Many of you have heard about how my small, democratic emergency physician group distributes shifts. For decades, we have let the market decide what a shift was worth. If partners don’t like working a particular shift, its “weighting” is adjusted until it pays enough to get people to work them voluntarily. Eventually, when the price gets high enough, a partner decides the additional incentive to work the shift makes it worth it to them.
So, for many years, no partner in our group has ever worked a combination of shifts they did not voluntarily choose. If someone wants to work five day shifts, five evening shifts, and five night shifts each month, they can do that. If they want to work all nights, they can do that. If they want to work all day shifts, they can do that, too. It just means the person working all day shifts probably will make less money than the doc working all nights. They also get to choose how many shifts to work, so long as that number is between 6-18 a month. Nobody gets to avoid shifts because they have administrative duties, medical problems, childcare issues, another job, or seniority. We’ve also never let anybody out of night shifts just because they’re older. In my opinion, this is a great way to run a group and distribute shifts. Everybody gets what they want. I’ve always been amazed that more groups don’t do it this way.
Perhaps the most interesting thing about this system is that you get to really find out what a night shift is worth to a physician. The nurses on the night shift get paid $1 more per hour. Few docs will voluntarily work at night for that. Night shifts are painful. Consultants are more surly, if they’re available at all. While hospitals are supposed to be 24/7/365 operations, we all know that the care provided isn’t quite the same at 3am on Sunday morning as at 10am on Tuesday morning.
While night shift workers are usually pretty young and fun and while it’s nice not to have a bunch of administrators watching your every move, the medicine is just different at night. More pediatric fevers and anxious parents before midnight, and more substance abuse, psychiatric comorbidities, and police involvement after midnight. Night shifts are not only a cardiac risk factor, but they tend to mess up the rest of your life, especially if you’re flip-flopping back and forth between night shifts and daytime activities. The bottom line is that most doctors don’t want to work night shifts, but EDs have to be staffed for all 24 hours. That means EM groups have to find ways to make sure all the night shifts get covered.
Night Shift Distribution Methods
One method is to make everybody work the same number of them. This distributes the pain evenly, and it is certainly one version of “fair.” Another frequently seen method is to distribute them evenly, but let certain docs out of them because they have seniority, are older, or have administrative duties that must be done during the day. Sometimes, recently hired docs or prepartners are forced to work more night shifts. I interviewed for a group once that required new hires to work all nights for five years. I just think it’s more fair to let the market sort out their value.
More information here:
A Recent Change in Our Method
It’s usually a bad idea to miss a partnership meeting. Not only do you miss providing your input on group decisions, but you might find you got volunteered for a job you didn’t want to do! Well, I was on shift for a recent meeting, and in that meeting, some changes to our long-standing method were made. It seems that over the years, as our group has had to cover two less busy EDs in addition to our main one, a larger percentage of our shifts are now night shifts. At our main facility, we have shifts that start at 6am, 10am, 2pm, 6pm, and 10pm. Only 20% of the shifts are a true overnight shift. At another facility, our shifts start at 6am, 2pm, and 10pm, so 33% of those are night shifts. And at a free-standing ED we cover, we have 12-hour shifts starting at 7am and 7pm, so 50% of those are night shifts. Thus, the percentage of night shifts over the years has increased from 20% to 33%.
Each of the shifts has its pluses and minuses. The 6am shift gets you off by about 2pm, letting you be around when the kids come home from school and have a normal evening life that allows you to attend events or coach and play on sports teams. I’m a big fan, but many of my partners hate having to get up at 5am to go to that shift. You’re also solo for a good chunk of the shift, so you take a lot of sign-outs from the overnight doc and the shift can be pretty busy. The 10am shift lets you sleep in, but it tends to eat up your whole day. Plus, it can be tricky getting out of a department at the busiest time of the day. The 2pm shift gives you time to go skiing or mountain biking (or start a blog) before work, but it has lots of evening activity conflicts. The 6pm shift gives you your whole day. Sometimes, you get out of it early, but it also means you’re going to bed well after midnight. The night shift lets you have an evening life and usually pays a lot more, but isn’t great for your health or the rest of your life.
One of our last shift-weighting adjustments was actually to make the day shift pay a little MORE because so few people wanted them. Now, it seems over the last year that there were more night shifts available than people really wanted, and the extra night shifts were being distributed only to those who work some night shifts. That wasn’t very fair, so I wasn’t surprised to see partners complain about that. The whole group agreed that wasn’t right.
But I WAS surprised to see another change come out of the meeting. Instead of increasing the night shift differential so people would voluntarily work a higher percentage of night shifts, we decided not to, at least for a while. That means a whole bunch of docs who haven’t worked a night shift in years (like me) are going to start being assigned to work our share of those extra “unclaimed” night shifts, which totaled up to about 12 out of 90 of the night shifts each month. Now, it seems I’ll be assigned a night shift about once a quarter. But I don’t even want to do that, so I texted a few partners to ask them how much I’d need to pay them (in addition to the night shift differential) to swap a day shift for my rare night shift. The price ranged from $0 (the differential is fine as it is) to $100 to “$1,000 but I’d probably do it for less.”
Suffice to say, I won’t personally be working any night shifts. Paying a bit more money to get out of those four night shifts a year doesn’t bother me a bit, but I do think the group might be making a mistake moving away from a market solution to this universal problem.
More information here:
Adopting Another Method
In the meeting, the group decided to exempt docs who are 60+ from having to work night shifts. That’s only 2 out of 22 docs, but it doesn’t feel fair to me. The 35-year-old docs have no guarantee that this group, much less this policy, is going to exist to benefit them in 25 years. Perhaps more significantly, it means those who are currently working all night shifts aren’t really being paid fairly to do so. They’re being paid less for those nights than at least some of us are willing to pay to get out of them.
In reality, what is happening is the same thing that happens with airline seats. The airline is trying to sell those seats for as much as they can. They charge more to desperate and less price-sensitive people and charge less to patient, more price-sensitive people. Basically, some of the docs in the group are saying, “If I can get out of most of my night shifts for a 30% differential, why should I pay a 50% differential on all of them to get out of the last one? Working just one night shift a month myself will save me a lot of money.” I’m not sure I’d stand for that if I were a nocturnist; I’d probably dump all my night shifts back on the group just out of spite. Plus, now there are backroom deals going on like the one I’ll be making once a quarter to pay more to get rid of my assigned night shift. Why should some night shifts pay more than others just because they were originally assigned to someone like me or because you’re my friend? That doesn’t seem fair to me at all.
What I suspect will happen in a few more months is that the night shift differential will be increased and these “extra” night shifts will all go away like they have in the past. Our differential right now is about 40%, and it has been as high as 50% in the past. In my view, nocturnists aren’t born; they’re created. And they’re created by fat night shift differentials. Those docs would rather work fewer shifts and make the same amount of money or work the same number of shifts and make more money. It isn’t that they love 3am medicine any more than I do; they just have a better use for a little extra income than I do at this stage of their financial life.
I could be wrong, though, and our “revolutionary” market-based system was never meant to last. Maybe we’ll know by the time this post runs.
What do you think? How does your group distribute night shifts and why? What night shift differential do you have?
