipulated to look good) by simply asking providers during your interview what their census is. If its 10-15 patients great, if its 25-35 then not so great.

I tried to never hand off anything to the day people because it usually just came right back to bite me in the ass the next night in the form of x+1 pending admits (who had been on the floor out of ER for 2-4 hours).
 
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tantacles

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Sorry if you've already answered these
1) At what point of residency did you know you're not gonna pursue fellowships? I ask because for GI/Cards etc. don't you kind of have to be on top of things from day 1?
2) When did you start receiving job offers?
3) How many nocturnist shifts per month would equate to 300k/year in a closed ICU setting (i.e. no procedures, intubations, codes etc.)? Is it hard to find a closed ICU job vs open ICU?
4) Also dumb question, Is the reason why open ICU hospitalists make more because they're able to bill for the ICU stuff they're doing?

Thanks for this!

1. Near the end of my third year. I had been working on research up until that point and was just about ready to apply.

2. December of my third fourth year.

3. I don't know. I don't work in the closed ICU setting. One of the places I work at $300,000 would only be about 10 shifts per month, but they are 14 hour shifts, and that is the per diem rate and not the salaried rate, so not sure how it compares. At another it would be 12 shifts per month. Totally depends on the practice environment.

4. I don't make more for having an open ICU necessarily, and I don't know that I can say that you do at most places. I have NP coverage in my ICU, though. And my practice pools billing from all physicians, so if my personal volume is low, I don't get paid any less. You have to assess each place individually as every place does it differently.

Edit: 3rd => 4th
 
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tantacles

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I would add:

Assess how well staffed the day coverage is. This immediately and directly impacts you as the lone nocturnst because if the day staffing is poor and they are handing off 3-4 admits per night (yes this happened to me) and patients fall apart often during the night because they had shoddy plans in place or warning signs were ignored because their daytime providers were massively overloaded then your job is much much harder. This is much easier to do than assessing # of admits per night (which can be manipulated to look good) by simply asking providers during your interview what their census is. If its 10-15 patients great, if its 25-35 then not so great.

I tried to never hand off anything to the day people because it usually just came right back to bite me in the ass the next night in the form of x+1 pending admits (who had been on the floor out of ER for 2-4 hours).

I think this is a great tip. I try not to pass anything off, but I'm frankly not admitting a patient that comes after 6 am when I have an hour to assign the old patients and wrap up anything that wasn't looked at through the night.
 

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When did you start emailing hospitals for job openings? Since med peds is 4 year program, it sounds like you got your job locked in pretty early (December of year 3). I was going to wait till early next year or end of this year to start emailing hospitals (I’m a PGY3 categorical) especially since I feel like salaries are on the lower end due to covid
 

tantacles

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When did you start emailing hospitals for job openings? Since med peds is 4 year program, it sounds like you got your job locked in pretty early (December of year 3). I was going to wait till early next year or end of this year to start emailing hospitals (I’m a PGY3 categorical) especially since I feel like salaries are on the lower end due to covid

Typo. Started applying in my 4th year in September.
 
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I think I can, but who knows? I think many people find full time DAY hospitalist hard to sustain with children too. My partner is a pediatrician, and he and I plan to have children eventually. That being said, would I rather work 10 night shifts per month or 14 day shifts? I think scaling back to 10 night shifts per month will make it easier to care for my children, but no one can predict how it will go.

That being said, if my child is sick and has to stay home from school, as a nocturnist, I don't have to take any time off to make that happen, which is a huge advantage.

I would definitely work the former...

Are you responsible for codes, cross cover, and procedures?
 

JamaicanHerb

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I'm in the same boat as OP, as i started 2 weeks ago. 7 on/ 7 off, working in a beach town covering 2 hospitals with 1 NP and open ICU but with 24 hour intensivist coverage but NP covers nights and if the icu doc needs to come in they will, making more than OP. but I work more shifts so naturally i would be making more. Night 6 gets rough. I haven't gotten a real paycheck just yet though since the pay lags 2 weeks behind. I handle no codes. NP cross covers pages first and if they can't handle it it goes up the ladder to me.
 
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tantacles

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I'm in the same boat as OP, as i started 2 weeks ago. 7 on/ 7 off, working in a beach town covering 2 hospitals with 1 NP and open ICU but with 24 hour intensivist coverage but NP covers nights and if the icu doc needs to come in they will, making more than OP. but I work more shifts so naturally i would be making more. Night 6 gets rough. I haven't gotten a real paycheck just yet though since the pay lags 2 weeks behind. I handle no codes. NP cross covers pages first and if they can't handle it it goes up the ladder to me.

I just got my first paycheck last week! What a great feeling. And now I have a couple of weeks off to celebrate and get paid again for doing no work. Except board studying, I guess. Meh.
 
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boxin

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Thanks for sharing your thoughts. How long do you plan to do this gig? Some folks have said nocturnist is not a sustainable job long term.
 
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tantacles

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Thanks for sharing your thoughts. How long do you plan to do this gig? Some folks have said nocturnist is not a sustainable job long term.

I've heard many people say that myriad jobs are unsustainable. Right now, I plan to do this gig forever, but I plan to scale back to only doing my scheduled 10 shifts per month once I reach my financial goals, have children, or do something else that makes me not as interested in working so much. Personally, I find daytime medicine completely unsustainable due to the burden placed on the hospitalist, so this guy says that days are not at all sustainable long term.

But hey, honestly, I know nothing. I was sure I wanted to do fellowship before I realized I would hate my life if I did, so changing my mind is sort of just a fun routine at this point.

Ultimately, from what I've seen, it comes down to the person. And the practice environment. And the colleagues. And myriad other factors that are completely immeasurable. Anyone who generalizes and says that any given type of internal medicine job is unsustainable (or sustainable, for that matter) is overgeneralizing based on factors they can not predict and certainly can not extrapolate to all people.

My question back to you: What seems unsustainable about the job? What are people saying that concerns you? "Your job is unsustainable" is so general as to be meaningless, so I'd love to hear some more specific concerns so that I can discuss your concerns and my way of handling them. Every job has its miseries, but right now, my job is SO GOOD.
 
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JamaicanHerb

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Thanks for sharing your thoughts. How long do you plan to do this gig? Some folks have said nocturnist is not a sustainable job long term.

For me I get this look when i tell other hospitalists that I am doing nights, a look of despair. And then i mimic back what I hear on SDN about nights be unsustainable so ill probably do it for 3-5 years. But then I did days for 2 weeks training before I did nights and after 2 weeks I thought, days is unsustainable. But thats because i was just harping what i heard in SDN. The real world isn't like SDN. Most the people you meet dont care for SDN or WCI but they heard of it. Don't listen to what they say here. Don't listen to me. Just do it and figure out if its right for you, or switch to days or do the myriad of other things you can do being an physician. We made it, you are a highly skilled professional, you can do whatever you want or walk.

Now that I do nights, you'd have to pay me a higher differential to do days. But its like any job, you won't know until you do it. Most these people that say nights is unsustainable have families, I don't so I can't tell from their perspective. But either shift I can't imagine you being there for your kids anyways.
 
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boxin

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I've heard many people say that myriad jobs are unsustainable. Right now, I plan to do this gig forever, but I plan to scale back to only doing my scheduled 10 shifts per month once I reach my financial goals, have children, or do something else that makes me not as interested in working so much. Personally, I find daytime medicine completely unsustainable due to the burden placed on the hospitalist, so this guy says that days are not at all sustainable long term.

But hey, honestly, I know nothing. I was sure I wanted to do fellowship before I realized I would hate my life if I did, so changing my mind is sort of just a fun routine at this point.

Ultimately, from what I've seen, it comes down to the person. And the practice environment. And the colleagues. And myriad other factors that are completely immeasurable. Anyone who generalizes and says that any given type of internal medicine job is unsustainable (or sustainable, for that matter) is overgeneralizing based on factors they can not predict and certainly can not extrapolate to all people.

My question back to you: What seems unsustainable about the job? What are people saying that concerns you? "Your job is unsustainable" is so general as to be meaningless, so I'd love to hear some more specific concerns so that I can discuss your concerns and my way of handling them. Every job has its miseries, but right now, my job is SO GOOD.

I agree that daytime medicine especially with social issues, discharge stuff make it less attractive and night shifts is usually pure form of medicine.

I feel that what makes it unsustainable is possibly having family at some point in the future and health issues that come with working at night (sleep cycle, sure, can be fixed), heartburn, for some folks. I'm glad you really enjoy your job; at the end of the day, it's about if you enjoy it regardless of it is nights or days.
 

boxin

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For me I get this look when i tell other hospitalists that I am doing nights, a look of despair. And then i mimic back what I hear on SDN about nights be unsustainable so ill probably do it for 3-5 years. But then I did days for 2 weeks training before I did nights and after 2 weeks I thought, days is unsustainable. But thats because i was just harping what i heard in SDN. The real world isn't like SDN. Most the people you meet dont care for SDN or WCI but they heard of it. Don't listen to what they say here. Don't listen to me. Just do it and figure out if its right for you, or switch to days or do the myriad of other things you can do being an physician. We made it, you are a highly skilled professional, you can do whatever you want or walk.

Now that I do nights, you'd have to pay me a higher differential to do days. But its like any job, you won't know until you do it. Most these people that say nights is unsustainable have families, I don't so I can't tell from their perspective. But either shift I can't imagine you being there for your kids anyways.

You're right, the real world is not like SDN. Just wanted to ask people thoughts.
 

tantacles

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I agree that daytime medicine especially with social issues, discharge stuff make it less attractive and night shifts is usually pure form of medicine.

I feel that what makes it unsustainable is possibly having family at some point in the future and health issues that come with working at night (sleep cycle, sure, can be fixed), heartburn, for some folks. I'm glad you really enjoy your job; at the end of the day, it's about if you enjoy it regardless of it is nights or days.

Not sure about heartburn. Haven't experienced that one yet, but I haven't seen that associated with night shift. Granted, I haven't exactly scoured the literature.

I guess the question, though, is what about the sleep cycle is bad provided you can switch over to nights? Children typically go to school or daycare during the day if you work day shift, so why would that not be the case for night shift? And working fewer shifts actually means more time to spend with your children, not less. While my partner is working 9-5, I could sleep and then pick up the kids at 3 pm, avoiding the need for aftercare at school altogether. It's actually kind of a win.
 
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blue.jay

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I've terrible heart burn since I started nights. My sleep cycle is messed up. I've put on weight and feel like I aged 2 times older working half nights for the past 2 years. No amount of money will make me do nights, not worth dying from sickness.
 
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tantacles

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I've terrible heart burn since I started nights. My sleep cycle is messed up. I've put on weight and feel like I aged 2 times older working half nights for the past 2 years. No amount of money will make me do nights, not worth dying from sickness.

Sorry to hear that. I don't intimate that nights is for everyone, but it's definitely for me.
 

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I'm a new day attending and I gotta say the grass is definitely looking very green on the other side.... seriously, this social bs and administrative stuff is exhausting! How long did it take to get used to your role? Did you join where you trained?
 

tantacles

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I'm a new day attending and I gotta say the grass is definitely looking very green on the other side.... seriously, this social bs and administrative stuff is exhausting! How long did it take to get used to your role? Did you join where you trained?

I've only been working in this position for two months (just graduated). I feel pretty adjusted, but I did a ton of moonlighting with my residency's non-teaching hospitalist group in the months before graduating, and they basically wanted me specifically to be there because they didn't have to worry because I was essentially at attending level (2 months before the end of residency), so they were barely even looking over my orders. I love nights, so adjusting to that part was easy.

Once I figured out the system at my hospital, everything has worked better. Hospitalist cell phone sucks? Well, now I visit the ED at the beginning of my shift and make sure the attending has my cell so they can text me directly and I can call them back (which I do within 10 seconds if I'm not with a patient). Nurses call all the time? I round on the nurses frequently to catch those pages before they hit (and learned that one in residency). There are myriad other things that you just figure out if you're creative and a problem-solver.

And no, I did not sign on where I trained. I moved away and signed on somewhere else and love it much more than I would have loved working at my home program.
 
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tantacles

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For me I get this look when i tell other hospitalists that I am doing nights, a look of despair. And then i mimic back what I hear on SDN about nights be unsustainable so ill probably do it for 3-5 years. But then I did days for 2 weeks training before I did nights and after 2 weeks I thought, days is unsustainable. But thats because i was just harping what i heard in SDN. The real world isn't like SDN. Most the people you meet dont care for SDN or WCI but they heard of it. Don't listen to what they say here. Don't listen to me. Just do it and figure out if its right for you, or switch to days or do the myriad of other things you can do being an physician. We made it, you are a highly skilled professional, you can do whatever you want or walk.

Now that I do nights, you'd have to pay me a higher differential to do days. But its like any job, you won't know until you do it. Most these people that say nights is unsustainable have families, I don't so I can't tell from their perspective. But either shift I can't imagine you being there for your kids anyways.

We need a nocturnist slack or something to compare experiences.
 

jdh71

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Sorry to hear that. I don't intimate that nights is for everyone, but it's definitely for me.

You ever get tired of that west coast job, you let me know and you might like to take a look at a nocturnist position where I am in the Mountain NW. Good sized metro area. Booming right now. The hospitalists here don’t run codes. Are not expected to do procedures or intubate. And even though the ICU is “open” we take primary in basically all hospitalist patients moved into the unit with a critical care consult.

You know his the PM feature works. Just FYI.
 
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tantacles

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You ever get tired of that west coast job, you let me know and you might like to take a look at a nocturnist position where I am in the Mountain NW. Good sized metro area. Booming right now. The hospitalists here don’t run codes. Are not expected to do procedures or intubate. And even though the ICU is “open” we take primary in basically all hospitalist patients moved into the unit with a critical care consult.

You know his the PM feature works. Just FYI.

I’ll think about it. I don’t do procedures here either. The ED does any overnight procedures we need, and they’re fee for service, so they generally have no trouble intubating, LPing, and central lining our patients as needed.

And I like being the code leader!
 

tantacles

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Understood. You may find the inconvenience begins to outweigh the excitement over time.

Definitely. It’s a hospitalist’s prerogative to change his mind!

Interestingly enough, though, I don’t really find codes exciting. They’re methodical. I just recognize that I’m good at leading them and therefore enjoy it.
 
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palipad123

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Definitely. It’s a hospitalist’s prerogative to change his mind!

Interestingly enough, though, I don’t really find codes exciting. They’re methodical. I just recognize that I’m good at leading them and therefore enjoy it.
Hey thanks for doing an AMA. I am currently in the process of applying to IM residencies. One of the programs I am considering is a primary care IM residency program where we spend more time outpatient compared to inpatient. I plan on intially being a nocturnist after residency ( to pay off student loans) and then swtich to primary care outpatient ( or maybe day time hospitalist). Do you think going to a primary care IM residency program instead of a categorical program will affect my chances in getting a good job as a nocturnist or a hospitalist? Thank you for your time!
 
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Hey thanks for doing an AMA. I am currently in the process of applying to IM residencies. One of the programs I am considering is a primary care IM residency program where we spend more time outpatient compared to inpatient. I plan on intially being a nocturnist after residency ( to pay off student loans) and then swtich to primary care outpatient ( or maybe day time hospitalist). Do you think going to a primary care IM residency program instead of a categorical program will affect my chances in getting a good job as a nocturnist or a hospitalist? Thank you for your time!
Primary care and hospital medicine look like 2 different specialties (at least where I am training)...
 
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Osteoth

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Primary care and hospital medicine look like 2 different specialties (at least where I am training)...

People switch, some people do both. Best thing about IM is the flexibility and versatility.
 
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tantacles

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Hey thanks for doing an AMA. I am currently in the process of applying to IM residencies. One of the programs I am considering is a primary care IM residency program where we spend more time outpatient compared to inpatient. I plan on intially being a nocturnist after residency ( to pay off student loans) and then swtich to primary care outpatient ( or maybe day time hospitalist). Do you think going to a primary care IM residency program instead of a categorical program will affect my chances in getting a good job as a nocturnist or a hospitalist? Thank you for your time!

I don't think this will affect your job prospects at all. Internal medicine residency prepares you for both primary care and hospitalist work.
 

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Hey thanks for doing an AMA. I am currently in the process of applying to IM residencies. One of the programs I am considering is a primary care IM residency program where we spend more time outpatient compared to inpatient. I plan on intially being a nocturnist after residency ( to pay off student loans) and then swtich to primary care outpatient ( or maybe day time hospitalist). Do you think going to a primary care IM residency program instead of a categorical program will affect my chances in getting a good job as a nocturnist or a hospitalist? Thank you for your time!

I can second this, being someone who now interviews people and is involved in the hiring process for hospitalists/nocturnists. No it won't affect your prospects lol. The chief of hospitalists at NYU graduated from the primary care program.
 

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I dont know exactly what I want to do yet but does it matter university program vs community program when looking for work. I am at university program and I know we have a shortage of pretty much any doctor where I am but just wondering.
 

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I dont know exactly what I want to do yet but does it matter university program vs community program when looking for work. I am at university program and I know we have a shortage of pretty much any doctor where I am but just wondering.
If you want to be a nocturnist, it almost definitely does not matter where you train.
 
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tantacles

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Actual update!

Ok, so it's been 6 months since I started working as a nocturnist. The verdict?

I love it.

I mentioned in my initial post that I had picked up some part time work with other hospitals in the area. I work for two large hospital systems at a total of 7 sites now. I've upped my total number of shifts to about 20/month. In the month of January, my gross income was $60,000, but that is an outlier. my income with 10 shifts at my main hospital and 8-10 shifts at other hospitals comes out to about $40,000/month, but January was just special for a number of reasons involving some shift swaps allowing me to work minimal shifts at my main squeeze and extra at the per diem place I work at that costs more.

For me, working at multiple different places is excellent. Routine is cool, I suppose, but having a different practice environment every week invigorates me. I've also learned multiple different medical systems and am getting more insight into why different places manage different conditions, well, differently.

Shift lengths also vary. Some places have 10 hour nights (HATE), some 12, and some 14. My personal view is that if you're going to work a night shift, your night is ruined anyway, so you might as well work a longer night shift, particularly if you're paid hourly, which I am at my side gig(s).

Also remember that if you look for it, there are nonclinical opportunities that will allow you to work from home or work non-clinically. State medical boards, consulting companies, and myriad other places need doctors but don't know where to find them. So network! Talk to people. ask if people know of any non-clinical work.

And most of all, remember that if you are a night person, you are in power. No one wants to work nights, and this makes contract negotiation much easier.

Happy job hunting, all.

I'll update again possibly in six months, but continue asking questions!
 
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Cath Up

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Great thread, thank you for taking the time to write it. This may be better asked in other specialty forums, but since this is specifically about nocturnists- are nocturnist positions in other specialties common, with a similar set of practice benefits (<social issues, >pay)? For example psych, EM, gas?
 

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Great thread, thank you for taking the time to write it. This may be better asked in other specialty forums, but since this is specifically about nocturnists- are nocturnist positions in other specialties common, with a similar set of practice benefits (<social issues, >pay)? For example psych, EM, gas?

Certainly in EM, though I don't think the social issues part changes. Psych probably less so, while there are psychiatric emergency departments that require 24/7 psych coverage most of them are in academic institutions staffed mostly by residents and even the ones that aren't can't offer the same salary that a private practice psychiatrist could generate doing normal daytime office psychiatry. Most people don't want to have their SSRIs adjusted at 3am, and in places without psych EDs the normal EM doctors babysit psych patients until the morning.

Gas I have no idea, on one hand any big hospital needs anesthesia in house 24/7, but on the other I don't know how common the shift work model is in gas. Not really a specialty bogged down by social issues at any time of the day though.

Pulm crit/critical care can do nocturnist, very similar setup to IM hospitalist except in the ICU. I don't know if any other medical subspecialties have a nocturnist model. Peds hospitalist/critical care have nocturnists but obviously lower salary than adults, plus whatever hospitalist fellowship nonsense they currently have going on.

While trauma and acute care surgery require overnight coverage, I don't know if you'd get enough operative experience to make purely nights a good idea.

I'm in IM though, so if anyone from these specialties corrects me than I'd believe them over me.
 
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Cath Up

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Certainly in EM, though I don't think the social issues part changes. Psych probably less so, while there are psychiatric emergency departments that require 24/7 psych coverage most of them are in academic institutions staffed mostly by residents and even the ones that aren't can't offer the same salary that a private practice psychiatrist could generate doing normal daytime office psychiatry. Most people don't want to have their SSRIs adjusted at 3am, and in places without psych EDs the normal EM doctors babysit psych patients until the morning.

Gas I have no idea, on one hand any big hospital needs anesthesia in house 24/7, but on the other I don't know how common the shift work model is in gas. Not really a specialty bogged down by social issues at any time of the day though.

Pulm crit/critical care can do nocturnist, very similar setup to IM hospitalist except in the ICU. I don't know if any other medical subspecialties have a nocturnist model. Peds hospitalist/critical care have nocturnists but obviously lower salary than adults, plus whatever hospitalist fellowship nonsense they currently have going on.

While trauma and acute care surgery require overnight coverage, I don't know if you'd get enough operative experience to make purely nights a good idea.

I'm in IM though, so if anyone from these specialties corrects me than I'd believe them over me.
I appreciate the rundown, thank you!!
 

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If a chronic trach with a COPD exacerbation on 40% fio2 gets admitted to the floor is the correct answer to cry about it to the pulmonary and critical care guy at 1am?

Asking for a friend.
 

tantacles

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Great thread, thank you for taking the time to write it. This may be better asked in other specialty forums, but since this is specifically about nocturnists- are nocturnist positions in other specialties common, with a similar set of practice benefits (<social issues, >pay)? For example psych, EM, gas?
I'm sure they exist, but I haven't seen them in most specialties. Definitely exists for intensivists and EM physicians, though! And I bet you could negotiate something with regard to taking night call with many specialties. People HATE nights.

Edit: And pediatric hospitalists, but **** that PHM fellowship scam.

You are in the Midwest?
West coast.
If a chronic trach with a COPD exacerbation on 40% fio2 gets admitted to the floor is the correct answer to cry about it to the pulmonary and critical care guy at 1am?

Asking for a friend.
Baby, I don't cry. I had my tear ducts removed.
 
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Gonzalo de Montalvo

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Thanks for the thread! I see you've mentioned financial goals a couple times, so if I may ask, are you pursuing financial independence (FI) or FIRE (retire early)? I will have an insane amount of debt after DO school/residency considering compounding interest (we're talking like ~500k), and as someone interested in personal finances and FI it just drives me up the wall.

So I guess I just wanted to say I aspire to do what you're doing (hospitalist/nocturnist + per diems/locums, etc) and feel like you're someone that I hope to be like when I'm an attending (just an M1 here, so...). I'd like to think I can pay off my loans and build a sizeable nest egg within a few years of graduating residency and from your posts it seems like I could do what I imagine. Any thoughts on all this? Suppose you were hell bent on earning 500k after tax, what would that look like and how long would it take?

All money aside I think what you're doing just sounds like a blast, a dream. I occasionally still toss around the idea of going into surgery but I know deep down money might be a confounding factor in my interest there--I'm a little more cerebrally oriented, and I came to med school for primary care specialties and love the idea of working countless hours in the hospital, rounding, etc. I just want to be a doctor's doctor internist, 3 year residency get in-and-out, do maybe a little outpatient mixed in as an attending, oh, and swim through money like scrooge mcduck. Thanks again for the post.
 

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Thanks for the thread! I see you've mentioned financial goals a couple times, so if I may ask, are you pursuing financial independence (FI) or FIRE (retire early)? I will have an insane amount of debt after DO school/residency considering compounding interest (we're talking like ~500k), and as someone interested in personal finances and FI it just drives me up the wall.

So I guess I just wanted to say I aspire to do what you're doing (hospitalist/nocturnist + per diems/locums, etc) and feel like you're someone that I hope to be like when I'm an attending (just an M1 here, so...). I'd like to think I can pay off my loans and build a sizeable nest egg within a few years of graduating residency and from your posts it seems like I could do what I imagine. Any thoughts on all this? Suppose you were hell bent on earning 500k after tax, what would that look like and how long would it take?

All money aside I think what you're doing just sounds like a blast, a dream. I occasionally still toss around the idea of going into surgery but I know deep down money might be a confounding factor in my interest there--I'm a little more cerebrally oriented, and I came to med school for primary care specialties and love the idea of working countless hours in the hospital, rounding, etc. I just want to be a doctor's doctor internist, 3 year residency get in-and-out, do maybe a little outpatient mixed in as an attending, oh, and swim through money like scrooge mcduck. Thanks again for the post.
According to the FM forum, it‘s possible to make $500k as a PCP or hospitalist/nocturnist. Not sure if it’s “probable” (depends how representative you think SDN is), but it’s “possible.” For example, these threads are just from last year 2020:


 
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tantacles

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Thanks for the thread! I see you've mentioned financial goals a couple times, so if I may ask, are you pursuing financial independence (FI) or FIRE (retire early)? I will have an insane amount of debt after DO school/residency considering compounding interest (we're talking like ~500k), and as someone interested in personal finances and FI it just drives me up the wall.

So I guess I just wanted to say I aspire to do what you're doing (hospitalist/nocturnist + per diems/locums, etc) and feel like you're someone that I hope to be like when I'm an attending (just an M1 here, so...). I'd like to think I can pay off my loans and build a sizeable nest egg within a few years of graduating residency and from your posts it seems like I could do what I imagine. Any thoughts on all this? Suppose you were hell bent on earning 500k after tax, what would that look like and how long would it take?

All money aside I think what you're doing just sounds like a blast, a dream. I occasionally still toss around the idea of going into surgery but I know deep down money might be a confounding factor in my interest there--I'm a little more cerebrally oriented, and I came to med school for primary care specialties and love the idea of working countless hours in the hospital, rounding, etc. I just want to be a doctor's doctor internist, 3 year residency get in-and-out, do maybe a little outpatient mixed in as an attending, oh, and swim through money like scrooge mcduck. Thanks again for the post.
Absolutely planning for fatFIRE, though more interested in the FI than the RE. I love my job and even if I am financially independent will want to scale back at some point. Edit: but probably not retire.

Making $500k after taxes will be very difficult, though I'm sure it's possible. @wamcp is the master of W2 income from my perspective, and if I remember correctly he hit 600K post-tax (is that right?) working like a dog. I will be hitting around $500k this year in W2 + 1099 earnings. To get to 500k/year, I end up working 19-20 night shifts per month. To make $600k pretax, I would likely have to work 23-24ish night shifts per month. 600K after tax from W2 alone? Almost impossible in my situation.

Your goals are not unreasonable, and if you love work, there is generally no shortage of need for hospitalists.
 
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tantacles

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According to the FM forum, it‘s possible to make $500k as a PCP or hospitalist/nocturnist. Not sure if it’s “probable” (depends how representative you think SDN is), but it’s “possible.” For example, these threads are just from last year 2020:



Yeah, I make $500k pre-tax, but that's working 19-20 shifts per month.
 
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