In 1995, Lee Goldman, MD, chair of medicine at the University of California at San Francisco, hired Robert Wachter, MD, MHM, and they begin to develop a model wherein internal medicine physicians would practice solely in the hospital setting. This new style of practice emerged in hospitals around the country as primary care physicians were “no longer willing or able to manage  the  care  of  their patients needed while hospitalized.” 1 Twenty-six years later, the practice of hospital medicine continues to grow and evolve as well as do the costs of hospital medicine.

Yet, the recruitment of a hospitalist for long-term retention is challenging considering the time, expense, and current physician shortage.2 According to the Society of Hospital Medicine’s 2020 State of Hospital Medicine Report (SoHM), 74.8% percent of Hospital Medicine Groups in the South reported having unfilled positions during at least a portion of the year.3 One way in which  hospital  medicine has evolved in hospitalist hiring has been the addition of a nocturnist to ease some of the pressure points of maintaining a hospitalist group. However, finding a no cturnist may be even more difficult and, if found, there is an increasing financial burden in addition to a rotation burd

en. SoHM also reported nearly three-quarters of hospital medicine groups serving adults have unfilled positions within their groups during at least a portion of the year.4

This situation burdens both the hospital and the hospital medicine group. For example, a hospital medicine group in a rural hospital employs two hospitalists, Drs. Smith and Jones, who work a seven days on/seven days off schedule and are on call 24/7 during the “ on” week. Drs. Smith and Jones cannot be physically present in the hospital 24/7 so they receive messages from the hospital around the clock. Dr. Smith feels that this call schedule is no longer sustainable and asks the hospital to hire a nocturnist or two in order to provide flexibility in the call schedule. However, because night coverage is typically more expensive than day coverage because of lower volumes of billable services, the hospital cannot justify hiring even one dedicated nocturnist. Moreover, because the hospital is in the rural area, the hospital is having difficulty attracting a third hospitalist to ease the night call burden. Lastly, the hospital attempts to hire a couple of locum tenens nurse practitioners but even the margins for this move are difficult. After multiple conversations between both parties, Dr. Smith resigns.

Key Factors for Physician Recruitment and Retention in Rural Hospitals Factors for a Successful Recruitment and Retention Model:

This scenario highlights the recruitment and retention challenges in rural locations because of call schedule and the lack of night call support. Because hospital administrators and heads of hospital medicine groups feel pressure to both generate revenue and protect staff wellness, they may be driven to make less-informed hiring decisions to prevent “Dr. Smith” from resigning. However, the costs associated with hiring a hospitalist are high as they may include items such as use of a search firm, marketing, interview/site-visit, sign-on bonus, relocation, loan repayment, professional liability insurance, not to mention the tail coverage insurance for the previous hospitalist, the lost productivity for existing employees who assist at any point in the recruiting and hiring process, and the costs incurred once the hospitalist arrives.

An article from the New England Journal of Medicine Career Center in December 2019 offered: From the moment a position is identified, there may be up to $250,000 invested in a single candidate, including marketing, interview expenses, sign-on bonus, and relocation stipend. With interview expenses alone ranging upward of $30,000 for each candidate, not to mention the average sign-on bonus of $30,000, the costs add up quickly….

Once the contract is signed, onboarding begins. The costs incurred include hospital credentialing, health-plan enrollment, occupational health requirements, EHR training, coding education, and system orientation, as examples. One company that offers credentialing and analytics placed “ the cost to train, credential, market and onboard a physician” at $200,000 to $300,000.5

If the hospitalist hire ends up not being a fit, the hospital has lost this time, money, and effort that went into the recruitment and onboarding in addition to the potential revenue lost during the period the hospital is without the physician. Moreover, admissions data collected from 226 Florida hospitals evidenced that nighttime admissions accounted for 19% of the total admission volume in a 24-hour period. Taken collectively, the data seems to indicate an opportunity to leverage nocturnist, nurse practitioner telemedicine solution to address the dilemma of balancing revenue and hospitalist staffing shortages.6


Lynk Health offers a nocturnist nurse practitioner solution for rural hospitals that does not supplant your hospital’s person- to-person hospitalist care but, rather, augments and supports your hospitalist, night nurse, and patient relationships. Typically, this solution allows Lynk Health’s nurse practitioners, trained in either adult-gerontology primary care, family, or Acute Care to take patient hand-offs from the daytime hospitalist and provide hand-offs to the daytime hospitalist the following morning, monitor patients admitted from the emergency department, and take calls from floor or unit nurses related to, for example, a change in status, rapid response, or code.

In any of these scenarios, Lynk Health provides the hospital with a mobile telemedicine workstation (enabling two-way videoconferencing monitoring through our proprietary Teleconnect) that can be taken into a room in order to bring the nurse practitioner and patient face-to-face in addition to a phone number for the floor or unit nurse who prefers to call. Regardless of the connection, the Lynk Health clinician will document directly into your hospital’s Electronic Medical Record system any patient evaluation and orders and provide a hand-off to the hospitalist at the beginning of the morning shift.

Because Lynk Health nocturnist nurse practitioners are working, either from 7 p.m. – 7 a.m. or the hours you establish for nighttime coverage, as if they were physically in the hospital, response times average less than three minutes from the moment the floor or unit nurse calls. This quick response time leads to nurse satisfaction as issues are addressed promptly and relieves the burden of the hospitalists taking night calls; hospitalist satisfaction as they are relieved from the night call; and hospital satisfaction as the margins are better with this solution as opposed to hiring additional hospitalists or locum tenens nurse practitioners. Lynk Health is able to provide nocturnist nurse practitioner solutions to multiple hospitals each night at the touch of a button.


1 Beresford, L. (January 7, 2022). SHM celebrates 25th anniversary as the home for hospital medicine. Society of Hospital Medicine.
2 Association of American Medical Colleges. (April 23, 2019). New findings confirm predictions on physician shortage [Media release].
3 Society of Hospital Medicine. (September 2020). 2020 state of hospital medicine report.
4 Society of Hospital Medicine. (September 2020). 2020 state of hospital medicine report.
5 New England Journal of Medicine Career Center. (December 2019). The high costs of hiring the wrong physician. Recruiting Physicians Today, 27(6), 1-2.
6 Sanders RB, Simpson KN, Kazley AS, Giarrizzi DP. New hospital telemedicine services: potential market for a nighttime telehosp italist service. Telemed J E Health. 2014 Oct;20(10):902-8. doi: 10.1089/tmj.2013.0344. Epub 2014 Mar 24. PMID: 24660844; PMCID: PMC4188377.

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