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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.
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.
