Editors’ note: We originally conceived this article with the authors just before Hurricanes Katrina and Rita devastated the Gulf Coast last year. Once the hurricanes hit, we decided to “bump” this article in favor of running coverage of the hurricanes and their effects on hospitals in the Gulf Coast area.
The Ochsner Clinic Foundation rests on the eastern bank of an acute flexure in the Mississippi river similar to its twin just downstream, which lurches around a crescent forming the historic and infamous French Vieux Carré, or Old Quarter. From a perch on the hospital’s 11th floor I often start my evening by taking in the full scope of the river’s powerful swirling eddies and copious flotsam churning past in the westerly sun. The view has become a familiar sight to me over the past several years as our hospital’s primary night shift internist.
Though my comrades jokingly refer to me as Ochsner’s “nocturnist,” an assignment surprisingly relished by few, the position has proven mutually beneficial in serving a vital role for the hospital and our group, while accommodating my own crepuscular nature and lifestyle.
Our night position—officially known as IHC (or in-house call)—was conceived from several requisites desired by both administration and physicians. Ochsner Clinic Foundation is steeped in academic history, and the nights have traditionally been dominated by semi-autonomously operating residents. During the past five years, practice changes in the local area afforded Ochsner unprecedented growth, requiring constant accommodation and development of our hospitalist group. Many of these changes were accelerated by the devastation wrought by Hurricane Katrina. With a nod to quality over quantity, we decided against expanding the teaching program in favor of developing several non-resident-based hospital services.
These unique and burgeoning parallel systems of care quickly presented many challenges for those staff clinicians stationed at home when problems arose during the evening. The original expectation was that the residents would have no direct involvement in the care of this subset of patients to avoid overburdening a system already operating near capacity. Subsequent intradepartmental disputation ensued over how to provide our patients with personal on-site care through the wee hours while arresting the surge of hectoring beeps that inevitably start after midnight. The exigency of solving this problem grew as our physicians’ slumber waned and patient admissions soared over the following months.
Our group’s consensus that a full-time night staff physician was needed soon emerged as the best potential remedy for our predicament. As no person wanted to be commandeered for the job, volunteers were sought for a trial run with the very reasonable hours of 4 p.m. to midnight, Monday through Friday. Hardly ever retiring to bed before the witching hour, I accepted the first week of our nascent, early evening shift.
The Rise of the Nocturnist
The expectations were simple. I was to independently admit “bounce-backs:” observation level patients, hip fracture service patients, and overflow admissions from a frequently dropsical emergency department. This specious solution proved very successful but ultimately served to highlight the overall need for a hospitalist to remain in-house for the duration of the evening and early morning hours.
The subsequent creation of a newly expanded, more permanent role for our IHC was proffered for consideration. This vision of moving to 24-hour staff coverage on site met with universal acceptance from the physicians, nursing staff, residents, and administration. The lone problem remained of finding physicians willing to dedicate themselves to working primarily at night.
Rather than rotating doctors weekly, we hoped to maintain some consistency by having certain physicians dedicated to staffing nights. From this graveyard shift arose true nocturnists, as in my case, working evenings nearly 75% of the time. Implementation of a weekend nocturnist to cover Saturday and Sunday is being developed as the need for coverage increases and the success of the current system continues.