What to ask for in a nocturnist contract?

[doctayj]

I'm a relatively new residency grad (IM) and have been a full time nocturnist at a community hospital in a small city for the last year. I'm trying to make adjustments for my contract renewal but don't know many full-time nocturnists so am not sure what to ask for or if I am asking too much.

I'm typically doing 10+ admissions in my 12 hour shift (and have done up to 15). There's an open ICU so I intubate around 1-2x monthly. Cross cover census is 60s to 70s but in the winter up to 90s. I'm solo at night, no other physicians or NPs. I can call critical care in if I'm in a bind but they cover multiple hospitals in town so I try to avoid it.

I'm paid hourly at 175/hour with no RVU or quality incentives. The only other nocturnists are locum and are paid 200/hour. They have been working here for years because it is hard to hire full time nocturnists. I've asked for a pay increase to 200/hour to match what the locum physicians are getting or adding RVU incentives. None of the locum docs intubate and from what I gather from other staff I'm doing a much more thorough job. Initially admin said no to the pay increase but I've persisted in asking because I don't think it is unreasonable for the amount of work I'm doing.

Is 200/hour asking too much? What else should I ask for in the contract?

Thanks in advance.

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[PugsAndHugs]

10+ admissions, cross covering 60-70 patients, AND intubating? How is this all even possible in a span of 12 hours… Something doesn’t add up. If you somehow are doing all of these things, you deserve way more than $175/hr

 

[BicepsTriceps]

10+ admissions, ICU coverage, small town, community hospital.

My man you should be making $2500 a night minimum.

Put your notice and have them hire you as locum.

Also stop intubating. Who's intubating when the locums are here? ED? Have them do it when you're here too.

 

[emergentmd]

If docs who don't care, do less, less efficient is making $200/hr, you should be making $250/hr.

You do a better job, more efficient, part of the medical staff, work more shifts, etc.

Its a slap in the face when you are doing a better job and getting paid less. Threaten them to leave, and they will give you more than $200/hr.

 

[anonperson]

I'm a relatively new residency grad (IM) and have been a full time nocturnist at a community hospital in a small city for the last year. I'm trying to make adjustments for my contract renewal but don't know many full-time nocturnists so am not sure what to ask for or if I am asking too much.

I'm typically doing 10+ admissions in my 12 hour shift (and have done up to 15). There's an open ICU so I intubate around 1-2x monthly. Cross cover census is 60s to 70s but in the winter up to 90s. I'm solo at night, no other physicians or NPs. I can call critical care in if I'm in a bind but they cover multiple hospitals in town so I try to avoid it.

I'm paid hourly at 175/hour with no RVU or quality incentives. The only other nocturnists are locum and are paid 200/hour. They have been working here for years because it is hard to hire full time nocturnists. I've asked for a pay increase to 200/hour to match what the locum physicians are getting or adding RVU incentives. None of the locum docs intubate and from what I gather from other staff I'm doing a much more thorough job. Initially admin said no to the pay increase but I've persisted in asking because I don't think it is unreasonable for the amount of work I'm doing.

Is 200/hour asking too much? What else should I ask for in the contract?

Thanks in advance.

Geez. You are getting ripped off. You are intubating, cross covering a ton of patients and admitting? And they're paying locums more than you.

Find a new job.

Tell administration that unless they come up to your salary demand you are resigning. And follow up on your resignation threat.

You are working like a pseudo intensivist and taking on a huge amount of liability with this volume.

Unless you are really set on the location, there are much better jobs out there.

 

[doctayj]

10+ admissions, cross covering 60-70 patients, AND intubating? How is this all even possible in a span of 12 hours… Something doesn’t add up. If you somehow are doing all of these things, you deserve way more than $175/hr

10+ admissions, ICU coverage, small town, community hospital.

My man you should be making $2500 a night minimum.

Put your notice and have them hire you as locum.

Also stop intubating. Who's intubating when the locums are here? ED? Have them do it when you're here too.

I'm going to really insist on 200/hour and try to get RVUs too. They initially said that if I get RVUs my hourly rate will be lowered but honestly with the amount of stress it is I think I should get both. I did bring up switching to locum and they said that I couldn't stay at this facility if I did locum because 'it pays more and then everyone would switch'.

The ER does come up to intubate for the locums. I've had them come as backup if I think the airway will be especially difficult. Intubating is something I actually want to keep proficient at though. I definitely don't have time to do lines or other procedures with the volume of everything else.

 

[doctayj]

Geez. You are getting ripped off. You are intubating, cross covering a ton of patients and admitting? And they're paying locums more than you.

Find a new job.

Tell administration that unless they come up to your salary demand you are resigning. And follow up on your resignation threat.

You are working like a pseudo intensivist and taking on a huge amount of liability with this volume.

Unless you are really set on the location, there are much better jobs out there.

Have you had experience giving ultimatums like that? I hate confrontation and have already sent multiple emails listing all the things I'm contributing to patient care and told them I'm looking into other options. They replied that they're waiting for the budget meeting and will have to get back to me. It seems like a no-brainer for them to pay me the locum rate because they're not paying for my housing/travel as I'm local, and if I leave they will have to fill with a locums doc.

My family is from here so we want to stay here, but I was med/peds trained and could easily switch to clinic or even urgent care. I love hospital medicine and think I'm doing a good job (given the circumstances) but I'm starting to worry I'll get sued for missing something.

 

[doctayj]

10+ admissions, cross covering 60-70 patients, AND intubating? How is this all even possible in a span of 12 hours… Something doesn’t add up. If you somehow are doing all of these things, you deserve way more than $175/hr

I'm doing them but just not as well as I would like lol. It was a major shift from knowing everything about all my patients in residency to just trying to stay afloat here. I'm constantly triaging what to address first and feel like I'm on roller skates all night. If I get less than 8 admissions it feels like a vacation.

 

[dgdg]

If you can't walk away, you can't negotiate.

 

[rokshana]

If docs who don't care, do less, less efficient is making $200/hr, you should be making $250/hr.

You do a better job, more efficient, part of the medical staff, work more shifts, etc.

Its a slap in the face when you are doing a better job and getting paid less. Threaten them to leave, and they will give you more than $200/hr.

not sure why you are assuming the locums is doing a worse job that the OP.

 

[rokshana]

Have you had experience giving ultimatums like that? I hate confrontation and have already sent multiple emails listing all the things I'm contributing to patient care and told them I'm looking into other options. They replied that they're waiting for the budget meeting and will have to get back to me. It seems like a no-brainer for them to pay me the locum rate because they're not paying for my housing/travel as I'm local, and if I leave they will have to fill with a locums doc.

My family is from here so we want to stay here, but I was med/peds trained and could easily switch to clinic or even urgent care. I love hospital medicine and think I'm doing a good job (given the circumstances) but I'm starting to worry I'll get sued for missing something.

are you getting benefits? health insurance? retirement benefits? life insurances? paid PTO? realize that locumd doesn't get those, so you have to consider the benefits package you are getting to be part of your compensation. Also locums has to pay all the taxes, with no contribution from the employer(ie FICA)

I don't disagree that you should be compensated better fr what you are doing...but you may lose benefits if you were to go locums...

 

[rokshana]

Have you had experience giving ultimatums like that? I hate confrontation and have already sent multiple emails listing all the things I'm contributing to patient care and told them I'm looking into other options. They replied that they're waiting for the budget meeting and will have to get back to me. It seems like a no-brainer for them to pay me the locum rate because they're not paying for my housing/travel as I'm local, and if I leave they will have to fill with a locums doc.

My family is from here so we want to stay here, but I was med/peds trained and could easily switch to clinic or even urgent care. I love hospital medicine and think I'm doing a good job (given the circumstances) but I'm starting to worry I'll get sued for missing something.

if you are playing intensivist without the training, then your worry is a valid one.

 

[emergentmd]

not sure why you are assuming the locums is doing a worse job that the OP.

Because I was an ER locums for a few years. I did a good job, but locums goal is to be avg and have no interest in making the department any better. If I am getting paid 50% more than a full timer, I want to maximize the $/work ratio. Do you think a Locums guy would bust their butt when busy or stay late?

 

[rokshana]

Because I was an ER locums for a few years. I did a good job, but locums goal is to be avg and have no interest in making the department any better. If I am getting paid 50% more than a full timer, I want to maximize the $/work ratio. Do you think a Locums guy would bust their butt when busy or stay late?

Since I am a “locums guy” I’m biased… but frankly the places I go, I do t find the perm people to be all that great in general… though these places all have a level of chaos, so there may be a reason why the perm people are not so great…🤷🏽‍♀️
And yes, I do bust my butt and do stay late… after all I’m not trying to rush to pick up the kids from day care or make dinner…and I get paid by the hour so I get paid for staying late.

 

[CCM-MD]

This job is ideal for someone who wants to get sued or burn out. It sounds like an absolute dumpster fire for every reason except for the compensation. The pay sounds right around or above the median depending on location (you're paid more than the nocturnists where I am). There is no harm in asking, but expecting to be paid the Locum rate while being a permanent employee is probably not going to happen. Time to find a new job.

"None of the locum docs intubate and from what I gather from other staff I'm doing a much more thorough job". Sounds like the locums docs don't want the liability. Don't be a hero. I've seen enough new grad "heros", it usually doesn't end well.

 

[anonperson]

Have you had experience giving ultimatums like that? I hate confrontation and have already sent multiple emails listing all the things I'm contributing to patient care and told them I'm looking into other options. They replied that they're waiting for the budget meeting and will have to get back to me. It seems like a no-brainer for them to pay me the locum rate because they're not paying for my housing/travel as I'm local, and if I leave they will have to fill with a locums doc.

My family is from here so we want to stay here, but I was med/peds trained and could easily switch to clinic or even urgent care. I love hospital medicine and think I'm doing a good job (given the circumstances) but I'm starting to worry I'll get sued for missing something.

My story:
Not IM.
Contract was for 2 years guaranteed salary. Admin wanted a new compensation structure. 6 months prior to the end of the 2 years, we met and they revealed details about the contract which would have resulted in a $10k to $15k paycut. I told them if this is the contract, I won't sign it

Tried to negotiate a bit here and there but they weren't really interested. Once that became clear, I found a new job and gave my notice.

New job is less work and more pay. Much better quality of life.

----------------------------------------------------

This current job will lead you to get sued. What happens if you goose an intubation? You will be held to the same standard of care as a CC or ED physician. That can derail your career.

I can already tell you how this is going to play out.

Your hospital administration doesn't really care about how good you are. They just want a warm body who won't get the hospital sued that often.

They're stringing you along. Why would they bother paying you more anyways? They can throw some cash at a locums and be fine. Remember, they are not looking for good, just good enough.

Hospital administrators also don't mind paying locums. It's from a separate part of the budget and they can always point to it as a temporary cost. If they pay you more, then that increase is stuck on their balance sheet to an extent.

I have dealt with the same exact situation (just a different specialty).

Main takeaway: your administration doesn't care about you and hates paying you ( this is ironic because physicians are what generates revenue for the hospital).

 

[anonperson]

not sure why you are assuming the locums is doing a worse job that the OP.

Some locums are fine but in my experience a fair amount have questionable skill sets. May be specialty dependent.

For the hospital I'm at. They hired a few locums OBs who were pretty terrible. Bad enough where there are lawsuits for bad outcomes that are coming down the pipeline.

They collect a nice paycheck though.

 

[IMGASMD]

Have you had experience giving ultimatums like that? I hate confrontation and have already sent multiple emails listing all the things I'm contributing to patient care and told them I'm looking into other options. They replied that they're waiting for the budget meeting and will have to get back to me. It seems like a no-brainer for them to pay me the locum rate because they're not paying for my housing/travel as I'm local, and if I leave they will have to fill with a locums doc.

My family is from here so we want to stay here, but I was med/peds trained and could easily switch to clinic or even urgent care. I love hospital medicine and think I'm doing a good job (given the circumstances) but I'm starting to worry I'll get sued for missing something.

It’s not confrontation. It’s a negotiation. I am certainly not doing this for free, we are doing this to make a living and take care of our families.
We’ve been told and taught to take the high road, where did that get us?
The “worst” case scenario is to find another job.
You’ll be just fine. Good luck.

https://www.inc.com/jeff-haden/tk-highly-effective-negotiation-tactics-anyone-can-use.html

 

[collegestud2013]

I'm a relatively new residency grad (IM) and have been a full time nocturnist at a community hospital in a small city for the last year. I'm trying to make adjustments for my contract renewal but don't know many full-time nocturnists so am not sure what to ask for or if I am asking too much.

I'm typically doing 10+ admissions in my 12 hour shift (and have done up to 15). There's an open ICU so I intubate around 1-2x monthly. Cross cover census is 60s to 70s but in the winter up to 90s. I'm solo at night, no other physicians or NPs. I can call critical care in if I'm in a bind but they cover multiple hospitals in town so I try to avoid it.

I'm paid hourly at 175/hour with no RVU or quality incentives. The only other nocturnists are locum and are paid 200/hour. They have been working here for years because it is hard to hire full time nocturnists. I've asked for a pay increase to 200/hour to match what the locum physicians are getting or adding RVU incentives. None of the locum docs intubate and from what I gather from other staff I'm doing a much more thorough job. Initially admin said no to the pay increase but I've persisted in asking because I don't think it is unreasonable for the amount of work I'm doing.

Is 200/hour asking too much? What else should I ask for in the contract?

Thanks in advance.

Those volumes sound crazy for one person to handle at night. As mentioned above it's recipe for both burnout and liability. With those volumes, would first try to to see if they will approve additional coverage at night for a PA/NP to be in-house with you for the full shift; someone to rotate in on admissions and take some of the cross-cover calls; I would go for that more than trying to raising your own pay if you're going to stay there. Of course, the problem is even if they approve additional staffing, it can take many months to onboard someone new.

Also, agree with others that if you're not completely comfortable intubating or doing a certain procedure, would have the ED providers or someone who is properly credentialed do it.

Keep in mind locums are usually paid 1099 (and thus have to pay both parts of the FICA taxes) and don't get benefits, so $200/hr for them will effectively be worth a bit less than $200/hr for you assuming you are paid as W2. Also, IMO $200/hr for locums is low for the volume of work and liability you are describing.

Then again, it sounds you may have some leverage since it's usually much harder to recruit nocturnists, especially those in less saturated small city. Would resign if they don't make any changes and find another job (though if there's a non-compete you may have to move).

 

[Splenda88]

For comparison

Our 2 nocturnists cross cover around 70 ICU/stepdown beds. Average admission is 16 for the two of them. They often have a PGY2 that do 4-5 admissions out of that 16. They make $2225/shift or 405k/yr (no RVUs or incentives). They do NOT intubate or do any procedure.

I think asking for $200/hr in your situation is not asking for too much. It's hard to find people to work night; you gotta take care of these night owls.

 

[chessknt]

I can't believe an er doc would come be backup for a procedure like that... do you know how to do a cric if your assessment is wrong and you can't get the airway? Can you do a bronch if there is a massive aspiration?

I had a job like that once upon a time before I did a fellowship (slightly less busy). Started with a Crna in house to do airways then they took it away to save money. The day hospitalists wouldnt give any real hand off and their patients would be actively decompensating at least once a week. With what I know now I was completely overconfident (dangerously so) in what I thought I could do--not just in procedures but also transferring people to the ICU with care plans that were complete crap in retrospect. I see it now in one of the hospitals I work at--we have nocturnists who admit to ICU overnight and I have to make major adjustments to their plans 70% of the time.

 

[Make Or Break]

I'm a relatively new residency grad (IM) and have been a full time nocturnist at a community hospital in a small city for the last year. I'm trying to make adjustments for my contract renewal but don't know many full-time nocturnists so am not sure what to ask for or if I am asking too much.

I'm typically doing 10+ admissions in my 12 hour shift (and have done up to 15). There's an open ICU so I intubate around 1-2x monthly. Cross cover census is 60s to 70s but in the winter up to 90s. I'm solo at night, no other physicians or NPs. I can call critical care in if I'm in a bind but they cover multiple hospitals in town so I try to avoid it.

I'm paid hourly at 175/hour with no RVU or quality incentives. The only other nocturnists are locum and are paid 200/hour. They have been working here for years because it is hard to hire full time nocturnists. I've asked for a pay increase to 200/hour to match what the locum physicians are getting or adding RVU incentives. None of the locum docs intubate and from what I gather from other staff I'm doing a much more thorough job. Initially admin said no to the pay increase but I've persisted in asking because I don't think it is unreasonable for the amount of work I'm doing.

Is 200/hour asking too much? What else should I ask for in the contract?

Thanks in advance.

Hell no not for 175. 175 is base pay with no cross coverage, 6-8 admits, no procedures, closed icu. Find another job or negotiate a higher salary asap. They will give you the runaround with “budget meetings”. You are just another cog in the machine. I would give them an ultimatum to raise your rate in 2 or 3 months otherwise they can find someone else to work that dumpster fire. But knowing how hospitals work I doubt they will. They can pay perm as much as locums but don’t want to.

 

[Make Or Break]

Go locums, they do not value you.

 

[anonperson]

I'm a relatively new residency grad (IM) and have been a full time nocturnist at a community hospital in a small city for the last year. I'm trying to make adjustments for my contract renewal but don't know many full-time nocturnists so am not sure what to ask for or if I am asking too much.

I'm typically doing 10+ admissions in my 12 hour shift (and have done up to 15). There's an open ICU so I intubate around 1-2x monthly. Cross cover census is 60s to 70s but in the winter up to 90s. I'm solo at night, no other physicians or NPs. I can call critical care in if I'm in a bind but they cover multiple hospitals in town so I try to avoid it.

I'm paid hourly at 175/hour with no RVU or quality incentives. The only other nocturnists are locum and are paid 200/hour. They have been working here for years because it is hard to hire full time nocturnists. I've asked for a pay increase to 200/hour to match what the locum physicians are getting or adding RVU incentives. None of the locum docs intubate and from what I gather from other staff I'm doing a much more thorough job. Initially admin said no to the pay increase but I've persisted in asking because I don't think it is unreasonable for the amount of work I'm doing.

Is 200/hour asking too much? What else should I ask for in the contract?

Thanks in advance.

Please update with your negotiation process and how it works out. Valuable information for others to learn from.

 

[dozitgetchahi]

I'm going to really insist on 200/hour and try to get RVUs too. They initially said that if I get RVUs my hourly rate will be lowered but honestly with the amount of stress it is I think I should get both. I did bring up switching to locum and they said that I couldn't stay at this facility if I did locum because 'it pays more and then everyone would switch'.

The ER does come up to intubate for the locums. I've had them come as backup if I think the airway will be especially difficult. Intubating is something I actually want to keep proficient at though. I definitely don't have time to do lines or other procedures with the volume of everything else.

Even if they pay you what you want, I still think you should leave. This is way too much volume and liability risk.

It always surprises me what we as docs get conned into out there, especially when we’re fresh out of training and relatively clueless (don’t worry, it happened to me also when I got ripped off at my first hospital job as a rheumatologist, and paid way less than I should have been…)

Also, I’m in agreement with others here in that you should stop intubating. You’re not “staying proficient” at intubations if you’re doing them once/twice per month. An average anesthesiologist is intubating more in an hour than you are in a month. I can practically guarantee that you don’t have the experience or practice to do this safely, consistently. How many of them did you do during residency?

 

[dozitgetchahi]

10+ admissions, cross covering 60-70 patients, AND intubating? How is this all even possible in a span of 12 hours… Something doesn’t add up. If you somehow are doing all of these things, you deserve way more than $175/hr

This kind of stuff sounds crazy, but it definitely happens out there.

When I was a resident, we did a few ward months at a huge but janky community hospital that our academic system was affiliated with. The hospital had ~800 beds, of which 550 were general medicine. The night coverage for those 550 beds consisted of one nocturnist and two nurse practitioners (we were told that they had just added the 2nd NP, meaning that it used to be only 1 doc and 1 midlevel). That hospital was a complete ****show at night. As residents, we were told to “tuck the patients in real good” because the night coverage team didn’t even attempt to take sign out from you and would not follow anything up…they were basically there only to run codes and put out fires (and they did plenty of each on a nightly basis).

 

[Nocturnist]

I'm a relatively new residency grad (IM) and have been a full time nocturnist at a community hospital in a small city for the last year. I'm trying to make adjustments for my contract renewal but don't know many full-time nocturnists so am not sure what to ask for or if I am asking too much.

I'm typically doing 10+ admissions in my 12 hour shift (and have done up to 15). There's an open ICU so I intubate around 1-2x monthly. Cross cover census is 60s to 70s but in the winter up to 90s. I'm solo at night, no other physicians or NPs. I can call critical care in if I'm in a bind but they cover multiple hospitals in town so I try to avoid it.

I'm paid hourly at 175/hour with no RVU or quality incentives. The only other nocturnists are locum and are paid 200/hour. They have been working here for years because it is hard to hire full time nocturnists. I've asked for a pay increase to 200/hour to match what the locum physicians are getting or adding RVU incentives. None of the locum docs intubate and from what I gather from other staff I'm doing a much more thorough job. Initially admin said no to the pay increase but I've persisted in asking because I don't think it is unreasonable for the amount of work I'm doing.

Is 200/hour asking too much? What else should I ask for in the contract?

Thanks in advance.

Congrats, you've officially found the worst nocturnist job in America! I wouldn't do it for 500/hr, the liability isn't worth it. Open ICU is my hard line in the sand.

Take away the open ICU, and I'd honestly need 250-300/hr to put up with 10 admits a night on top of cross-coverage, triage, rapid response, consults etc.
I'm supposedly at the lowest paying part of the country and my base is $180/hr for 6-8 admits a night. Add productivity incentives and I'm at well over $200. My per diem job is at 200-225/hr for 4-8 admits and no cross coverage.

Don't even try to negotiate, just find another job asap. A 15% raise is not going to make this gig make any more sense.

 

[Splenda88]

Congrats, you've officially found the worst nocturnist job in America! I wouldn't do it for 500/hr, the liability isn't worth it. Open ICU is my hard line in the sand.

Take away the open ICU, and I'd honestly need 250-300/hr to put up with 10 admits a night on top of cross-coverage, triage, rapid response, consults etc.
I'm supposedly at the lowest paying part of the country and my base is $180/hr for 6-8 admits a night. Add productivity incentives and I'm at well over $200. My per diem job is at 200-225/hr for 4-8 admits and no cross coverage.

Don't even try to negotiate, just find another job asap. A 15% raise is not going to make this gig make any more sense.

The hospitalist market is good right now. You gotta ask yourself if these salaries are sustainable

 

[collegestud2013]

The hospitalist market is good right now. You gotta ask yourself if these salaries are sustainable

It's already starting to saturate in the big cities and even the more desirable smaller cities. Maybe the less desirable small towns and rural areas, and the nocturnist jobs might not be affected much yet.

Considering just about any IM or FM grad can get into hospitalist work pretty easily (and these are the 2 biggest residencies and both specialties are not competitive to match into) , and with the other major option for IM/FM grads being primary care still a relatively unattractive option at the moment given all the headaches PCPs still have to deal with (though factors like increased reimbursement for primary care visits may shift how many go into it), the fact that hospitalist groups require subsidies from the hospital in most cases to break even, and of course the increased use of PAs and NPs to staff hospitals, supply and demand could shift and have a downward pressure on pay.

 

[Splenda88]

It's already starting to saturate in the big cities and even the more desirable smaller cities. Maybe the less desirable small towns and rural areas, and the nocturnist jobs might not be affected much yet.

Considering just about any IM or FM grad can get into hospitalist work pretty easily (and these are the 2 biggest residencies and both specialties are not competitive to match into) , and with the other major option for IM/FM grads being primary care still a relatively unattractive option at the moment given all the headaches PCPs still have to deal with (though factors like increased reimbursement for primary care visits may shift how many go into it), the fact that hospitalist groups require subsidies from the hospital in most cases to break even, and of course the increased use of PAs and NPs to staff hospitals, supply and demand could shift and have a downward pressure on pay.

That is not good news.

Our group just hired a new FM grad and he told us most of his co-residents went into hospital medicine. Hope this is an isolated trend.

I am in a small city and I am hoping for the market stay the way it is now (or even better) for another 8+ yrs.

 

[Splenda88]

We have a big FM residency program we work inpatient with. I've yet to run into anyone who wants to do any form of OB, peds, and all of them want to do hospitalist

If this trend continues, people will start asking themselves what's the point of FM residency if most of these FM grads want to practice IM.