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Doctors of the Night

POSTED: June 08, 2011, 12:00 am

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Being in a hospital at night or over a weekend can be hazardous to your health, and even has a name: "the weekend effect." A raft of studies has documented higher rates of death, complications and medical errors affecting patients treated at night or on weekends.

"After normal working hours it's mostly maintenance," said Jessie Gruman, 56, director of the Washington-based Center for Advancing Health, a nonprofit health-policy group. "There's a real sense of vulnerability you have at night when you know things are not happening at full speed. There's less nursing care, less access to a doctor and more demands on doctors," added Gruman, a veteran of more than 35 years of hospitalizations to treat cancer-related illnesses.

To bridge the chasm between the day and night shifts, hospitals from Syracuse to Seattle are hiring a new breed of subspecialist called a "nocturnist" -- an experienced doctor who works overnight taking care of patients outside the emergency room. The growing demand for these physicians, who typically work fewer hours and command higher salaries than their daytime counterparts, is being fueled by several factors: the widespread acceptance of inpatient specialists known as hospitalists, who are often eager to bolster night coverage by hiring nocturnists; mandatory limits on the work hours of interns and residents, the most inexperienced doctors who traditionally cared for patients at night in teaching hospitals with little supervision; and a push by the federal government and other groups to improve safety.

"I think it's a very good thing for patients," said John Nelson, a pioneer of the hospitalist movement who coined the term "nocturnist." Added Nelson, who is based in Seattle, "It shouldn't matter if a patient arrives with pneumonia at noon or midnight. What matters is that patients have a doctor who's there and awake and expecting to work."

That may not be the case. A 2008 study published in the Journal of the American Medical Association found that patients who suffered a heart attack in the hospital during off hours -- when 50 to 70 percent of patients are admitted -- were less likely to survive than those who had a cardiac arrest during normal business hours. Last year researchers at the University of Pennsylvania found that the quality of cardiopulmonary resuscitation at three urban teaching hospitals was poorer at night than during the day. And the president of New York's Beth Israel Medical Center decried the "stark discrepancy in quality between daytime and nighttime inpatient services" in a 2008 article in the New England Journal of Medicine.

Linda Dembo knows firsthand what can happen to hospital patients at night. In May 2007, her 13-year-old son Jonathan was admitted to a St. Louis hospital for surgery to fix a blocked shunt that had been implanted in his head as part of successful treatment for brain cancer he had as a baby.

The neurosurgeon was at home, and Jonathan was being cared for by a resident, his mother said.

"It was a skeleton staff and very quiet," said Dembo, recalling that Sunday night. She said she insisted that a nurse summon a doctor when her son began complaining of a severe headache around 9 p.m. Dembo said that the resident on duty ordered a sedative by phone; she and her son fell asleep around 10:30, and Dembo said that records show no doctor saw him. At 5 a.m., Jonathan was found dead; an autopsy was not performed, but Dembo said she was told he probably died of aspiration, essentially choking in his sleep.

"I know in my heart that had a doctor come and seen him, the outcome would have been very different," she said.

Greasing the Wheels

Catherine Washburn, a nocturnist at Johns Hopkins Bayview Medical Center, said that adding physicians at night benefits patients because they can start treatment immediately. "I can grease the wheels . . . and move people into the hospital more quickly and efficiently," she said. Patients bound for the intensive care unit who once waited six hours in the emergency room for a bed are now moved into the intensive care unit within 90 minutes of arrival.

Precise numbers are not available, but Nelson estimates that about 1,500 hospitals employ at least one nocturnist, compared with fewer than 100 a decade ago. Besides Hopkins, they include Sentara Williamsburg Regional Medical Center in Virginia, the University of California San Francisco Medical Center, the Cleveland Clinic and the Baptist Health System in San Antonio.
At hospitals that don't employ nocturnists, such as Virginia Hospital Center in Arlington, a team of hospitalists shares night and weekend coverage.

Although arrangements vary, full-time nocturnists typically work three or four shifts per week, often from 7 p.m. to 7 a.m. As recently as a decade or so ago, night coverage outside emergency rooms was mostly provided in community hospitals by a "house doctor" -- sometimes a moonlighting resident or an out-of-favor physician nearing retirement -- or by doctors in private practice who rotated taking "beeper call" at home, fielding problems by phone or, if necessary, returning to the hospital after a full day's work to handle an emergency.

In teaching hospitals, exhausted, overworked and largely unsupervised interns and residents fresh out of medical school routinely worked 100 hours or more per week, sometimes 36 hours straight without sleep. Senior doctors could be called at home, but trainees were supposed to figure things out and learn from their mistakes, which sometimes killed patients.

"There was an ethic of self-sufficiency," recalled nocturnist advocate Winthrop Whitcomb, a co-founder of the Society of Hospital Medicine and director of health-care quality at Baystate Medical Center in Springfield, Mass. As a resident in the early 1990s, Whitcomb said, he witnessed a patient who was admitted at night and died the following day from cardiac compression that went undiagnosed until it was too late.

In 2003, after years of vehement opposition by hospital and doctors' groups, the Accreditation Council for Graduate Medical Education limited work weeks to 80 hours for interns and residents, rules modeled after those adopted in New York in 1989. The ACGME was prodded by high-profile cases of patient injury and death, most notably that of 18-year-old Libby Zion, who died of cardiac arrest in a Manhattan hospital hours after being admitted at night for a flulike illness; she was cared for by a sleep-deprived intern who was juggling more than 40 patients.

Other requirements to bolster patient safety have also led to increased staffing at night. Standards issued by the Joint Commission, which accredits hospitals, have led to the development of rapid response teams led by doctors to care for patients whose condition worsens. Beginning next year, the new health-care law requires that Medicare payments to hospitals reflect patient satisfaction scores.

"There are consequences to bad care that didn't exist before," said Robert Wachter, associate chairman of the department of medicine at the University of California at San Francisco and an expert in hospital medicine. "And there is an increased level of expectation that patients have for quality and safety."

Dr. Terance Millan discusses his role as a nocturnist at North Florida Regional Medical Center.

Not the Graveyard Shift

When internist Terance Millan agreed to work the night shift at North Florida Regional Medical Center in Gainesville in 1997, he thought it would be only temporary. "But here I am 14 years later," said Millan, 51. Working nights enabled him to spend time caring for his children, now 20 and 22, and offered flexibility that his wife, also a doctor, needed.

Millan is one of three staff nocturnists; each works 15 days per month from 4 p.m. to midnight or 7 p.m. to 7 a.m. He said he likes the autonomy, the esprit among the night staff and the fact that "when I'm off, I'm off."

Nights were slow at the beginning, but that has changed dramatically. "We're very busy," said Millan, who sometimes admits 22 patients during his shift, many of whom are very sick.

Hopkins' Washburn, 47, said her workload has escalated since 2006, when she began working part time. Her schedule – every Friday from 8 p.m. to 8 a.m. and the same shift every other Saturday -- has given her the flexibility to home-school her three children. She has trained herself to fall asleep when she gets home, relying on earplugs, a darkened room and her family's cooperation.

Working nights, Washburn said, "is not difficult for me. I think some people can tolerate it. There are fewer interruptions and distractions at night." Although she does not officially supervise residents, they consult her about patients and she evaluates ICU admissions and confers with nurses and other staff when problems arise.

Gruman says that as both a patient and an advocate, she regards the use of nocturnists as "long overdue. The need for night coverage has always been there," she said. "It's so hard for me to believe that it's taken this long."

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente. This article was written in coordination with the Washington Post.

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