When the sun goes down, one segment of the physician population wakes up. They're not vampires, even if they do have to syphon the odd vial of blood. These creatures of the night spend traditional sleeping hours practicing medicine.
Nocturnists, also known as nighttime hospitalists, work night shifts — typically from 6 or 7 PM to 6 or 7 AM — in inpatient hospitals and emergency departments.
Long hours and sleep deprivation are nothing new to hospital physicians, yet it may seem counterintuitive that health professionals would choose a path that disrupts their sleeping and eating schedules while offering limited resources at work. At night, hospitals are often stripped down to the bare bones: fewer patients and visitors, fewer staff members, and fewer open departments. The halls tend to be empty, illuminated only by fluorescent lighting.
That's part of the appeal. And some say the benefits — including higher pay — make the unorthodox environment and hours not only worth it, but even preferable.
"The hospital is surprisingly more beautiful at night, in my opinion," said Nina Lum, MD, a family medicine doctor who occasionally picks up night shifts. "It's quiet, and there's less foot traffic from nonpatients, which really facilitates work on the real patients. Sometimes this can bite you in the back because you don't have all the services your patient may need, as these departments are closed. But to me, it's better for patient care when providers are less distracted."
Why Embrace a Nighttime Workday?
In 2011, The Washington Post detailed the emergence of "a new breed of subspecialist called a 'nocturnist.' " Before the rise of the subspecialty, patients were often placed in the care of less experienced healthcare professionals during off hours. The results showed: A 2008 study found that inpatients who experienced cardiac arrest were at greater risk for death during nights and weekends compared with during the day shift.
A slew of similar studies followed and led to the call for nocturnists. In a 2020 resident physician survey, 61.3% of respondents who had a nocturnist reported "always receiving adequate supervision to ensure patient safety overnight," compared with only 40.5% of those without a nocturnist.
Today, there remains a need for experienced healthcare professionals to work the night shift. Health facilities tend to offer a 15% pay increase, on average, to incentivize physicians to work nights.
The biggest concern is the potential impact of a long-term night schedule on physicians' health and lifestyle. "I think at some point, money no longer becomes an incentive when physicians' health or quality of life or well-being or family stability is in question," Lum says.
Still, some nocturnists find that the night schedule improves their quality of life. "The pay was an added bonus, but the main reason I switched to nights was to make my own schedule," said Charmaine Gregory, MD, an emergency care physician who has been a nocturnist for 17 years. "I wanted to take back control of my life. I went into emergency medicine because I wanted to be able to work so that I can live, and not the opposite."
The decision to become a nocturnist is often linked to individual needs and lifestyle factors, such as stage of life, family responsibilities, and career priorities.
"I recommend it for physicians who are in the earlier stages of their career, like when they've just graduated from their residency, like me," says Matthew Nguyen, MD, an internal medicine specialist who has been a nocturnist for 2 years. "I think it's really good for someone who is in their younger years or in the early stages of becoming a physician, because [you get to practice] more medicine. Your main duties throughout the night are seeing patients, putting in orders, admitting, versus when you work in the daytime, there are a lot more meetings you have to go to, and you have to talk to social workers. At night, it's strictly practice."
That Pesky Sleep Problem
A key point of skepticism about working as a nocturnist is the sleep schedule that comes with it. While trying to get enough sleep, nocturnists may have to face daytime disturbances like sunlight, barking dogs, construction noises, and family members or roommates who operate on opposite schedules.
Nguyen finds it easy to sleep during the day, with a little help from aids like an occasional melatonin, an eye mask, and blackout curtains. But he also talks to colleagues who say the sleep schedule gets in the way of their family lives. "I'm single with no kids, so it doesn't really bother me, but my colleagues have family and talk about how tough it can be sometimes," he says. "For example, they might go to bed at 10 a.m. and have to pick their kids up from school at 3 p.m., so they have to wake up in 4 or 5 hours."
But Gregory finds that the nocturnist schedule helps her family life. It previously allowed her to homeschool her kids and to take them on field trips and playdates. Now that her kids are older and in school, she can go to their sports games and afterschool activities. "I would say that being a nocturnist is very conducive to having a family," she says. "I'm able to do all the things that, traditionally, people who are stay-at-home moms would do. Being a nocturnist allowed me to essentially be there for my children a whole lot more than if I were working the different shifts in the daytime or afternoon."
Gregory's work as a nocturnist is made easier by the fact that she can sleep in a silent house or a noisy one. For those who aren't so lucky, she suggests blackout curtains, ear plugs, and devices like fans that create white noise and keep bedrooms cool.
Does It Take a Health Toll?
It's important to note that night-shift workers have a 25%–40% greater risk of depression and anxiety, due in part to disruptions to their circadian rhythm caused by their sleeping and eating schedules. Nocturnists often feel they have no choice but to align their eating habits with their topsy-turvy sleep schedule, making a "midnight snack" more of a necessity than a novelty.
"I don't make healthy decisions with my nutrition when I work nights," Lum says. "I eat my lunch around midnight, and that throws your body off a little bit. And often at night I'll go to a vending machine for a snack, which is not a usual habit during the day."
Both Lum and Nguyen say planning ahead helps to limit the negative impacts of the nocturnist lifestyle on nutrition. Lum says she's "most successful" when she prepares a meal in advance to eat during her shift, and Nguyen also preps mid-shift meals like chicken and rice. Even so, new evidence suggests that eating only during the daytime, and not at all at night, can prevent night-shift workers' "mood vulnerability."
Gregory points out the importance of drinking plenty of water and being intentional about movement during night shifts, too. Even in the ER, nocturnists tend to spend a lot of the night entering data into computers with minimal bathroom or stretch breaks. "Even if it means taking the stairs to other parts of the hospital or doing a couple minutes of jumping jacks, you have to incorporate movement into your routine because you can get sedentary," she says. "To me, that is the thing that hurts you the most. You have to really keep moving and stay active, despite being up at night when everybody else is sleeping."
At times, when it feels like the whole world is tucked up in bed, nocturnists share the understanding that the need for effective healthcare never sleeps.
"Maybe because there are quote-unquote less resources we tend to be very team-oriented," Gregory says. "No matter what comes up, that's the thing that allows us to troubleshoot it and make it work. We have to get it done. We have to figure out a way. That can-do attitude — I love that about night-shift workers."
And when they're not busy banding together to solve a late-night problem, nocturnists may even find themselves with some peace and quiet.
"Many times, I'm alone at 4 a.m., just wandering the quiet halls on those slow nights," Nguyen says. "I'm accustomed to it. It's even stranger to pick up shifts in the daytime, when the hospital is crowded, and there's so much chaos and noise. I actually have to wait to use the elevator."
Molly MacGilbert is a Brooklyn-based freelance writer and editor.
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Image 3: Matthew Nguyen
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Cite this: Medicine After Dark: Life as a Hospital 'Nocturnist' - Medscape - Nov 02, 2022.