NWH’s Dr. Newborn believes his staff, and hospitalists in general, are “skilled at appropriately triaging the need for specialists to come in at night.”
In his experience, most specialists are happy to have hospitalists on board because they improve patient care and the specialists’ lives and practices. “They are glad that treatment for their patients doesn’t wait until 7 a.m., that they don’t have to come in at night as often, that they don’t have to do all their admissions and that they get patient referrals,” he says. “As a result, they’re generally happy to take hospitalists’ calls in the middle of the night.”
Lab and ancillary services have increased, too. In the ED, advanced imaging, blood drawing, and electrocardiograms are available all night, says Dr. Newborn. There is a computerized system of patient and medication information that can warn doctors and other staff about potential medication problems.
Nevertheless, night-shift hospitalists are on their own more than their day-time colleagues.
At Beth Israel in Manhattan, the day-shift hospitalists are part of a teaching service. “The hospitalist communicates with the resident who is the in-house physician, or the ICU intensivist, or the fellows who are post-residents training in a specialty,” says Dr. Rizk.
The Beth Israel hospitalists are on a team or are assigned patients based on floors or wards rather than shifts. “The advantage is that one hospitalist cares for a given patient for a longer term, working with all the acquired knowledge,” says Dr. Rizk. “We minimize the number of providers working with a patient and the physician knows the goals for care and the treatment plan well.”
At night, the Beth Israel hospitalists are on-call, but because of the hospital’s growth, Dr. Rizk is working to establish a 24-hour, seven-day hospitalist program that will not be a teaching service. She is recruiting for two night-shift hospitalists who will staff the units.
She knows from her efforts to expand her staff in general that recruitment of night hospitalists will be a challenge. Dr. Rizk agrees with many who think night-shift hospitalists must be given incentives such as higher salaries, more time off, or hybrid schedules (such as one month of night shifts per year).
Yet there are benefits to working at night, she and others agree. “Since it’s shift work, when your beeper is off, you are off,” she says. “You can have more time off, and it can suit personal needs and lifestyles.”
It can be quieter at night with few meetings and little committee work. It can be a good fit for a physician who is between residency and working toward further specialization.
Most importantly, she says, it makes it possible to really focus on patients.
“It’s medicine without the committee,” says Dr. Laumeyer at Kaiser. “At night, there are fewer people to run decisions by, but you can learn and make a big difference.”
She cautions, however, “You have to be comfortable with what you can do on your own and get help with what you can’t.”
Dr. Nagamine agrees. “The most important thing is to recognize the limits of your experience and the scope of your practice. You also must be very aware that what you’re doing at night may be different than it would at 2 p.m. As long as you recognize a discrepancy, you can decide if you need to take another step to ensure the best patient care.” TH
Karla Feuer is a journalist based in New York.
References
- Silbergleit R, Kronick SL, Philpott S, Lowell MJ, Wagner C. Quality of emergency care on the night shift. Acad Emerg Med. 2006 Mar;13(3):325-330.
- Tobin AE, Santamaria JD. After-hours discharges from intensive care are associated with increased mortality. Med J Aust. 2006;184(7):334-337.
- Priestap FA, Martin CM. Impact of intensive care unit discharge time on patient outcome. Crit Care Med. 2006 Dec;34(12):2946-2951.