Nocturnist Salary Pay Differential Nightshift Benchmarks Are Elusive.

A nocturnist is a  hospitalist who only works at night. A hospitalist is a doctor that only works in the hospital.  Most hospitalists are internists.    In 2012, 60% of hospitals were using hospitalists to care for patients in the hospital.   Far fewer had the honor of nocturnists (16%) wandering  their halls at night. The nocturnist movement will be the next phase of growth in hospitalist based care just as other medical and surgical specialties experiment with their own version of the hospitalist  model.

The hospitalist movement has matured rapidly over the last 15 years. It will continue to expand as physicians and hospitals realize great value in having physicians separated from the distractions and time cost of outpatient medicine.  Hospitalist income will continue to grow as outpatient doctors continue to demand access to hospitalists as they too strive for work-life balance.

Medicine, like so many other fields,   has been turned into just another job that must be managed by people with too many titles behind their name.  In an era where work hour restrictions for interns, PQRS  and patient satisfaction surveys trump patient care, physicians have become more inclined to simply show up, put in their hours and go home during normal working business hours.  We are well on our way toward a universal VA culture mentality.    We have sown the fields we have planted with the policies we have implemented and we must live with the consequences, doctors and patients alike.

Fewer and fewer physicians will be willing to put in the nights, weekends and holiday hours as their reward for 24 hour access to care is a punch in the gut, a lawsuit from  an entitled mentality and a $10 gratuitous thank you payment from the Medicaid National Bank for their two  hours of critical care service.  

With the nocturnist movement for hospitalists and other medical and surgical subspecialties set to explode, physicians willing to work these most undesirable shifts should understand what their value is to hospitals and hospitalist groups that need access to their care.   Not only will they demand on call pay, they will demand higher support for night shift work.

For many hospitalist groups,  all members work the same number of days and nights.  RVU benchmarks are equivalent across all members.  That makes night shift differential pay unnecessary.  However, as the hospitalist movement matures and hospitalists  choose increasingly to balance quality of life and work by limiting their exposure to the rigors of night call,  defining the value of asymmetric night work within hospitalist groups becomes imperative.   

Some doctors may be willing to take on the additional lifestyle disruption of night shifts.    That offer may come  with additional monetary compensation, more vacation, greater flexibility or a bigger benefit package.  Whatever the cost, a price tag is attached.    For some groups, the promise of long term commitment might even come with a promise of eliminating a percentage of night call coverage with each additional year of group loyalty.  That is a price tag paid for by younger hospitalists to the benefit of those with a long term commitment in mind.  

If some doctors are working more nights than other doctors, how should compensation be adjusted?  Groups should define this asymmetric value so  doctors don't feel they are picking up additional hardship without additional compensation as other doctors enjoy a better lifestyle at their expense.  

Let's use a hypothetical salaried hospitalist group covering one hospital.  This ten member group has four daily rounders and one hospitalist covering the night for a total of 5 shifts in a 24 hour period.  That's 1,460 days shifts/year and 365 night shifts /year that need covered in this 24 hour per day in-house coverage model.  If every hospitalist worked the same number of day and night shifts, then every hospitalist would work 146 day shifts (1,460/10) and 36.5 night shifts (365/10).  Every hospitalist would work 182.5 shifts a year (146 +36.5).  If every doctor worked the same number and types of shifts, defining a night shift differential pay model would be unnecessary.   Everyone would be treated equally.  Fairness prevails.

But, lets say, on January 1st, five hospitalists bribed the scheduling doctor so they didn't have to  work any more night shifts.  365 nights would now be divided between 5 hospitalists instead of 10.  That means the five hospitalists still working nights would need to work 73 nights a year instead of 36.5 (73x5=365 nights). There is value in that hardship.  How to value that additional hardship is something hospitalist groups need to explore and define.    

There are still 1,460 day shifts that need to be covered, but since five hospitalists are working an additional 36.5 nights each (for a total of 182.5 total nights), they must give up 182.5 days to the five doctors no longer working nights, assuming they wish to keep the total number shifts/hours worked per hospitalist per year as equal.  

What does this do to the hospitalist experience?  The five hospitalists working nights would now be working only 109.5 day shifts in order to make room for all their 73 night shifts.  They would be forced to reduce their quality of life that comes with nocturnist work.    There is value in that hardship.  They should be compensated for that hardship. The hospitalists working no nights would now be working 182.5 day shifts per year and dramatically increase their quality of life by eliminating their night shift experience.   There should be a cost to that lifestyle improvement. 

As you can see, both doctors would be working the same 182.5 shifts a year.  While all doctors are equal at 182.5 shifts a year, the doctors working nights have gained hardship by working more nights (73/year) than fair value (36.5/year) while the doctors working no nights have gained greater lifestyle (working zero nights instead of 36.5/year).   Both should have compensation adjusted to reflect the loss or gain in lifestyle.  Even though both groups of hospitalists work the same number of shifts/hours, they should be compensated according to the lifestyle adjustments they have committed themselves to.   If they are not, then fairness will not prevail and group dynamics will suffer. 

What additional compensation should the five hospitalists receive for working above and beyond the all-hospitalists-are-equal scenario of 36.5 nights per hospitalist per year?  How much compensation should be cut from the hospitalists not working any nights?  Those are the questions every group needs to ask themselves to define what's fair in their circumstances.  It may be different for doctors who view lifestyle in Hawaii as more important than for doctors working in the cold winters of North Dakota. 

While offering flexibility in scheduling can bring great satisfaction  to hospitalist groups, that flexibility must be weighed against the lifestyle benefit or harm to all members of a hospitalist group when such actions are taken. In the interest of fairness, night shift differentials need to be defined so all group members feel like they are being fairly compensated for their lifestyle adjustments. Without fairness, retainment and recruitment will suffer and hospitalist groups will find long term commitments from their members difficult to achieve. 

What is the right adjustment for nocturnist compensation or partial night shift differentials for groups that allow asymmetric night shift coverage?  I have no idea.  There isn't a lot of data on this issue that I could find.   I  presented my questions to a  Society of Hospital Medicine list serve.  I got only two responses.  One response indicated a 1.5 night shift differential was used in one group.  The other response indicated a 1.25 night shift differential pay but this was increased to 1.5 due to a vocal outcry for the disruption night shifts created on quality of life.  This increase in payment actually resulted in a full time nocturnist in the group.

One article published by The Hospitalist eWire (link no longer active) on May 22nd, 2013 does help shed some light on the night shift differential benchmarks.   They provided an online survey to their readers and many thought 20% or 33% more  for nocturnists was reasonable.  Of the 212 survey respondents, two-thirds chose 20% or 33%,   17% chose "the same" and 17% chose 50% or 66% more for compensation.  Despite generally lower relative value unit productivity on night shifts, earning less on the night shift is not an accepted standard.   Working nights now commands a lifestyle premium that was unlikely to  exist a decade ago.   that is must be paid for.  It's important to understand there are many variables that go into the local market economics of nocturnist compensation and no model fits all groups well.

 How much is the night shift differential worth in your hospitalist group?  As quality of life becomes more valuable with every passing year,  I believe the night shift differential will continue to rise in value.  Hospitalist groups need  to define what is fair for their differential, in their own unique circumstance.  Make sure to visit all my free posts about E/M coding as well as well as my section of resources for hospitalists interested the economics of practicing medicine.

Post explaining this E/M pocket coding card for hospitalists.

EM Pocket Reference Cards Using Marshfield Clinic Point Audit
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