How one physician is making the most of overnight medical education
Lois Margaret Nora, MD, JD, MBA
In medical school, I experienced some of my favorite and least-favorite experiences during overnight call. And I have been dismayed at the substantial reduction in overnight experiences that more recent generations of medical students have had. So, I was excited to hear about some particularly interesting work by Dr. Jessica Chambers of Dell Medical School at the University of Texas at Austin. I was delighted to have time to talk and to learn more about her career and how she’s made the overnight rotation much more than something to simply endure. The following post is a synopsis of our conversation.
Dr. Chambers attended medical school at Texas A&M University before pursuing residency at UT. Now a practicing nocturnist and assistant professor of internal medicine, she’s been working to transform learning in the overnight hours. As we spoke, it became clear that she’s done so through a combination of passion and leadership.
Anyone who has worked overnight call knows the hospital environment is quite different at night. There are fewer patients and visitors coming and going, and the staff is smaller. Certain issues are more common in the evening, fewer specialists are available, and there is reduced access to hospital services, such as some types of imaging and surgery. However, Dr. Chambers says that’s also part of what makes overnight medicine so beneficial to learners: “I think your decision-making and triage skills are different than those developed in the daytime.”
Medical students and residents on the night rotation are part of small, highly interprofessional teams, giving them valuable experience communicating and collaborating with colleagues, and valuable exposure to team-based care. Dr. Chambers says overnight teams also spend more time on functions like admission and bedside management, enabling learners to interact with patients in a more holistic way. “We get to understand the perspective of the nursing staff, what the charge nurse does, the interplay with the respiratory therapists and the social worker in the ER. Instead of focusing on how to get the patient out of the hospital, we’re really focused on how to best take care of the patient in the hospital,” she says. “That, I think, is why I found this niche. It’s such an ideal time for education because we often don’t have other things we have to focus on.”
A dedicated curriculum for the overnight rotation
The overnight medicine curriculum Dr. Chambers developed came out of early bedside talks she gave while working with residents. As common issues like shortness of breath, chest pain, headache – “very rote things, but out of them comes a lot of medicine” – became favorite lecture topics among residents, it became clear to Dr. Chambers that there was value in developing a defined list of areas that should be covered on the overnight rotation. Some arise organically in a hospital where the overnight team can be responsible for well over 100 internal medicine patients, and others can be worked in as short lectures during downtime.
About six months into her first faculty role as a nocturnist, Dr. Chambers recognized opportunities for a more structured approach to educating learners on the overnight shift before they reached residency. “I thought, wouldn’t it be great if you had practice doing this as a fourth-year medical student, because this was the scariest rotation I had as an intern.” She went on to establish an elective with a reasonable schedule – 11 p.m. to 7 a.m., four nights a week – to entice students who might be reluctant to try something more time-intensive. “This is not about overloading them with patient care; this is very particular to how to cross-cover patients at night,” she said.
As Dr. Chambers built out her course objectives, she saw an opportunity to help students and residents build communication skills. Overnight medicine provides more opportunity for connection with patients, who may feel especially vulnerable and alone after visitors leave. Clinicians often find they have more time for bedside conversations, where they can enhance their understanding not only of a patient’s medical condition, but also the patient experience. While these skills are important for nocturnists, they are valuable for any clinician.
Dr. Chambers also asks learners to build skills for working with the care team, and I was especially intrigued by the way she approaches this teaching with fourth-year medical students who take part in her elective rotation. Students are asked to be the point of contact for a subset of patients, meaning they gain experience talking with nurses, pharmacists, and respiratory therapists; entering orders into the EMR; and making decisions about care.
The work is guided – a qualified physician is always present when a medical student is answering pages or replying to messages from the care team, and any order placed in the EMR by a student needs to be activated by a physician. But she encourages students to draw conclusions and also to ask questions when they are unsure of next steps. Modeling behavior helps; Dr. Chambers herself invites input from residents in the presence of medical students before making decisions, demonstrating to students that the nocturnist must have knowledge of many specialties but simply can’t be expert in everything. “They have to really embrace that level of not knowing, which is something we see every night.”
To that end, Dr. Chambers has also developed a Night Medicine Guide that draws on the expertise of her colleagues in other specialties. Listening to her describe the collaboration involved with creating the resource, I was impressed with her leadership in bringing multiple stakeholders together to develop this valuable resource.
The Night Medicine Guide reflects the guidelines of specialty medicine and outlines protocols for scenarios that can be handled by the overnight team, as well as scenarios that warrant a call to the attending physician. “A lot of the fright of doing a night shift is, when do I call cardiology? Should I call the GI doctor? Am I taking good care of this patient? Am I doing the standard of care at 2 a.m.?” she said. A grant from the medical school ensures every learner gets a copy of the guide.
I remember from my own days on the overnight rotation, one of the more challenging scenarios is trying to navigate the line between clinical issues you can handle and those that warrant a call to another specialist. It is a gray area that can be stressful and a source of conflict. As I thought about this, I wondered if Dr. Chambers’ guide might also be a useful tool for supporting clinician well-being. The clarity it provides for handling situations like pain, delirium, suicide risk, and others strikes me as reassuring and empowering for clinicians across the healthcare team.
A culture change for overnight medicine
Talking to Dr. Chambers was particularly interesting as I thought about how overnight rotations have been commonly perceived. Although it’s easy to understand that patients have needs around the clock, persuading others to see the unique value in learning at 2 a.m. seems less easy. It’s clear that leveraging the learning opportunity as Dr. Chambers has done has required a shift in perceptions about overnight medicine.
That change has taken time, Dr. Chambers says, and since she cannot work every night, it has also taken advocacy and leadership to shift views about how learners and clinicians can make the most of the overnight rotation. It has also taken work on her part to foster a positive team culture. Things like shared meals build community. And open conversation about what’s important to stay healthy while working overnight normalizes challenges and helps colleagues – particularly those who are still getting accustomed to the schedule. She is also a strong advocate for reasonable hours that allow for, for example, dinner with family before a shift begins. “I think that connection time is very important; it’s what leads to me loving this job. I don’t go to work missing my family more than I would any other job.”
While I knew I would learn from Dr. Chambers about the possibilities of learning as part of overnight medicine, I also learned some things I didn’t know about the health effects of night work. Resisting the body’s natural sleep cycle alone is challenging enough, but Dr. Chambers noted that overnight work is linked with poor eating habits, weight gain, metabolic syndrome, breast cancer, and potentially fertility issues. She also said the life of a nocturnist is likely not a good fit for people who do not sleep easily. It’s important, too, that nocturnists have a supportive home environment to facilitate daytime sleep, and a supportive working environment that includes scheduling important meetings at a reasonable time for someone who must sleep during the day.
I was thrilled to learn that Dr. Chambers is working as part of organized medicine to lead change beyond her institution. She has what sounds like an interesting talk planned at an upcoming meeting of the Society of Hospital Medicine about managing the health consequences of overnight medicine, and she’s been active with a number of other societies. Her efforts to reimagine overnight education and the culture of the overnight shift have also helped her find a growing community of like-minded physicians who have been on the forefront of changing perceptions of nocturnal medicine and seizing its unique learning opportunities. “You could obviously do this job very easily, but to do it well, to make sure the academic opportunities are very useful, you have to put in more time. However, I find it very easy if you love what you do, which I do. I love what I do.”
