Right when her colleagues at Boston Children’s Hospital are leaving at the end of the day, pediatrician Sarah Henry, MD, is just arriving at work. As a nocturnist, Henry has made a career of working the night shift, clocking 10 overnights a month, sleeping mostly during the day, and avoiding typical workday stresses like long commutes.
But the job’s real attractions are less practical. “The hospital at night is a different place than during the day,” Henry says. “There aren’t the meetings and conferences and people coming and going. It’s a leaner, more simplified environment where I can focus on patient care and spend more time with families. That’s something I really value.”
Nocturnists are one of several medical career paths to emerge in recent years, partly in response to medical advances but also to new ways in which health care is delivered. Here are five new specialties, what they entail, and the training needed to pursue them.
1. Cancer immunologist
Harnessing the immune system to fight malignancies is a burgeoning area of medicine that’s creating huge opportunities for new doctors. “It's a time of incredible progress that has translated into help for patients,” says Lisa Butterfield, PhD, president of the Society for the Immunotherapy of Cancer.
But the promise of these medications is tempered by new clinical challenges. New treatments like CAR-T cell therapy can cause alarming and even fatal immune overreactions, and drugs known as checkpoint inhibitors have led to the emergence of new forms of autoimmune diseases like inflammatory arthritis and even type 1 diabetes, among other adverse effects.
Health systems have a growing need for doctors who can treat these problems as new therapies — projected to rise from 47 agents to 75 by 2020 — enter the market. “I receive about 250 emails from around the world every single day asking for guidance,” says Maria C. Castells, MD, PhD, director of both the Drug Hypersensitivity and Desensitization Center and the Allergy and Clinical Immunology Training Program at Boston’s Brigham and Women’s Hospital. “This is something completely new that we’re trying to understand.”
The nascent field is also looking for clinician researchers to identify specific markers and phenotypes, which will offer clues to patients likely to experience certain side effects, and to characterize the new forms of autoimmune disease. “There are characteristic patterns of effects we are seeing frequently,” says Anne Bass, MD, a rheumatologist at the Hospital for Special Surgery in New York City, who helps manage autoimmune conditions in cancer patients on immunotherapies. “Some patients may be genetically predisposed to them.”
A career pathway has not yet evolved, but Castells envisions a specialty encompassing immunology/allergy and rheumatology and perhaps dermatology and gastroenterology. (Skin conditions and inflammatory bowel diseases are not uncommon for patients with autoimmune conditions.) For now, she says, a specialty in clinical immunology/allergy or rheumatology offers the best bet for interested students.
As the proportion of medically complex patients in hospitals rises, the outlook for nocturnists — doctors who practice hospital medicine primarily at night — is bright. “It adds a level of safety and service to the hospital,” says Atashi Mandal, MD, a nocturnist in California’s Orange County.
Nocturnists mostly do what hospitalists do —admit and provide coverage for patients — but they work entirely at night, which means they are often on their own, without the benefit of other specialists. Because of that, though, they often enjoy greater autonomy than their daytime counterparts.
Training is the same as for daytime hospitalists, which typically is board certification in internal medicine, family medicine, or pediatrics. Doctors may also seek Maintenance of Certification in Focused Practice in Hospital Medicine, or advanced training in subspecialties like cardiology or pulmonary medicine, but neither is necessary, says Philip A. Masters, MD, vice president of membership and international programs at the American College of Physicians.
According to the 2016 State of Hospital Medicine Report, more than 70% of hospitalist programs have nocturnists, and the demand is increasing, often outstripping supply. As a result, they can earn 15 to 20% more than daytime hospitalists or earn the same salary with fewer hours. But “finding it easy to sleep during the day is key,” Henry says. “Some people can’t do that.”
3. Lifestyle medicine physician
Some 80% of health care costs are related to chronic diseases, and 80% of chronic disease is related to lifestyle choices. That makes a powerful argument for lifestyle medicine specialists, says Wayne Dysinger, MD, president of the American College of Lifestyle Medicine and founding chair of the American Board of Lifestyle Medicine.
A patient’s food choices, exercise, sleep, stress levels, and ability to connect with others all fall under the purview of a lifestyle medicine doctor. “We address every aspect of a person’s life,” Dysinger says. “When a patient walks into my office, they’re just as likely to walk out with a prescription for broccoli as for Lipitor.”
Primary care and family medicine are natural homes for lifestyle medicine expertise, but the specialization can also be useful in a growing number of lifestyle medicine clinics that operate on a referral model or residential facilities where a patient might spend ten days to two weeks to jumpstart changes when the need is urgent.
The American Board of Lifestyle Medicine began offering certification in lifestyle medicine in October 2017, and so far 300 doctors have received it. Demand to sit for the exam is exploding, Dysinger says. U.S. candidates must already be board-certified by a medical specialty board recognized by the American Board of Medical Specialists or the American Osteopathic Association.
4. Clinical informatics
Also known as biomedical or health informatics, the field of clinical informatics involves collecting and analyzing patients’ health information and applying those insights to improve health, says Douglas B. Fridsma, MD, PhD, president and CEO of the American Medical Informatics Association. The field is taking off due to provisions of the Affordable Care Act, which mandates the use of electronic health records (EHR). But hospitals also are recruiting physicians who can fulfill the promise of these information troves, from making better clinical decisions to guiding research efforts.
Top jobs are chief medical information officer and chief health information officer, with varying proportions of time spent in the clinic and with informatics duties, says Howard D. Silverman, MD, MS, professor of the Clinical Informatics Fellowship at University of Arizona College of Medicine at Phoenix. Physicians versed in informatics can also find work with EHR vendors and Silicon Valley startups or in research.
Doctors need to become board certified in clinical informatics through an exam offered by the American Board of Preventive Medicine and the American Board of Pathology. Physicians in all 24 subspecialties are eligible, but candidates must have completed an Accreditation Council for Graduate Medical Education-accredited Clinical Informatics Fellowship Program to sit for the exam.
5. Medical virtualist
The telehealth market is expected to rise 30% each year between 2017 and 2022 as telemedicine gains traction as a way to deliver second-opinion consults and offer telepsychiatry and telestroke services. More health systems also are adding telemedicine to their raft of services, using their own physicians or those employed by telehealth companies to provide primary care triage, specialty consults, and virtual rounding. While these medical virtualists don’t yet require certification, many see a need for the specialty.
“As more health care institutions start to incorporate virtual care into their strategic planning, we need to make sure we are prepared to train future providers,” says Rahul Sharma, MD, emergency physician-in-chief for NewYork-Presbyterian/Weill Cornell Medical Center. Physicians will need to demonstrate competency in conducting the virtual interaction — including body language, eye contact, and the environment from which the visit is conducted — and gain expertise in the legal ramifications and regulatory issues of virtual medicine.
Aspiring virtualists should spend several years in a traditional clinic setting before specializing in the virtual world exclusively, however. Says Sharma, “The clinical acumen you get from face-to-face experience with patients is incredibly important.”