All in a Night’s Work
WHEN DOCTORS LEAVE THE HOSPITAL FOR THE DAY, ANOTHER TEAM OF DOCTORS—NOCTURNISTS—STEP IN.
They begin their shifts under cover of darkness, slipping through the hospital’s doors just as others are getting ready to head home. They do the work of several—often overseeing as many as 30 patients at a time. They’re specialists and generalists wrapped into one, able to shift identities in the blink of an eye. And you never quite know where they’ll turn up: at the bedside, assessing the condition of a heart transplant recipient; in the hallway, advising a resident on treatment plans; seated in the lobby, calming the family of a recently admitted patient.
They aren’t superheroes of the Marvel variety, though they sound like it. They’re nocturnists—shorthand for nocturnal hospitalists—a dedicated, experienced team of physicians who care for hospital inpatients overnight.
The rise of nocturnists is a fairly recent phenomenon, driven in part by the increasing popularity of the hospitalist field, limitations on physician and resident work hours, and a widespread push to improve patient safety. The nocturnist program, which began at Stanford Hospital 11 years ago, has grown exponentially, says Rita Pandya, MD, clinical assistant professor of medicine and the nocturnist group manager, and shows no signs of slowing down. “We currently cover nine services—hematology and oncology; gastroenterology, hepatology, and liver transplant; electrophysiology; pulmonary hypertension; cystic fibrosis; lung transplant; heart transplant; ventricular assistance device; and renal transplant—and we’re continuing to expand.”
“For these services, the nocturnists provide care for about 50% of the patient’s hospital stay,” explains Neera Ahuja, MD, clinical professor and division chief of hospital medicine. “This is not insignificant, and it is a responsibility that our nocturnists take very seriously.”
Each nocturnist shift, which lasts from 7 p.m. to 7 a.m., begins the same way: with sign-out, a critically important information exchange that brings nocturnists up to speed on the health and care plans for patients they will be responsible for, and a chart review. Inpatient work and patient admissions follow.
The rest of the evening is more variable, and it’s this element of surprise that appeals to nocturnists like Vijay Prabhakar, MD, a clinical instructor of medicine who has been on the service since 2018. “During the night, we complete any tasks that the day teams have asked us to follow up on and respond to any nurse pages or changes in patient condition,” Prabhakar explains. “We also interact with many different providers—nurses, residents, fellows, physician assistants, nurse practitioners, and attendings.”
Pandya recalls previous shifts that were so fast-paced she “almost felt like an intern again.” She continues, “You’re never quite sure what will come your way. We cover a lot of different specialties so we’re always taking in lots of information. That’s one of the things that makes this work so exciting, though. You’re constantly learning new things.”
Yet there are opportunities for continuity and connection on the night shift, too. “We end up seeing a lot of the same patients, and you get to know them really well,” says Pandya. “We spend time talking to them and get to know more about them each time. Just this past week I was able to take one of my patients’ service dogs out for a walk.”
Prabhakar agrees, describing a memorable night when the nurses of the hematology and oncology unit of the main hospital invited him to a late-night potluck for a departing colleague. “Getting to meet some of the nurses face to face and enjoy the delicious food was definitely something I will not forget.”
Midnight comes and goes, and the nocturnists’ complex shift remains in full swing. “As the sole primary providers in-house for a large number of patients,” Prabhakar says, “you have to be able to astutely assess, diagnose, and treat deteriorating patients and help stabilize them by morning.” During a recent night, Pandya details, there was a resident who needed help with a procedure, an overnight discharge that required paperwork, and a hospice patient who passed away. This work, she explains, “requires an ability to be proactive and a wide knowledge base that helps individuals toggle between various pathologies quickly.”
By 7 a.m., the hospital has awakened in earnest. Sun streams through the lobby windows and physicians and nurses file in, coffee in one hand, phone in the other, to begin their first shift. Meanwhile, the nocturnists complete their charts and sign-offs, wrap up their work, and head home to recharge. But don’t worry—they’ll be back tonight.
