TIMOTHY JOHNSON, MD, is so intent on changing perceptions about working nights—from them being a slog that residents must endure to being a great opportunity to both learn and advance patient care—that he changed the terminology around night work when he started as a nocturnist attending in 2018.
“We no longer call it ‘the night shift’ or ‘night float’ but ‘night medicine,’ ” Dr. Johnson says. “We want people to understand that this isn’t just a shift to get through until we hand off patients to their primary team in the morning.” In fact, he adds, “what happens at night is just as important as during the day, and we are half of patients’ primary team. We implement and modify care plans, and we can reduce patients’ amount of time in the hospital.”
In changing that perception, it helps that Dr. Johnson is practicing night medicine at VCU Health’s VCU Medical Center in Richmond, Va. Since 2011, that center has maintained an innovative program of having dedicated nocturnist attendings—known as academic nocturnists or GME nocturnists—whose sole job during the week is to help educate and supervise the residents working nights.
“We’ve been able to sell the role by focusing on how it enhances the resident experience and patient safety.”
~ Timothy Johnson, MD
VCU Health
The program is complete with a formal curriculum covering topics and common scenarios that residents frequently come across at night, as well as twice-weekly midnight reports. Those are similar to morning reports with interns presenting interesting cases they’ve run into during their two-week night rotations.
“The beauty of my role is that I don’t have any other clinical responsibilities, so I’m not being pulled in different directions with cross coverage or admissions,” says Dr. Johnson. “I can just focus on maximizing residents’ education at night.”
A more formal curriculum
Dr. Johnson himself spent his residency at VCU Health. He was motivated to take on an academic hospitalist position on graduation by the interactions he had with academic attendings during residency and the learning environment they fostered—an experience he wanted to emulate. At the time, he adds, the night-medicine curriculum was a little less formal and there was more variability in the amount of teaching the academic hospitalists provided.
When he came on board as an attending, Dr. Johnson helped make the curriculum more formal. “We tried to standardize what we teach at night so residents know what to expect and what skills they’ll obtain doing night medicine,” he explains.
That curriculum covers not only diagnostic skills but point-of-care ultrasound, for which he completed the Society of Hospital Medicine certificate of completion and is credentialed. It also focuses on frequent diagnoses that residents see at night including delirium, arrhythmias, hypertension, chest pain, acute hypoxia and respiratory failure, as well as complications of cirrhosis such as upper GI bleeds and hepatorenal syndrome.
“We have better ratios during the day with just me and a select handful of residents,” says Dr. Johnson, noting that “layers of medicine” like disposition planning and social work are not part of routine night medicine. As a result, more time can be spent at the bedside addressing patients’ acute complaints. “At night, we can really get down to what I call the nuts and bolts of medicine.”
Now, as the director of night medicine and an assistant professor at the VCU School of Medicine, Dr. Johnson is one of four academic nocturnists who rotate through nights, each doing about nine shifts per month. They get some scheduling support from colleagues who work a hybrid nocturnist schedule, supervising residents during some night slots while doing clinical work in others.
Maximizing teaching time
As a member of the Society of Hospital Medicine’s nocturnist special interest group, Dr. Johnson notes that interest is growing among that community nationally to provide more education at night.
But such a model, he adds, can sometimes be challenging financially for administrators to implement because the educational program doesn’t produce RVUs. (Dr. Johnson and his fellow academic nocturnists do provide clinical care on weekend nights when the residents are off.) “We’ve been able to sell the role by focusing on how it enhances the resident experience and patient safety.”
He also notes that night medicine is personally very satisfying. “As a nocturnist, I work with residents for a week at a time about once a month,” he says. “That’s much more than most hospitalists average throughout the year when attending on day wards.”
At the same time, he believes that those who see working nights as just a rite of passage that residents have to tolerate are missing key learning opportunities.
“If you’re not taking advantage of night education, then you’re losing a lot of time,” says Dr. Johnson. “Working at night shouldn’t just be something you have to get through.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
