The doctors who only come out at night
The fifth-floor call room at Boston Children’s Hospital is Dr. Sarah Henry’s home away from home.
She stashes chicken masala dinners and low-fat yogurt in the refrigerator and makes sure the janitor puts fresh white sheets on the bed. She hopes to sleep between 1 a.m. and 4 a.m. but knows there are no guarantees in her position.
Henry, 66, is Children’s chief “nocturnalist.” Her specialty: overnights.
Amid the growing national focus on patient safety, hospitals are increasingly hiring experienced physicians to work overnight shifts on general medical floors. Residents — doctors in training — and nurses often have managed patients during these off hours, with help from attending, or staff, physicians on-call at home.
But nocturnalists, or nocturnists as they are also known, give patients the benefit of a supervising doctor who checks on them in person. Groggy attending physicians who have already put in a full day are not repeatedly woken up to provide guidance.
“Night call is really busy,’’ said Dr. John Nelson, a physician at Overlake Medical Center outside Seattle and cofounder of the Society of Hospital Medicine, which represents doctors who treat acutely ill patients. “It always feels wrong when a nurse calls me at 2 a.m. and I want to be asleep and we need to talk about this patient.
“It makes sense to have somebody in the building,’’ he added.
Children’s Hospital was an early adopter of scheduling attending physicians to work overnight on general units — Henry has been head nocturnalist for three years. Unlike many doctors, she loves it.
Nights are more casual — one recent evening she wore a fleece pullover, scrub pants, and sneakers. Administrative meetings are rare and office politics are distant. “All the daytime stuff falls away and I can focus on specific patients,’’ said Henry, who was an environmental lawyer and then a sheep farmer before attending medical school at age 40. “There is a simplicity and clarity.’’
Since she doesn’t drink coffee (just “hippie tea’’), she takes the stairs between the street-level emergency department and patients on the 11th floor to clear her head. She oversees as many as 40 patients at night.
On a recent shift, she received her first page at 5:27 p.m., from the emergency department about a teen with kidney pain.
She called Dr. Carrie Danziger, the emergency room attending physician on duty. “I am eager to hear the story,’’ Henry said, knowing she would be responsible for this girl overnight.
Only attending physicians can transfer patients from one unit to another at Children’s. Without Henry onsite, Danziger would have had to call a staff doctor at home to admit and manage the teen — a patient the doctor would have never seen.
Medical publications now run advertisements for nocturnists. In 2014, 81 percent of adult hospitalist groups had a physician in the hospital all night, according to a survey by the Society of Hospital Medicine. That grew from 55 percent two years prior.
Brigham and Women’s Hospital in Boston recently expanded the number of doctors onsite overnight and now has 30 nocturnists. South Shore Hospital in Weymouth is advertising for its fifth nocturnist. Beth Israel Deaconess Medical Center also has staff doctors in the hospital overnight on general medical floors, while Boston Medical Center uses nocturnists in its adult units.
Massachusetts General Hospital also has staff doctors onsite overnight, though it doesn’t call them nocturnists, a term usually reserved for physicians who work the shift only as a career choice. Doctors generally get a pay boost or more time off, or both, for agreeing to work overnights routinely.
At Children’s, attending physicians have traditionally worked overnight in the emergency room and intensive care unit, but services such as oncology and pulmonology still have supervising doctors on-call at home.
Boston Medical Center, which has fewer seriously ill pediatric patients than Children’s, does not use nocturnists on its pediatric units, although the hospital this year expanded the hours of the daytime attending physician until 9 p.m.
Boston Medical Center and Children’s share a joint residency program, and residents see pros and cons to each approach. The traditional system gives residents more autonomy before going out to practice medicine on their own.
“We talk about this a lot,’’ said Dr. Elyse Portillo, a third-year resident in the program. “The assumption is these are children who are deemed safe for the floor by the ER staff. One of the thoughts is that this is a nice environment for trainees to practice with a little bit of autonomy and make decisions.’’
But at times at Children’s, particularly as a younger resident, she has been relieved to have an attending physician on hand.
Boston Medical Center “pushes you to think through problems a little more,’’ said Dr. Paul Critser, a third-year resident. But having an attending physician onsite helps for really complicated patients and for procedures like a lumbar puncture when “you want an extra pair of hands,’’ he said. “At BMC you’d be trouble-shooting those procedures on your own.’’
Dr. Robert Vinci, Boston Medical Center’s chairman of pediatrics, pointed out that there are lots of backup resources: overnight attendings in the neonatal intensive care unit and the emergency room and a second-year resident on the inpatient service who is in contact with an attending at home. “We feel there is a very reasonable amount of supervision,’’ he said.
Teaching hospitals such as Children’s encourage residents to contact attending physicians for help, whether they are in the hospital or at home. But it can be tricky for residents to know when a patient’s condition warrants a 2 a.m. call to an attending, said Nelson, of the Society of Hospital Medicine. Having a doctor in-house who welcomes the contact makes the communication easier.
How to respond is sometimes dicey for the on-call attending physician, too. “Boy is that a tough call to make,’’ he said. “I have stayed home when in retrospect there was potential value of me coming in.’’
Dr. Ebrahim Barkoudah, medical director of nocturnist service at the Brigham, said he does not know of any research comparing the safety of having attending physicians on-call versus in the hospital overnight. But he believes nocturnists are able to ease congestion in the ER by admitting patients to floors at all hours.
“The issue is the cost,’’ said Dr. Vincent Chiang, chief of the hospitalist program at Children’s. “Physicians are more expensive than trainees. And you need higher incentives to get people to sign up’’ at night.
During the recent overnight shift in May, Henry ordered pain medication for the teenager and calmed the distraught family of an 8-year-old boy whose eye was swollen shut from an unknown infection and required antibiotics.
There was a foot abscess, feeding problems, asthma, and pneumonia. She questioned the Russian mother of a 7-year-old boy being monitored for appendicitis, communicating with help from an interpreter on video conference.
“We’ll keep a close eye on him,’’ Henry told her.
Because it was near the end of their training in June, the third-year residents were more experienced. It there hadn’t been a nocturnist, they may have called attendings at home for guidance on some cases but Henry doubts any patients would have been serious enough for a senior physician to drive in. But it was busy enough to keep her up most of the night.
She recalls previous nights when her presence was a real benefit. A newborn arrived in the emergency room with a complicated shoulder abscess. The post-operative plan was to send the 2-week-old to the general pediatric floor. But Henry intervened, advocating for the baby to stay in the neonatal intensive care unit.
A nocturnalist’s work usually doesn’t involve dramatic saves, Henry said, but an added safety check, tweaks that improve patient care and satisfaction.
“That baby needed a much higher level of monitoring,’’ she said. “When you have a big complicated issue, it’s better to have someone who can navigate it and think about whether there is a better option.’’