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December 5, 2016

A Moonlighter’s Guide to the Galaxy

Like ice cream on a hot day, moonlighting can be an epic idea or an epic mess, depending on your preparation for the situation. (A little luck never hurts either.)

Moonlighting, or having a second job in addition to your main employment, is a popular option among residents looking for additional income and experience. Having been a healthcare recruiter for more than 10 years, I’ve learned a thing or two about moonlighting to share with you, like where to find opportunities, how moonlighting can help you down the road and what newbies should know. Many moonlighting opportunities are available because they are in unpopular locations, but that doesn’t mean they can’t deliver your desired outcome - plus a little extra.

Why moonlight?

Erik Stamper, D.O.

Erik Stamper, D.O., had a rough first shift as a moonlighter during residency. Though his story isn’t the norm, it’s still an important warning to understand the total environment. · Photo by Wirken Photography

Speaking of outcomes, why is moonlighting a good idea? Simply put, it’s the best way to get out of your comfort zone and see medicine outside a controlled academic environment. Plus, it can help you get a head start on paying back those student loans. Since the monetary benefits are pretty self-explanatory, I would like to focus on a few other benefits of being exposed to a new setting at this point in your career. You may not be getting these benefits in your program’s curriculum, but they will complement the clinical skills established there.

Leadership experience. As a resident you have many chances to hone specific clinical skills (which, it goes without saying, are critically important), but in many situations throughout your career you will find yourself in situations that call for you to be more of a general than a foot soldier. Though it’s fantastic that you can intubate anyone while blindfolded, what happens when patients begin to stack up and you don’t have the time to properly handle each one? This is when it is critical to know your team and available resources, as well as how to best motivate them to achieve results in the quickest manner. As I will expand on later, your nursing support can make or break your shift, so having their buy-in is key. This doesn’t mean you need to order them pizza every day (although that doesn’t hurt), but you do need to take the time to mesh well with the folks you will be counting on.

Political/relational experience (i.e. playing nice in the sandbox). No matter where you go, there will be folks who will be easy to get along with and there will be . . . the others. Unfortunately, as a resident you won’t usually receive the benefit of the doubt right away; you will have to earn it. This may take some time, but in the interim, moonlighting provides an excellent chance to learn how and when to push colleagues, specialists and others to get the help you need. Though I would not recommend being too blunt initially, you will need to be able to establish yourself if you want to care for your patients properly and get the requisite support. Speak with your current attendings; they have no doubt encountered similar situations and should be able to provide tips on handling difficult personalities while still getting what you need.

Steve Roberts, M.D.

When moonlighting, be sure to identify who can act as a second opinion. "Having backup that is only a phone call away helps me even in the most isolated locations," says Steve Roberts, M.D. · Photo by That’s a Pretty Picture

Confidence. It is my belief that what separates pro athletes from amateurs is merely practice and a high level of confidence in their abilities (which pretty much comes from practice). It is one thing to conduct a complicated procedure with three techs, two attendings and a partridge in a pear tree, but what happens when it’s just you? Do you know what to do? Do you know whom to call to find out? Your confidence level will not only be blatantly obvious to all those around you but will also be infectious. If you know you can handle a situation, others will follow.

Perspective. To promote consistent clinical practice, most academic or residency environments are designed to be as controlled as possible. But part of learning is understanding multiple perspectives, and in many cases these perspectives can only be gained in the flesh. For this reason, emergency and internal medicine physician Sam Clemmons, M.D., emphasizes the importance of moonlighting as part of the educational process. Clemmons, who started in the military, has worked in both rural and urban settings. He is currently the president of Elite Emergency Service in Franklin, Tennessee, handling contract management on a large scale. The variety of his background has helped him gain a perspective on all aspects of medicine, which in turn helps him understand and contribute to it on a macro level.

How to find moonlighting opportunities

Moonlighting opportunities usually aren’t hard to find, and there are often multiple options available, making you a chooser rather than a beggar. Moonlighting positions vary greatly depending on your geographic location and specialty, but in most cases they can be found in the same two ways - online and through word of mouth.

The internet is by far the best place to start; it will give you the ability to scour all opportunities available before making your decision. The more you know, the more leverage you have.

Talking to your attending, previous grads, local recruiters and others in your circle is another great way to find moonlighting jobs. Health care is a small community - take advantage of it. Out in the field, your CV will not take you nearly as far as a reference. The more contacts you have who will vouch for your clinical and leadership skills, the easier it will be to find a moonlighting position and, eventually, a permanent position.

Before your search, it is important to note that many residency programs have policies in place regarding moonlighting. Some will allow only third-year residents to moonlight, and others have geographic or clinical restrictions. Be sure to check with your supervisor or program director early on so that you fully understand those restrictions. One last thing to keep in mind is that the Accreditation Council for Graduate Medical Education (ACGME) has set an 80-hour cap on the total amount of combined educational and moonlighting time residents and fellows may work in any given week (including in-house call activities). Be sure you have a good grasp of any additional applicable rules in your area and specialty.

Avoid these moonlighting pitfalls

Now that I’ve highlighted the positive benefits of moonlighting, I need to take a moment to lay out some of the pitfalls you can run into. To get started along that road, I have included a short story from Erik Stamper, D.O., who is now assistant emergency medical director at Research Medical Center in Kansas City, Missouri:

My first shift moonlighting was during my third year of residency. I drove two hours to get some real-life ER experience [at a facility that] happened to be about a one-hour ambulance ride from the nearest larger facility.

We had no specialty backup coverage, but, hey, they were paying me a decent rate. I was told that I would only see one patient per hour and at most 12 total in a shift. There would also be double coverage, so I was told the other provider would help me with questions I may have about transfers, admissions, processes, etc.

The attending physician I was working with was board-certified in internal medicine, [and] half of my shift would also be covered by a moonlighter (whom I was told was board-certified in ophthalmology). After 15 minutes of conversation during my first shift, the attending physician said she was going to get some food to eat and take a break. She never came back.

So, in short, after 15 minutes I was the only physician available in a facility [with] which I had very little orientation (if you count the 15 minutes), and an ambulance was bringing in a stroke patient. The first patient I saw was a stroke [whom] I gave TPA after a negative CT head for hemorrhage (thankfully they had an off-site radiology service to read CTs). My shift was hell, and those 12 patients promised to me quickly became 25 with five transfers to larger facilities. By the way, the second-half moonlighter, the ophthalmologist, never showed up for his shift. I survived that shift only because the nurses were great and realized I was left for dead by the other physicians. A nurse at this facility told me that when the other doctors realized an EM resident was working, they typically left or took very long breaks. After my shift, I got in my car and drove back home two hours at 2 a.m. Did I mention the odd shift schedule availability? I never went back to the facility and ended up moonlighting at a facility that was farther away but had more specialty backup coverage and double coverage that was also staffed and was run by a national EM group.

Phew! Though Stamper’s situation isn’t the norm, it is still a scenario you could find yourself in if you don’t know what to look for before you step foot on-site. To ensure your shift goes as smoothly as possible, take the time up front to review the following clinical and logistical suggestions.

These will not prevent all possible curveballs but should minimize your chances of getting caught off-guard with a preventable situation.

Clinical moonlighting suggestions

EMRs. Since the days of the ol’ paper T-sheets, EMRs have been evolving at a rapid pace - with many companies adding their own variations to make their systems unique. This means that while some things are similar or common sense, others can be completely counterintuitive depending on the system you were trained on. Fortunately, most systems are accessible remotely, so you can spend some time familiarizing yourself with the ins and outs even if you aren’t on-site. Stamper noted that if you are unable or too tired to finish all of your charts post-shift, you can do charting at home and play around with the system so you will be more efficient during your next shift.

Orientation. The term "orientation" can mean different things to different folks. Some hospitals consider orientation to be as simple as giving you a badge, a few passwords and a map to the restroom, while others provide entire shadowing shifts to get you acclimated. Regardless, find out what the orientation process will entail and whether you are comfortable with it. Ask who will be conducting the orientation and, if possible, be sure it’s the medical director or a long-time attending at that specific location. Though it’s not always possible, it is a good idea to ask for a shadow shift prior to starting a shift on your own. You will be extra help, so you should not be pushed to work outside your comfort zone the first time you are working independently.

Emergency Medical Treatment and Labor Act. The regulations under EMTALA regarding transfers and admissions can vary by location, and it is your responsibility to be in the know. As you can see from Stamper’s story, a variety of scenarios can pop up unexpectedly. Knowing your way around patient transport laws and hospital subspecialty coverage can help you avert a potential disaster. It’s important to realize that you will be the physician responsible for the care of any patient during transport, and you may need to write orders for the paramedic or flight crew. Think through potential problematic scenarios and determine what you would do if a woman in labor shows up when you have no OB coverage and the nearest accepting facility is 30 minutes away. If you are uncomfortable or don’t know what you would do in cases covered under the EMTALA laws, you are increasing your chances for a lawsuit. "Don’t assume risk or think that you will be able to figure it out because learning on the fly is how you get sued," Stamper says.

Lifeline. This is simple but important: Be sure to have the phone number of another attending whom you trust and can call during your shift. (Also be sure to warn him or her before your shift - you might be calling for help at 3 a.m.) Steve Roberts, M.D., a traveling emergency medicine physician who floats at facilities throughout the Midwest and Southeast with EmCare, pointed out that having a second opinion can make all the difference in the world, especially when you find yourself in a unique situation. "The longer I do this, the more I realize what I do not know. Having backup that is only a phone call away helps me even in the most isolated locations," says Roberts. It is always difficult to be prepared for all possible scenarios, so having resources identified just in case is a prudent idea.

Last but not least, do your homework on the facility and your specific unit. Have a strong grasp of the coverage and specialty backup available. Look for information regarding mid-level providers and nurse-patient ratios. If there’s anything you can’t find on your own, be sure to ask the director!

Logistical moonlighting suggestions

Contracts. Handshake deals have their place in friendly competitions and Super Bowl wagers, but in employment scenarios, get everything on paper - ideally in contract form. That being said, not every single detail may be listed in the main contract itself, so keep all written correspondence for backup on any promises made.

While not the most important aspect of moonlighting, rate is obviously an important piece of the puzzle. Rates will vary in amount and structure depending on location and specialty, so make sure you understand your pay rate up front. If you are being paid based on RVUs, ask about the average RVUs per hour at that location. If you have metrics, bonuses or other incentives, make it a point to understand the ins and outs. Roberts recommends speaking with one of the attendings already working there (offline if possible). Pick his brain to see what other folks are currently making, as well as his thoughts on it.

Reimbursements. Additionally, dig into any expense/travel reimbursement options with the company. Since many moonlighting opportunities are in rural settings, there is a good chance the company will offer to pay travel or reimburse for it (if not, remember to write it off on your taxes), so be sure to ask. Also, inquire about the specifics, such as what kind of hotels they’ll cover (there’s a big difference between a Super 8 and a Homewood Suite with a kitchenette), whether you can get the travel points, how long it takes to be reimbursed, what the mileage rate is, whether can you fly instead of drive, whether per diems are offered, etc. After a long, stressful night shift, the last thing you’ll want to deal with is a hotel issue that prevents you from getting to your bed. Getting this hammered out in the beginning will not only save you from some gray hairs, but may also earn you some travel perks along the way.

Insurance. Confirm that malpractice coverage is provided and that it is high enough to cover any potential issues per the state guidelines. Malpractice varies quite drastically from state to state, but most states make it easy to obtain the insurance guidelines as well as recommended coverage levels. If you are unsure what you have, just ask the company to provide you a copy of the certificate of insurance (COI). That is probably a good idea in either case.

Lastly, trust the organization you are working for. Whether it be a large company with the resources to back you up in case of any issues or a smaller company that can react very quickly, know whom to contact with potential travel or clinical issues - and make sure you can count on them to help. Roberts points out that it is critical to find someone in the organization to trust. This may be the head of the program, a recruiter or a scheduler. An ideal scenario is to get the security of a large company but the relationship associated with a small group - trust people not institutions. Oh, and I’ve said it before but I’ll say it again: Get everything in writing!

Moonlighting can be immensely rewarding on both a clinical and personal level in addition to providing some extra money while you’re in residency. I can’t overstate, however, how important it is to be prepared when you arrive. Following these simple steps and doing your homework can make all the difference in the galaxy.

Derek Sawyer is a physician recruiter for American Physician Partners.



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