Brian Hurley, M.D., didn’t go into his psychiatry residency at Boston’s Massachusetts General Hospital aiming for a mix of moonlighting shifts. Although working part-time was a definite senior-year goal, he hadn’t thought initially of spreading his talents over several places.
But as a business school graduate, Hurley sensed the value of his skills and the fact that he could stabilize his moonlighting income by parlaying his abilities in several places. He wouldn’t have to depend on pay based only on an hourly rate, which may not be that high, or patient volumes, which can vary with each shift. Instead, he’d benefit from differing compensation approaches.
If McLean Hospital, the second facility in his residency program and one of his part-time employers, doesn’t need him, he can pick up shifts at other hospitals.
For Hurley, it’s a win-win. By averaging 10 to 15 part-time hours a week, he’s not only supplementing his income in an effort to shave $400,000 in school loans, but also expanding his skills. He excels at emergency psychiatric evaluations and consultations on patients in distress. Moreover, Hurley is demonstrating that maximizing your moonlighting experience starts by prioritizing training.
"Being a good moonlighter for me has always been about being a good resident," he says. "I spent the first years of my program becoming the best clinician possible. I believed the stronger I am clinically, the better I’d be taking care of my patients…the better I’d be at moonlighting."
Is moonlighting for you?
Perhaps you’re of the same thinking. Saddled with debt and the economic realities of living on a stipend, part-time work can be very alluring. The money you earn in a night or on a weekend can ease the financial pressure, adding favorably to your compensation mix. But how do make the best of the experience? How do you ensure that in earning and learning from moonlighting, you’re not cheating your residency or putting patients at risk?
Truth is, every residency or fellowship program must craft moonlighting policies that reflect strict guidelines of the Accreditation Council for Graduate Medical Education (ACGME) for when, where and how you can act independently outside the scope of training. Included are a bevy of items, from requesting permission of your program director to logging your part-time hours. In between are stipulations for obtaining a full medical license and presenting a signed contract plus proof of professional liability coverage when you go beyond the protections of training.
Since program directors don’t usually deviate from those rules, you need to be aware of precisely what’s required of you in satisfying them. But you’ll also have other things to keep in mind in reaping the full financial and educational benefits of any part-time position. Even if you can’t start moonlighting until you’re a few years down the training pike, you can get your credentials in order, explore your options and set realistic goals for your skills.
"Transparency is great for all things in life," says Gary Frishman, M.D., director of the OB/Gyn residency program at Providence, R.I.-based Women & Infants’ Hospital/Warren Alpert Medical School of Brown University. "So make sure that you know in your heart that this is within your scope of experience, since no program director wants to read about his or her resident getting into problems on the front page of the paper."
Since program directors are serious about every aspect of training, not surprisingly many have concerns about extra responsibilities. The common worry is that the time you spend elsewhere will impinge on your program tasks by zapping your energy and mental alertness.
As Thomas Swoboda, M.D., residency program director for emergency medicine at Louisiana State University (LSU) Health-Shreveport, observes: "The main job of our residents is residency, not moonlighting. It’s to learn and take care of patients in the facility where they’re hired to train. Moonlighting cannot affect those obligations. It simply cannot."
Adds Barrett Bradt, M.D., chief resident of the same program and a seasoned moonlighter: "Our chairman obviously understands that the major motivation for any young doctor to do this is money. But he really hammers home that our primary objective needs to be experience. My motivator initially was the money but I can honestly say that the most beneficial aspect has been the experience."
If, like Swoboda, your chief is open to the concept of part-time work, however, it can be a positive proposition for everyone. But nothing will short-circuit your efforts faster than going behind your director’s back. Instead, by first asking permission and then following every directive, you’re on track to maximize this experience.
From there, the most critical requirements will be that you remain in good academic standing and don’t push the envelope in terms of your duty hours. "The deal breaker for us is that they have to be academically strong," Frishman says of young doctors in his program who are allowed to take graduated part-time assignments as they progress from years two to four. "It would be inexcusable if moonlighting took away from them graduating as the best OB/Gyns possible."
No matter how much you want to earn, remember that any part-time job has to fit ACGME’s 80-hour averaged workweek with appropriate consecutive hours off between shifts. And don’t be surprised if your director limits what you can do, especially if he or she senses that you’re overwhelmed by your academic requirements or facing a demanding rotation. Upper-level residents working in the internal medicine program of Cleveland-based University Hospitals Case Medical Center, for instance, are forbidden to moonlight when they’re assigned to an acute, critical care or other rotation that’s likely to approach 80 hours. But they’re free to spread their wings during shifts with small enough time commitments to buffer their part-time pursuits.
In either case, Keith B. Armitage, M.D., vice chair for education and residency director for the department of medicine, is always monitoring his residents for their mental and physical well-being, especially if he’s concerned that someone is moonlighting excessively to cover a personal issue. "We don’t want people to exhaust themselves," says Armitage. "We promote a work-life balance in our training program, so we want to make sure that our residents aren’t working too much."
As a third-year psychiatry resident training at Northeast Ohio Medical University, Elizabeth Menefee, M.D., recognizes that any moonlighting shift can be labor-intensive and exhausting, given the fact that it has to fit between her regular shifts. So she limits her overnight moonlighting on-calls to no more than once a week or three times a month at a psychiatric emergency facility that’s also a required external rotation for part of her training.
Although the lure of additional income initially drove her interest in part-time work, she and her husband aren’t dependent on it, so she’s fashioned a schedule that’s doesn’t intrude on their personal lives. "For me, it’s really been about finding that balance and making sure that I set limits," she says of the part-time shifts during which she’s evaluating and treating patients in crisis. "If you’re doing this for financial reasons, it can be very appealing to work up to 80 hours, but you can burn yourself out. For me the answer to that was ’No.’"
Whether a second job is in your near or far future, you’ll want to secure the credentials you’ll need to work outside your program sooner rather than later. Since the only way to practice independently in a setting separate or "external" to your residency is via a full license, you’ll want to apply when you’re first eligible, depending on your state licensing board.
In the meantime, you may find an "internal" opportunity within the same location or system as your residency for which you can use your training license. Frishman’s program, for instance, allows OB/Gyn residents to work outside the hospital during their fourth year. It’s not always an attractive option, however, especially for doctors who aren’t sure they’re staying in Rhode Island post-training. The hassles and cost of securing a license they may not need long-term can discourage them from jumping through the hoops.
Instead, residents often participate in hospital-sponsored moonlighting opportunities, handed down year-to-year. By focusing on non-direct-patient-care tasks (such as teaching medical students about physical exams), they can use their training licenses to make extra money as early as year two. More importantly, besides being within their scope of abilities, the jobs are in-house so they’re still under direct supervision.
"This is a win-win for everyone," Frishman says. "Our residents are helping out with teaching, which we take great pride in. They’re also performing a service at the same time it’s educational for them."
If your target is that external position, however, make sure that your DEA number and other pertinent certifications are up-to-date, especially if you’re headed to a setting where they’re paramount. And above all, allow plenty of time for the paper chase.
At Fairview Health Services, a Minneapolis-based health system, for instance, once physician leaders have approved a moonlighting resident or fellow, managers start the necessary processing to ensure that a person’s privileges and payer enrollment status are approved so the facility can bill for their services.
"We try to streamline this as much as possible but it’s still an important activity," says Lynne Peterson, Fairview’s manager of physician recruitment. "Residents can’t just say, ’Hey, I want to moonlight’ and expect to do it next week. They really need to think about it sooner rather than later."
Danielle McDermott, M.D., MS, a University of Colorado-Denver epilepsy fellow, was a third-year neurology resident when she secured a full Colorado medical license to facilitate her integrated medicine practice part-time position. Although McDermott’s program doesn’t allow residents to practice independently within the scope of their specialty until they’re finished with training, she was able to perform basic assessments on the patients who sought the clinic for treatment of their headaches, backaches and other chronic pain. She also negotiated for her employer to pay her malpractice coverage and DEA certification.
When McDermott’s part-time job, which spanned her last year of residency through her first year of fellowship, ended in a cost-cutting move, she was fine with it. Even though the money had drawn her in, she decided that with a husband, child and demanding program she needed to prioritize family and studying. "You really need to think, ’Is this worth sacrificing the little time that you have outside your program?’" she says. "I realized that there were better things I could do with my time."
Back to business basics
Because making good business decisions is as important to moonlighting as it is to other parts of your career, you want to nail down any items, such as your contracts and professional liability coverage, that might affect your availability for extra work.
Nothing will take the wind out of your sails faster, for instance, than realizing after you’ve lined up a position that your residency or fellowship agreement doesn’t allow it. Even if the contract permits it, be aware of the language since it can vary significantly, from policy particulars to innocuous clauses such as "at the discretion of your director." You want to know what you need to do to stay in good standing.
As to a moonlighting contract, if you’re doing "extra duty" or part-time work in-house, you probably won’t have to sign elsewhere since it’s all part of the same structure. But if you’re going outside your program or system, expect (or even ask for) a contract that details hours, duties and malpractice coverage. Also make sure it doesn’t contain clauses that impinge on your residency commitment. A restrictive covenant, for instance, can actually prohibit a doctor from renewing his or her program contract, says Eric Katz, M.D., program director and vice chair for education for the department of emergency medicine at Maricopa Medical Center in Phoenix.
For that reason alone, Katz recommends sharing your moonlighting contract with your director if it’s not already required. "Our job as program directors is to be a little bit paternal," he says. "But it has to be made clear for everybody involved that a person’s residency is his or her primary job."
The contract McDermott signed not only covered the basics but detailed specific items important to her. Besides indicating that either of the two parties could end the agreement at any time, McDermott wanted a stipulation that it would be her choice as to whether or not she would prescribe a narcotic medication. As a neurologist, she’s well aware of the addictive nature of such powerful drugs. "I wanted to make that decision on my own," McDermott says. "I felt strongly that I needed to be in control."
You want to be equally certain that your malpractice coverage is sufficient. If your part-time work is internal, you may or may not have to get a separate policy, depending on what you’re doing and where you’re doing it. If it’s extra duty work for pay at your training location, for instance, your services may fall under your existing policy, even if you have to obtain an extension. Then again, if you’re working at another facility that’s part of your program, you might have to show proof of separate coverage.
If you’re moonlighting externally, the usual scenario is that you have to get separate malpractice coverage, either from your new employer or on your own. It’s unlikely that your training coverage will follow you, even though you might be lucky. Hurley, for instance, doesn’t have to purchase anything on top of what his program already provides for the places where he moonlights as long as his director has signed off on them. "That’s been of real value to me."
Besides proving that you have coverage, make sure that you understand the parameters. Is the policy occurrence or claims made and what does that mean for coverage now and with future claims? Do both require a tail policy or just a certificate of insurance to show that you were covered for services rendered during your moonlighting stint? Will you be safe if you were under an umbrella policy that’s still in place for the practice or once you leave are you on your own? You need to know.
Despite her employer’s willingness to provide malpractice coverage, McDermott hadn’t pushed for a tail policy, partly because she was unfamiliar with the nuances of professional liability. So when her original coverage expired after she left, she was shocked that she’d have to buy additional coverage at an unaffordable price. Instead, McDermott reviewed her notes on each of the patients she assessed or followed during her tenure, deciding that her potential exposure was relatively low. Also since Colorado has a two-year-statue-of-limitations on malpractice lawsuits, she knew the time for being sued was short; one year had already passed. But it’s still a cautionary tale. "When residents tell me that they’re thinking about moonlighting," says McDermott, "I say the same thing: ’Make sure you have tail coverage.’ I was a little naïve about it but it’s a huge issue."
Although you need to be business savvy in maximizing the experience, you also need to be pragmatic in using your skills. Since programs usually limit residents from doing jobs that they’re not technically ready to do - e.g. surgeons-in-training can’t operate and anesthesiologists-in-training can’t put people out - you’ll likely have to land a more general position. If you’re a fellow, your choices may be broader simply because you have a specialty under your belt.
Whatever the position, it needs to be appropriate in scope, obligations and demands. Whether you’re about to be one of many urgent care physicians on the weekend or the only rural hospital emergency doctor overnight, do you have the right stuff to safely and confidently perform those duties? Make sure that you’re clear as to the number and types of patients and duties and don’t be afraid to ask yourself: "Will the work put me at risk for a malpractice lawsuit?" "Who will be my backup to avert any such possibility?"
"You need to look at what’s expected of you and what you’re actually capable of providing," says Bradt. "Those things can be very different. You have to know that your skill set is where it needs to be to accomplish what you’re going to be called on to do."
Also, since you’ll likely encounter things you don’t know, haven’t seen before or don’t normally do, at least initially, it’s prudent to have a backup. In Swoboda’s program, for instance, if residents need help moonlighting, they can run the problem by any faculty member. "We want the best for the patient," he says. "We don’t want to take any chances or have anything bad happen."
For his part, Bradt isn’t shy about calling when he’s stumped and asking the attending, "This is what I have with my patient. What do you think?" Then again, nothing tests the limits of someone’s knowledge more than working without faculty or senior resident level to cover you. You have to figure out what’s going on with the patient and come up with ideas on treatment. "You don’t realize how beneficial it is to have back-up until you’re out there by yourself in a situation where there is no one," says Bradt. "You start thinking, ’What do I do next? How do I take care of this patient?’ That’s when you start asking, ’What do I really know? What don’t I know? What do I need to work on?’"
Indeed, any patient-centered experience can sharpen your clinical wits and skills. But the ACGME is very clear that your program must graduate you as a capable, independent practitioner based solely on its requirements without any extras. As Katz notes, "When a resident says to me, ’I’ll be a better doctor if you let me moonlight,’ my answer is ’You’re going to be a perfectly fine doctor whether or not you moonlight.’"
It’s enticing to think of the extra money you can earn by moonlighting. After all, you’ll only have to expend the energy for a short time and be done with it. In the meantime, it may help you alleviate your financial stress. In rare instances, Katz will approve a second-year student’s moonlighting request. "I think we underestimate just how much finances can dominate someone’s thoughts and life," he says. "My theory is that by working a bit more to relieve stress, a resident may actually learn more."
Yet it’s difficult to maximize the experience if you’re spreading yourself too thin. At the least, you need to be cognizant of the challenges; at the most, build in safeguards to protect your personal time. Although Bradt has been able to finesse his schedule to accomplish his work tasks, for instance, carving out time for his wife and two children is still challenging. They take solace in the fact, however, that after graduation his work life won’t be so hectic. "The biggest juggling act is weighing the benefits of making extra money to help pay off your debt and better yourself and your family," he says, "versus spending more time with them."
As for Hurley, an evening spent moonlighting is in an evening he can’t talk to friends, read his emails or carry on other activities. "When you don’t do that, your social life feels different," he says. "For me, it’s been a matter of figuring out the right titration of doing everything possible so moonlighting, while a good opportunity, is not at the expense of other parts of my life."
Chris Hinz is a frequent contributor to PracticeLink Magazine.