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How to balance the pros and cons of an exclusive night shift schedule

Dear Director,

I’m an experienced physician who is thinking of switching to a fixed overnight schedule.  I’m wondering your thoughts on the benefits to this and any potential risks to my career.

 

I’ve been fortunate that my ED has a nocturnist who covers about 40% of our night shifts. This obviously reduces the load on everyone. As I was complaining to him the other night about leaving the hospital at 1am and then needing to return for morning meetings, he responded by saying that the only way he could continue to thrive as an emergency physician was because he took the shifting sleep cycles off the table by working a fixed shift. For this, and many other reasons, one might choose to work as a full time night doc.

I’m a Night Owl

There are clearly those people who just like nights. I was a night owl in my younger days and loved nights as a resident, but I admit to now finding them harder to recover from. Meanwhile, I’ve worked with many people of all ages who just love nights. From a work flow process, it may be the best shift. After all, you come in to a rocking ED when you’re caffeinated and ready to go from the great tunes on the commute in and then as you get fatigued through the shift, the pace slows down, you get caught up, and then you’re out the door. Contrast that to the day shift that doesn’t heat up until midway through or an evening shift that has you hustling the whole time and leaves you exhausted. It could be that some circadian rhythms are set differently, but clearly some people prefer the vampire existence that night shifts mandate. The key for night owls, particularly if you have kids, is having a quiet and dark environment to get good quality sleep during the day and recognizing that night shift work is a known risk factor for cardiovascular disease.

Night Shift Culture

I’ve yet to find an ED where the night shift isn’t just a little more relaxed than the day shift. Maybe this is because most EDs slow down around 3am and staff can hang out more. It could be that the patients who present at night are “different” and the staff bonds more from caring for them. Let’s be honest, the stories your friends want to hear at cocktail parties about life in the ER usually come from a night shift. More likely, it’s because the hospital administrators aren’t around so there’s less pressure to follow all of the rules and less hospital politics come into play. The bond that seems to form between ED nurses and their dedicated doc tends to be much stronger than with docs who rotate through the nights—think of how everyone comes together so well at night for the trauma, SIDs case, or crazy drunk brought in by police. I view the ED night staff as having an “us against the world” survival mentality, which creates a unique, close-knit culture. 

Financial and Schedule Benefits

When nights are split evenly among the group, I’m not a fan of having a higher pay rate for the night shift. After all, if everyone is working nights and it all balances out, the added paperwork and tracking is unnecessarily cumbersome. However, for a full time night doc, most groups will pay an added stipend above the baseline rate to minimize the nights that the others have to do. This can vary from $10/hour to 20% of your hourly rate. From my very non-scientific surveys, most average an extra $15-20 per hour. This can be big money: 8 hour nights x $15/hr x 150 shifts equals $18,000. For someone paying back loans or raising cash to put a deposit on a house, this can make a real impact. In addition to the extra cash that can be earned, many nocturnists are able to negotiate added schedule control. Sometimes you can completely control your own schedule. Other times you may get a fixed schedule. I’ve been in two different hospitals where the night doc did a fixed Sunday to Tuesday/Wednesday (depending on the week) to insure that they had weekend days free to coach their kids as well as to more easily schedule a nanny. It worked for the group because the nocturnist still covered their share of weekends while working for the individual doc by giving them the time they needed to be free and well rested. While reducing weekend or holiday coverage may not be a typical benefit, depending on your group’s situation, it may be negotiable as well.

Risk Factors

There is definitely more clinical autonomy when you work nights. If ER docs were seen as cowboys in the 1970s and 80s, then the last remaining piece of the wild west is on the night shift since you’re often working without a safety net. I’ve had a couple of new grads tell me that they would like to start as a full time night shift doc. Sometimes I’ve felt that I’ve needed to protect them from themselves. Why? As fun as it can be to work nights, there is a learning curve to managing an ED, trouble shooting a new ED environment, and there is significantly less help available in most hospitals at night. This could mean reading all of your own x-rays (in which case a miss is more likely in an inexperienced provider) or managing a difficult airway without the resources that might be available during day time hours such as an intensivist or anesthesiologist. Even something as simple as an IT glitch that might be resolved in minutes during the day may take hours at night and involve phone calls to other countries for technical support. While I recognize that there are numerous smaller facilities around the country that do this 24/7, in busier EDs, decreased resources may lead to more bad clinical outcomes that might not happen during a day shift, with the elevated emphasis on the politics that tends to be heightened in larger EDs and hospitals.

Career Development

Depending on your professional aspirations, being a full time night doc may have no impact on your overall career. After all, the founder of this newspaper has done pretty well working exclusively night shifts. The first piece to consider is the relationships that you’ll have with people in the hospital. While you’re likely to become more entrenched with your nursing staff, you may also become more alienated from the medical staff, since most of your physician interactions will be limited to brief phone calls when you’re waking someone up for an admission. Because of this, you need to make extra effort to remind yourself that there’s always benefits to attending your department meetings and interacting with your hospital colleagues outside of the ED through committee work or in the doctor’s lounge. Obviously, the ability to do this greatly diminishes when you exist in a night shift world. If you’re interested in ED administration or being involved in the hospital, it might be hard to get reengaged in that environment if you spend more than a year or two as a full time night doc. With that said, I have a colleague who is an excellent ED chair and all of his clinical shifts are weekend nights. Granted, his clinical commitment is about 50% compared to a full time clinician, but he likes his clinical atmosphere and is able to fulfill his admin commitments more easily. This model could translate very well if you’re interested in teaching, research, EMS, or any number of other activities where you need a fixed schedule and want your days free for meetings or other activities.

Conclusion

You’ll certainly make docs in your group happy if you become a full time night physician. You’ll likely make more money, have better control of your schedule, and enjoy the atmosphere. Being an experienced physician will help minimize some of the stress of reduced on-site back-up when you’re managing your sickest patients. Just be sure to have a good, dark room to sleep in at home and to make an effort to attend the occasional ED meeting or hospital function in order to stay connected.

Michael Silverman, MD, is a partner at Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.

 

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