The Nocturnist Guide You Never Wanted But Are Getting Anyway. Also, like, AMA? I guess? If you really feel like it? Compliment compliment question?

[chessknt]

Lol. I can be a pimp for BIG Pharma.

If you have research chops pharma will pay you for your opinion but that isn’t passive. And it isn’t anywhere near that amount.

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Members don't see this ad.

 

[Splenda88]

If you have research chops pharma will pay you for your opinion but that isn’t passive. And it isn’t anywhere near that amount.

I think I will do VA disability eval. Should be ok making 50k/yr since it will be a 1099 job.

 

[chessknt]

I think I will do VA disability eval. Should be ok making 50k/yr since it will be a 1099 job.

Not passive and in general disability evaluation pays under $100/hr so that is a bit of a time commitment there.

 

[tantacles]

Is this for real? You think there is a way just get money without effort by simply possessing a medical license?

best way I can think of it to marry someone who makes a lot of money (like greater than 1 m per year so ideally a ortho or neurosurgeon) then get divorced after a few years (make sure you don’t work during the marriage) and collect alimony.

Yessssss my medical prostitution business is progressing nicely.

 

[Nocturnist]

Does anyone know how one can somewhat passively add another 75k-100k/yr to his/her income using their medical license?

Convince the group to give you some bs but important sounding title. No, really...

We have a day time hospitalist in my group that became our documentation improvement and reimbursement capturing specialist. I'm pretty sure he literally went to one or two seminars. In exchange for this fancy title, he got to have his clinical duties dropped from 15 shifts to 8 shifts.

What does the dude do with his 22 free days a month? Picks up around 15-18 extra shifts a month, naturally.

I have no idea what he actually does aside from some yearly lecture and reminding us to use 'sepsis secondary to urinary tract infection' instead of urosepsis.

I think he spends at most a couple hours a week doing that gig, but the group's case mix index and reimbursements have gone to the moon.

Thats about as close to passive income as I can think of...

 

[tantacles]

I did a day shift. What utter nonsense. And I was paid less for it, of course, than I would have been for a night shift.

Never again.

 

[wamcp]

I did a day shift. What utter nonsense. And I was paid less for it, of course, than I would have been for a night shift.

Never again.

Started watching Mare of Easttown on my night shift that started couple hours ago. Two episodes in, and only three admits stacked up that i’ll go see soon. Can’t get paid to watch hbo if day rounding!

 

[Splenda88]

Started watching Mare of Easttown on my night shift that started couple hours ago. Two episodes in, and only three admits stacked up that i’ll go see soon. Can’t get paid to watch hbo if day rounding!

You guys are having a blast.

One my co-residents just got a nocturnist position that seems to be good. 5-7 admits for 370k + 30k sign on. These jobs are rare. Everyone wants you to admit 12-15 patients per night.

 

[tantacles]

Started watching Mare of Easttown on my night shift that started couple hours ago. Two episodes in, and only three admits stacked up that i’ll go see soon. Can’t get paid to watch hbo if day rounding!

I'm doing a virtual cross cover shift right now. MUCH better. Though speaking to a patient who wants to leave AMA through a vietnamese interpreter ipad over the phone is a bit dicey.

Oh, and I finally finished Schitt's Creek.

 

[tantacles]

You guys are having a blast.

One my co-residents just got a nocturnist position that seems to be good. 5-7 admits for 370k + 30k sign on. These jobs are rare. Everyone wants you to admit 12-15 patients per night.

How many shifts?

 

[Nocturnist]

I did a day shift. What utter nonsense. And I was paid less for it, of course, than I would have been for a night shift.

Never again.

Same.

I did one couple months out of residency as a favor to a colleague. After that day I told the office not to even cc me on any open day shift emails. Nver, ever again.

 

[Nocturnist]

You guys are having a blast.

One my co-residents just got a nocturnist position that seems to be good. 5-7 admits for 370k + 30k sign on. These jobs are rare. Everyone wants you to admit 12-15 patients per night.

I'm guessing thats a 7 on/ 7 off gig?

In that case if 15 shifts a month, comes out to around $171/hr. That's a good gig but not something I'd consider to be rare. I'm at about $10 an hour higher for a similar amount of work (anything over 6-7 admits is bonused handomly) and I dont consider my job particularly rare since my side gig is similar terms. I've always said 7 on/off nocturnists job are considered 1.5 FTE in my book and should pay accordingly.

I would never take a job that routinely demanded me to admit more than 8-10 a night. If I do so its on my terms because I'm feeling ambitious and want to pad my bonus.

 

[tantacles]

Same.

I did one couple months out of residency as a favor to a colleague. After that day I told the office not to even cc me on any open day shift emails. Nver, ever again.

Yeah, I was essentially just an admin monkey and felt like everyone was yelling at me even though I definitely went above and beyond the call of duty.

 

[Splenda88]

How many shifts?

7 nights on/off

 

[Splenda88]

I'm guessing thats a 7 on/ 7 off gig?

In that case if 15 shifts a month, comes out to around $171/hr. That's a good gig but not something I'd consider to be rare. I'm at about $10 an hour higher for a similar amount of work (anything over 6-7 admits is bonused handomly) and I dont consider my job particularly rare since my side gig is similar terms. I've always said 7 on/off nocturnists job are considered 1.5 FTE in my book and should pay accordingly.

I would never take a job that routinely demanded me to admit more than 8-10 a night. If I do so its on my terms because I'm feeling ambitious and want to pad my bonus.

I don't know what market you are on, but 370k/yr for 5-7 admits/night is considered good where I am (south east).

HCA (Envision) offered me 300-320k/yr for 14-16 admits/night with a NP/PA cross covering and taking on 4-5 out of these 16 admits. They presented it as a good deal because it was 50 minutes away from a major metro and 30 mins away from a couple of ok suburbs. I was going to be the only physician in a 120-bed hospital at night (not counting the ED doc).

I kind of agree with you. Nocturnist gigs should be 12 shifts max and no more than 8 admits/night. However, it is difficult to find these kind of arrangement since all the employers are taking advantage of a depressed market.

 

[rokshana]

I'm guessing thats a 7 on/ 7 off gig?

In that case if 15 shifts a month, comes out to around $171/hr. That's a good gig but not something I'd consider to be rare. I'm at about $10 an hour higher for a similar amount of work (anything over 6-7 admits is bonused handomly) and I dont consider my job particularly rare since my side gig is similar terms. I've always said 7 on/off nocturnists job are considered 1.5 FTE in my book and should pay accordingly.

I would never take a job that routinely demanded me to admit more than 8-10 a night. If I do so its on my terms because I'm feeling ambitious and want to pad my bonus.

So what is going to happen when there are more than 7 admissions and you dont want to be ambitious ? They call a back up? The ED is going to refuse the admission?
The thing is… there are no actual caps on admission when you are an attending…if the admissions come, you will have to admit them… nice they will give you a bonus, but they are not going to let you refuse an admission.

 

[Osteoth]

So what is going to happen when there are more than 7 admissions and you dont want to be ambitious ? They call a back up? The ED is going to refuse the admission?
The thing is… there are no actual caps on admission when you are an attending…if the admissions come, you will have to admit them… nice they will give you a bonus, but they are not going to let you refuse an admission.

You get paid a bonus

 

[Nocturnist]

So what is going to happen when there are more than 7 admissions and you dont want to be ambitious ? They call a back up? The ED is going to refuse the admission?
The thing is… there are no actual caps on admission when you are an attending…if the admissions come, you will have to admit them… nice they will give you a bonus, but they are not going to let you refuse an admission.

They either get left to the day team or backup is called.

 

[rokshana]

They either get left to the day team or backup is called.

I know when I worked as nocturnist, you get a bad rep if you leave too many for the day team…start getting a lot left at the start of shift from the day team ad a consequence… sucks to walk into 4 waiting admits.
I’ll have to admit, I’ve never been at a place that had overnight back up…but generally didn’t need it…except Temple… ugh overnight you could easily have 15 admits

 

[Nocturnist]

I know when I worked as nocturnist, you get a bad rep if you leave too many for the day team…start getting a lot left at the start of shift from the day team ad a consequence… sucks to walk into 4 waiting admits.
I’ll have to admit, I’ve never been at a place that had overnight back up…but generally didn’t need it…except Temple… ugh overnight you could easily have 15 admits

I think that is an unfortunate truth for smaller programs with one nocturnist on and no swings. And I think that is definitely a factor that contributes to burn out and dissatisfaction among nocturnists.

The one place I worked at for about a year where I was the only nocturnist and there were no swings- for sure. If I walked into 1 or 2 undone my goal was generally to do as many as I could and not leave the day team any. Likewise if i walked into 5-6 undone, you better believe i'm not hustling at 5am to squeeze another one in. Plus the more admits I'm getting- the more time I'm on the phone triaging and chart biopsying and the less time I'm able to devote to admitting.

Unfortunately if the hospital gets several busy days in a row, it doesn't take much for that mutual dissatisfaction and disconnect between nights and days to build up. Its just one passive aggressive mess. With that said I think once you hit 8-10 admits, no Monday morning quarterbacker will give you a bad rep regardless how many are left. Sure, if I leave 10 for the morning and consistently doing 5, I expect to have some words with the director..but the most I've ever done there was 10 and they were very appreciative of my work when I gave my notice. A part of why I left that place was the stress and unpredictability of having nothing to buffer between me and a crazy busy night. Some nights I'd get 5 and sleep half the night, other nights I'd get 20, every floor had fires to put out, every hospital was looking to transfer. Successful nocturnist by definition have to be comfortable with not knowing what their night is going to look like (that's part of what I love about the job), but I think that successful and forward thinking programs also work to build buffers to protect from those extremes.

At my main job, we have so many admitters between swings, nocturnists, and APCs- that the responsibility for how many undone are left in the morning never falls on any one person's shoulders, nor do the rounders know how many each of us have done. I have colleagues that consistently do 5 a night. All us admitters know exactly who they are..and yet they're still employed. I shoot for 6-8 a night and my rep is solid.

My record is 18, my next best night was 14. If I do more than 10 a few nights in a row I'm going to feel it for the next couple days. 14-16 on a regular basis even with the midlevel doing 5 is brutal. I dont think that's sustainable. I do think 6-8 is the sweet spot for longevity.

 

[Osteoth]

I think that is an unfortunate truth for smaller programs with one nocturnist on and no swings. And I think that is definitely a factor that contributes to burn out and dissatisfaction among nocturnists.

The one place I worked at for about a year where I was the only nocturnist and there were no swings- for sure. If I walked into 1 or 2 undone my goal was generally to do as many as I could and not leave the day team any. Likewise if i walked into 5-6 undone, you better believe i'm not hustling at 5am to squeeze another one in. Plus the more admits I'm getting- the more time I'm on the phone triaging and chart biopsying and the less time I'm able to devote to admitting.

Unfortunately if the hospital gets several busy days in a row, it doesn't take much for that mutual dissatisfaction and disconnect between nights and days to build up. Its just one passive aggressive mess. With that said I think once you hit 8-10 admits, no Monday morning quarterbacker will give you a bad rep regardless how many are left. Sure, if I leave 10 for the morning and consistently doing 5, I expect to have some words with the director..but the most I've ever done there was 10 and they were very appreciative of my work when I gave my notice. A part of why I left that place was the stress and unpredictability of having nothing to buffer between me and a crazy busy night. Some nights I'd get 5 and sleep half the night, other nights I'd get 20, every floor had fires to put out, every hospital was looking to transfer. Successful nocturnist by definition have to be comfortable with not knowing what their night is going to look like (that's part of what I love about the job), but I think that successful and forward thinking programs also work to build buffers to protect from those extremes.

At my main job, we have so many admitters between swings, nocturnists, and APCs- that the responsibility for how many undone are left in the morning never falls on any one person's shoulders, nor do the rounders know how many each of us have done. I have colleagues that consistently do 5 a night. All us admitters know exactly who they are..and yet they're still employed. I shoot for 6-8 a night and my rep is solid.

My record is 18, my next best night was 14. If I do more than 10 a few nights in a row I'm going to feel it for the next couple days. 14-16 on a regular basis even with the midlevel doing 5 is brutal. I dont think that's sustainable. I do think 6-8 is the sweet spot for longevity.

Jesus Christ 18 admits? Pray those are all surgery transfers…

 

[gutonc]

Jesus Christ 18 admits? Pray those are all surgery transfers…

My last night doing hospitalist moonlighting was the one where I admitted 14. Screw that noise.

 

[Nocturnist]

Jesus Christ 18 admits? Pray those are all surgery transfers…

Yup, but that was completely by choice.
We were caught up around midnight (what I affectionately refer to as "winning the game"), when the ED started unleashing admits out of nowhere at that time of night when historically they tend to slow down.
I was feeling competitive that night, so I put my nose to the grindstone and floored it. A naive part of me was expecting some parade the next day or at least a small 'hey, nicely done" from admin. Nope, nada. But the bonus from that night alone paid for most of that month's vacation so it's all good. Not a record I'm looking to revisit anytime soon.

 

[tantacles]

Yup, but that was completely by choice.
We were caught up around midnight (what I affectionately refer to as "winning the game"), when the ED started unleashing admits out of nowhere at that time of night when historically they tend to slow down.
I was feeling competitive that night, so I put my nose to the grindstone and floored it. A naive part of me was expecting some parade the next day or at least a small 'hey, nicely done" from admin. Nope, nada. But the bonus from that night alone payed for most of that month's vacation so it's all good. Not a record I'm looking to revisit anytime soon.

I don’t think I will ever do 18 in a night. My work doesn’t do any kind of eat what you kill bonus, so anything I admit goes into pooled billing. I’ve done 10, but with cross cover on top of that I was barely done at the end of my 11 hour shift.

And more often than not, the evening ED physician will give me 5-6 between the hours of 8-10. If it’s one of the ones who knows how to text (I give them all my number and tell them to please just text the room number and what they have), things can be very easy, but if they’re stubborn and want to go through the clerk and have a conversation every time, each new admission conversation can eat 10 minutes.

 

[Nocturnist]

I don’t think I will ever do 18 in a night. My work doesn’t do any kind of eat what you kill bonus, so anything I admit goes into pooled billing. I’ve done 10, but with cross cover on top of that I was barely done at the end of my 11 hour shift.

And more often than not, the evening ED physician will give me 5-6 between the hours of 8-10. If it’s one of the ones who knows how to text (I give them all my number and tell them to please just text the room number and what they have), things can be very easy, but if they’re stubborn and want to go through the clerk and have a conversation every time, each new admission conversation can eat 10 minutes.

Agreed! If I'm not incentivized-i draw a hard line at 10 admits. I believe that's an honest, hard effort that nobody can criticize. Any more than that, they need to call backup or expect the day team to come into some undones. That one hospital I worked at for a year, the ED was staffed almost entirely with novice mid levels who all wanted to have a whole presentation by phone (and I couldn't trust some enough to not go through it all anyway). 20 admissions quickly eat up 2-3 hours of your night just accepting them!

 

[Planes2Doc]

So what is going to happen when there are more than 7 admissions and you dont want to be ambitious ? They call a back up? The ED is going to refuse the admission?
The thing is… there are no actual caps on admission when you are an attending…if the admissions come, you will have to admit them… nice they will give you a bonus, but they are not going to let you refuse an admission.

We have an "unseen" list. One of our NPs will put in basic orders and other necessary ones like antibiotics, breathing treatments, fluids, or therapeutic anticoagulation if needed. We have an NP for admissions and one for cross-coverage only, though depending on who it is, one might do these orders. We work on RVU bonus, so I may see more patients than my cap of 8 depending how the night is going. But ultimately, even if you max out at the beginning of the shift by walking in the door, people will still go on the unseen list even if it's only 9PM.

 

[aafisahar]

We have an "unseen" list. One of our NPs will put in basic orders and other necessary ones like antibiotics, breathing treatments, fluids, or therapeutic anticoagulation if needed. We have an NP for admissions and one for cross-coverage only, though depending on who it is, one might do these orders. We work on RVU bonus, so I may see more patients than my cap of 8 depending how the night is going. But ultimately, even if you max out at the beginning of the shift by walking in the door, people will still go on the unseen list even if it's only 9PM.

An entire night without being seen is dangerousml. If an admit comes at like 4am, that's understandable, but for 8-10 hours? That's a lot of faith in tuck in orders.

 

[Planes2Doc]

An entire night without being seen is dangerousml. If an admit comes at like 4am, that's understandable, but for 8-10 hours? That's a lot of faith in tuck in orders.

That makes sense, but the orders placed are pretty thorough. We have been working on getting the NPs to see more patients and so the unseens usually start well after midnight.

 

[chessknt]

One might wonder why they need an overnight physician at all if a single orderset can automatically take care of patients so well.

 

[tantacles]

One might wonder why they need an overnight physician at all if a single orderset can automatically take care of patients so well.

Because when a patient starts to crash, they need to be seen. It’s a placeholder for what should be done and not a perfect substitution.

 

[chessknt]

Because when a patient starts to crash, they need to be seen. It’s a placeholder for what should be done and not a perfect substitution.

Er doc can’t do that? Maybe patient wouldn’t have crashed if they had been seen? Nocturnist is too busy to admit people but can see crashing patients and manage them now? See the logical gymnastics of these caps? I can’t believe any employer would tolerate this for long. Either they don’t have enough docs and people leave because schedule is grueling or they have too many but allowing people to just chill after 8 admits and bend the daytime producers over is ridiculous.

Residents can handle more than that, I can do 8 icu admits with full procedural support in 13 hours overnight and could still have time to chill. A np should be able to handle 8 routine admits. A nocturnist should be able to handle double that if not having to deal with cross cover, not on a routine basis but to just call it quits at 8 especially if leaving people unseen for almost half a day… low standard of care there.

 

[tantacles]

Er doc can’t do that? Maybe patient wouldn’t have crashed if they had been seen? Nocturnist is too busy to admit people but can see crashing patients and manage them now? See the logical gymnastics of these caps? I can’t believe any employer would tolerate this for long. Either they don’t have enough docs and people leave because schedule is grueling or they have too many but allowing people to just chill after 8 admits and bend the daytime producers over is ridiculous.

Residents can handle more than that, I can do 8 icu admits with full procedural support in 13 hours overnight and could still have time to chill. A np should be able to handle 8 routine admits. A nocturnist should be able to handle double that if not having to deal with cross cover, not on a routine basis but to just call it quits at 8 especially if leaving people unseen for almost half a day… low standard of care there.

There have been nights at one of my hospitals where I got 18 admissions. I think it’s commendable that you’re able to handle that kind of volume. While it may be possible for me to have a colossal night where I admit 12-13 patients in a night, it becomes unsustainable. You triage, see the sickest of the sick, put in holding orders for everyone else, and then adjust as needed. Nocturnist life is a marathon, and you have to pace yourself.

However, I’ve said it before and I’ll say it again: NP’s, as a general class, do not have the training to determine which admissions are routine and which are not.

I appreciate that you are most definitely efficient and motivated. The reality of nocturnist life is very different from residency in many ways, and each institution has its own struggles. I think walking a mile in someone else’s shoes is worthwhile here to actually figure out what these jobs look like. I worked night shifts at about 7 different hospitals with 2 groups to figure out what actually worked in terms of work environment, and it does get hard no matter where you work; the struggles are just different, especially when you do this full time. Motivation waxes and wanes.

Am I saying it’s impossible to keep the kind of motivation and efficiency you have long term? No, but if I had to do 16 admissions per night, which it seems is what you’re suggesting, my life would be so miserable.

Nocturnists thrive because nobody wants this job. Nobody wants to work at night except us. That’s the truth of the job, and that’s why it’s possible to find positions where you can admit 8 per night.

 

[chessknt]

There have been nights at one of my hospitals where I got 18 admissions. I think it’s commendable that you’re able to handle that kind of volume. While it may be possible for me to have a colossal night where I admit 12-13 patients in a night, it becomes unsustainable. You triage, see the sickest of the sick, put in holding orders for everyone else, and then adjust as needed. Nocturnist life is a marathon, and you have to pace yourself.

However, I’ve said it before and I’ll say it again: NP’s, as a general class, do not have the training to determine which admissions are routine and which are not.

I appreciate that you are most definitely efficient and motivated. The reality of nocturnist life is very different from residency in many ways, and each institution has its own struggles. I think walking a mile in someone else’s shoes is worthwhile here to actually figure out what these jobs look like. I worked night shifts at about 7 different hospitals with 2 groups to figure out what actually worked in terms of work environment, and it does get hard no matter where you work; the struggles are just different, especially when you do this full time. Motivation waxes and wanes.

Am I saying it’s impossible to keep the kind of motivation and efficiency you have long term? No, but if I had to do 16 admissions per night, which it seems is what you’re suggesting, my life would be so miserable.

Nocturnists thrive because nobody wants this job. Nobody wants to work at night except us. That’s the truth of the job, and that’s why it’s possible to find positions where you can admit 8 per night.

I worked as a nocturnist for about half a year and would routinely walk in to 3-4 admits off the bat (day docs were swamped census 25+). I would avg 8 admits but had bad nights of 13. The job sucked but because of admin, not the work itself. I would never leave anything for day team unless it was truly last minute because it was like shooting myself in the dick if I was working again that night. No such thing as a cap or backup. Small community hospital that just went under last year from covid. Can’t imagine an 8 admit cap model being financially sustainable. Never in a million years would I have paraded around admin touting how important I was that the day team should get ****ed over even more because I didn’t want to work too hard. Maybe that was just my environment though and that approach is normal now?
I know there isn’t a backup or cap in icu and if I get slammed with admit just have to deal with it. Other people step in to help out (er doc for boarders, Pulm rounder etc) if it’s really bad.

 

[Nocturnist]

My hospital routinely has several undones waiting 8-12 hours in the morning to be admitted. At some point we trialed ED holding orders- the ED provider would be placing skeleton admit orders so they can go up to the floor in lieu of triaging them to a hospitalist. They're doctors too, right...whats the worst that could happen? Besides, nocturnists can just be replaced by an order set so what's the big deal?

That trial lasted 3-6 months before half the hospitalists left over multiple terrible outcomes and job dissatisfaction. Dvt prophy ordered for bleeders. Critical home meds not given. Contraindicated home meds ordered. Many misdiagnosed and decompensated on the floor, several deaths. They couldn't even get most diet orders correct.
Hospitalist chief was replaced over this debacle, we're only recently recovered as a group.The ED has tried resurrecting this a couple times since, CEO has vetoed it every time. ER docs, mid levels, algorithms, order sets...none of them can do what I do as well, safely, and efficiently as I do.

I work with residents at my side job, the overnight team of 2 interns and a resident caps at 10 admits and doesn't take any past 4am. Give them as a team more than 8, and they are collectively visibly stressed and struggling to get their notes done. The side job I left had me overseeing a NP- I've never seen them do more than 5 (and thats with half my cross coverage, no triaging or rapid responses, and me giving them the plan for their admit word for word).

My main gig has set a goal census of 12-15 for the rounders and upstaffed according to volumes so they don't exceed that. At my side gig the rounders census' is 10-12. Before these caps were being implemented on rounders, censuses were 20-25, rounders were getting 30k quarterly bonuses but still leaving in hoards due to burn out.

Nocturnist medicine really is a marathon.I'm there to provide excellent 24/7 care and do as much as I reasonably can in 12 hours while continuing to do so for the next 30 years.
You can try to be a hero every night or you can have longevity/job satisfaction but you can't have both. Any hospital or admin that tries to you otherwise is penny wise and pound foolish. The mentality and stigma of being perceived as weaker or being shamed by days for leaving undones has got to be checked at the door.

So does any concern over the financial viability of the nocturnist model. I sleep quite well knowing the hospital loses tens if not hundreds of thousands of dollars on me. Frankly, I DGAF. Just by walking through the door and staying awake for 12 hours- I'm already doing something that 90٪ of the rest of the world either doesn't want to do or can't do on a consistent basis. Even if I come in and dont do a single admit, I'm keeping hundreds of patients safe at night and advancing their plan of care. I'm immediately and continously available to provide anything from a sleeper to critical care to any/all of those patients (some nights I bill more CC time than the intensivist). If admin thinks they can get a better value, be my guest..they already would have. Yet despite increased subsidization, the percentage of adult hospitalist programs utilizing nocturnists increased to 72.3% in 2016 from 46.1% in the 2012 SHM report. I suspect its more than 90% today. Nocturnists continue to enjoy a shift or pay differential or both, and overall supply has never caught up to demand, nor will it soon. No one needs to parade how important to admin, the numbers speak for themselves. My nocturnist group has quadrupled in the last 5 years without signs of slowing down.

Tldr; do as much as you can sustainably, live to die another day.

 

[Splenda88]

My group pay nocturnists 55-60k extra depending on the hospital.

If I were to work night, I probably would do it for a short period of time (< 3 years) and I would not work anywhere where I would admit 8+ patients on a regular basis.

 

[tantacles]

All right. It happened. I went down to 1.0 FTE permanently (just my main job) because everything is opening, and working effectively 2 full time jobs (original job plus another hospital) just isn't worth it. 10 shifts per month is going to feel great. I saved a ton of money and feel super secure and now can just coast a little.

 

[Planes2Doc]

All right. It happened. I went down to 1.0 FTE permanently (just my main job) because everything is opening, and working effectively 2 full time jobs (original job plus another hospital) just isn't worth it. 10 shifts per month is going to feel great. I saved a ton of money and feel super secure and now can just coast a little.

Congratulations! Now you can enjoy the amazing benefits of a block schedule. I used to joke about being a stay-at-home dad all the time. But now it's a reality most of the month!

 

[Siggy]

My hospital routinely has several undones waiting 8-12 hours in the morning to be admitted. At some point we trialed ED holding orders- the ED provider would be placing skeleton admit orders so they can go up to the floor in lieu of triaging them to a hospitalist. They're doctors too, right...whats the worst that could happen? Besides, nocturnists can just be replaced by an order set so what's the big deal?

Someone seriously asked, "What harm could be done by asking a physician to work outside of their specialty?"

 

[Nocturnist]

Someone seriously asked, "What harm could be done by asking a physician to work outside of their specialty?"

One or two prominent members on this thread have already condoned this and thoroughly belittled my job as one that can be done by several zoo animals. Any surprise admin thought this was a clever idea?

 

[Splenda88]

Someone seriously asked, "What harm could be done by asking a physician to work outside of their specialty?"

Devil's advocate here: There is a great deal of overlap between IM/FM/EM, but I see your point.

 

[Siggy]

Devil's advocate here: There is a great deal of overlap between IM/FM/EM, but I see your point.

There is... and if being an internist is so easy, why were people apparently dying left and right?

I mean, sure, I can easily see adult medical patients in the ED... I have no business replacing an EM physician because I won't have the same speed, nor the ability to handle ortho, trauma, peds, or neonates. My risk stratification for admit vs discharge is also going to be weak.

 

[chessknt]

There is... and if being an internist is so easy, why were people apparently dying left and right?

I mean, sure, I can easily see adult medical patients in the ED... I have no business replacing an EM physician because I won't have the same speed, nor the ability to handle ortho, trauma, peds, or neonates. My risk stratification for admit vs discharge is also going to be weak.

I highly doubt that happened but it is the internet where anything and everything is real. Floor admits arent going to die because the ED didnt order a culture or check a UA or fix the blood glucose of 300 or K of 3.1 overnight give me a break.

 

[Siggy]

I highly doubt that happened but it is the internet where anything and everything is real. Floor admits arent going to die because the ED didnt order a culture or check a UA or fix the blood glucose of 300 or K of 3.1 overnight give me a break.

That trial lasted 3-6 months before half the hospitalists left over multiple terrible outcomes and job dissatisfaction. Dvt prophy ordered for bleeders. Critical home meds not given. Contraindicated home meds ordered. Many misdiagnosed and decompensated on the floor, several deaths. They couldn't even get most diet orders correct.

I'm just going off of what was the reported results. I do think there's a lack of respect for internal medicine as a speciality among internists though. It seems that there's two large camps in IM. The "we need a subspecialist for everything" camp and the "Gee, my specialty is super easy, I completely don't understand why everyone else can't do the thing that we took 3 years to start to perfect in residency in addition to their own specialty."

I agree those things shouldn't cause a death... unless that BGL of 300 comes with an anion gap of 30. However the fact that rapid responses occurs from time to time immediately after a patient reaches the floor or that I have hospitalist service NPs overnight consulting me (critical care) to give the patients a once over is an indication that IM is more complicated than a lot of people give it credit for.

 

[InternistDO]

You'd think that a subforum of internists would have a bit more respect for the specialty of internal medicine.

(You also don't need to have a patient die for their outcome to be made worse by bad care.)

 

[chessknt]

You'd think that a subforum of internists would have a bit more respect for the specialty of internal medicine.

(You also don't need to have a patient die for their outcome to be made worse by bad care.)

Well to be fair in this scenario it is having no doctor vs an er doctor and for some reason the Er doctors killed patients and made all the nocturnists quit (who are so overwhelmed after 8-10 admits that they can’t possibly do more work without a financial bonus hence holding orders with no actual workup). You tell me if you think dunking on em while drawing a hard line on the amount of work you want to do patient care be damned is worthy of respect.

You think the Er docs stop seeing patients after a certain number and just let the waiting room explode?

 

[kaycee18]

Only 2 admits per night is good, but I think 210k/yr is too low. Almost all the nocturnist jobs I have seen pay 300k+/yr (12 hrs, 7 days on/off); however, the average admit is 8-12. In my opinion, more than 8 admits per night on a 12 hr-shift is not safe.

I interviewed for hospitalist job the other day, and the PD was also selling me an open nocturnist position that pays 385k/yr.... 12 hrs, 7 on/off and average admit was 8-10.

How much does sound physician or team health pay for nocturnist per hour?

 

[CopaceticOne]

I highly doubt that happened but it is the internet where anything and everything is real. Floor admits arent going to die because the ED didnt order a culture or check a UA or fix the blood glucose of 300 or K of 3.1 overnight give me a break.

Here are some examples I’ve seen when something like this was trialed for a very short time at one of the hospitals I was at during residency:

1) patient septic and needed 2L of IVF in ED but now stable enough for the floor. They held all of the meds that they thought could affect blood pressure - including the sildenifil for patients severe pHTN (PASP upper 70s).

2) DKA patient with open gap, but bicarb still in ok range. Admitted to the floor to follow the standard weight based floor protocol of subq Aspart q2H. Except the patient at home is on a 85+5 schedule of U500 at home.

3) Frequent flyer COPD patient who is obese and still actively smoking came in with cough, SOB, DOE. Admit for “the usual” exacerbation. Except weight was up 30+lbs from just 2 weeks ago.

Not surprisingly each one of the above patients ended up in the ICU within 12hrs in very horrible shape.

 

[chessknt]

Here are some examples I’ve seen when something like this was trialed for a very short time at one of the hospitals I was at during residency:

1) patient septic and needed 2L of IVF in ED but now stable enough for the floor. They held all of the meds that they thought could affect blood pressure - including the sildenifil for patients severe pHTN (PASP upper 70s).

2) DKA patient with open gap, but bicarb still in ok range. Admitted to the floor to follow the standard weight based floor protocol of subq Aspart q2H. Except the patient at home is on a 85+5 schedule of U500 at home.

3) Frequent flyer COPD patient who is obese and still actively smoking came in with cough, SOB, DOE. Admit for “the usual” exacerbation. Except weight was up 30+lbs from just 2 weeks ago.

Not surprisingly each one of the above patients ended up in the ICU within 12hrs in very horrible shape.

So you are postulating if instead the Ed put no orders in and sent them to the floor sight unseen on some sort of automated order set dictated by an internist the outcomes would have been better? Because the comparison being made wasn’t im vs em it was em holding orders vs admit to floor without being seen on an I’m order set because the nocturnist was too busy to see them.

I am in icu, I can list examples of boneheaded **** that every specialty has done that lands people in my unit, that doesn’t mean that I need to go rush out and take care of everyone in the hospital to prevent it…

 

[CopaceticOne]

So you are postulating if instead the Ed put no orders in and sent them to the floor sight unseen on some sort of automated order set dictated by an internist the outcomes would have been better? Because the comparison being made wasn’t im vs em it was em holding orders vs admit to floor without being seen on an I’m order set because the nocturnist was too busy to see them.

I am in icu, I can list examples of boneheaded **** that every specialty has done that lands people in my unit, that doesn’t mean that I need to go rush out and take care of everyone in the hospital to prevent it…

I’m not postulating anything. I simply responded by giving examples of some not good outcomes that happened during the trial period - sorry, I should have said that we actually trialed both ED putting in held orders & a very basic standard admission order set for medical patients. In retrospective examination, both approaches had some bad outcomes.

The institution abandoned further implementation / continuation of processes which were trialed because neither EM nor IM were pleased when the outcomes when examined.

Instead (or maybe because of) the institution realized they actually needed to deal with the increased workload overnights by increasing nocturnist staffing. It is all about the money; and, I would hazard a guess that when they looked at the financial risk/benefit it made the bean counters uncomfortable to not have a patient’s admission managed in the same manner day vs night.

 

[Nocturnist]

Ever heard of the Duesberg Phenomenon? Named after UC Berkley Professor Peter Duesberg's theory that various noninfectious factors are the cause of AIDS and that HIV is merely a passenger virus, also rejecting the involvement of retroviruses and other viruses in cancer. Despite his claims being refuted by a large and growing mass of evidence showing that HIV causes AIDS, Duesberg kept doubling down on his claims- Over time moving from one of the forefront molecular biologists in the world to gaining notoriety as one of the most prominent HIV denialists. Something like 1/3 million deaths in South Africa are attributed to him.

We are witnessing in person the evolution of the chessknt phenomenon- an internet troll so spiteful of hospitalist and nocturnists he/she will double down on the theory of their laziness and ineptitude despite mounting evidence to its contrary.

Please do not feed the trolls.