American College of Physicians: Internal Medicine — Doctors for Adults ®


Moonlighting: good experience or a necessary evil?

From the May 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.

Working extra hours can expand your training and income, but educators point to potential drawbacks

By Christine Kuehn Kelly

Eric Milbrandt, ACP­ASIM Associate, clearly remembers the night he was moonlighting at a Nashville community hospital. A patient with exacerbated COPD who came to the emergency room was doing so poorly that he spent the entire night with her. The next morning, when she finally showed signs of improvement, he felt he had made a real difference.

"It was one of the first times I was able to call the shots and use the tools I had learned to fight for a patient," recalled Dr. Milbrandt, who is now a first-year fellow in pulmonary critical care at Vanderbilt University Medical Center and Chair of the College's Council of Associates.

Dr. Milbrandt's experience illustrates key benefits of moonlighting as a resident: The extra hours can provide clinical experience that enhances your training, and you get exposure to patients outside of your training program.

"For me, moonlighting has by far been my best educational experience," said third-year Johns Hopkins resident Erik N. DeLue, ACP­ASIM Associate, who moonlights in a local hospital's emergency department. "For the first time, I don't have anyone over me. I am making my own decisions."

Most residents, however, also view moonlighting as an important source of extra income. Although residents have traditionally picked up additional cash by working a few extra hours in the emergency room, many now use moonlighting to get a jump-start on loans.

Moonlighting is prevalent among housestaff. AMA statistics estimate that up to 37% of all residents moonlight, while the American Osteopathic Association believes up to 80% of residents in osteopathic programs moonlight. For internal medicine residents, educators say, the number is probably closer to 50%.

Keeping close tabs

Because so many residents are moonlighting, the Accreditation Committee for Graduate Medical Education (ACGME) has proposed that residents be allowed to work outside their training program only if their total combined educational program and moonlighting hours don't exceed the 80-hour weekly limits set by the Residency Review Committee (RRC). The RRC has also recommended that program directors approve all moonlighting and that the practice should not replace clinical experience. (The text of the ACGME proposal is available on the Web at; see appendix G.)

The rules reflect the feeling of many program directors, who view moonlighting as a necessary evil. While most educators say that they don't like moonlighting, they permit it—under certain conditions.

Most residencies, for example, already require the program director to approve all residents' moonlighting. "Moonlighting is a privilege that must be earned," explained J. Wolfe Blotzer, ACP­ASIM Member, director of the internal medicine training program at York Hospital, in York, Pa. "To be approved for moonlighting, our residents have to show leadership and be good role models for the interns."

At York, only third-year residents who are top performers in the program can be approved for moonlighting. Dr. Blotzer said he closely monitors residents who moonlight, making sure they are getting adequate sleep and that they are working only during rotations that allow extra free time. Because the program doesn't want residents to work more than an 80-hour week, housestaff are not allowed to moonlight when they are on medical service or intensive care rotations.

Complicating factors

Yet with so many residents eager to earn money moonlighting, educators acknowledge that many housestaff probably work more than a total of 80 hours a week. While training programs track program-related work hours, they typically have a harder time keeping tabs on moonlighting hours, said Herbert S. Waxman, FACP, the College's Senior Vice President for Education.

That's why some programs are taking another approach and asking residents to oversee moonlighting themselves. The University of Cincinnati's department of internal medicine, for example, developed a resident peer review committee to monitor moonlighting hours more than a decade ago. The committee documents the moonlighting activities of the program's residents through self-reports to ensure that residents follow program guidelines.

"There were compliance issues early on," said Gregory W. Rouan, FACP, director of the internal medicine program. "But in the past years, compliance has been more than 98%." The peer review process gives the residents a sense of control—and accountability—and helps ensure an accurate system for monitoring, he said.

Because not all programs have been successful in controlling moonlighting, the Federation of State Medical Boards (FSMB) has recommended that state medical boards require all applicants for licensure to have satisfactorily completed postgraduate year three training before they are given a full and unrestricted license. The proposal, which would have effectively eliminated most residents' ability to moonlight, was sharply criticized by the resident community. So far, states continue to permit residents who have passed their written exams and are in accredited residency programs to moonlight, but this may change.

Dr. Waxman said that the FSMB proposal is putting the current generation of residents in a squeeze. "Indebtedness is rising," he said, "and at the same time future income potential is being curtailed."

One solution may be restoring student loan deferrals, said Dema Daley, executive director of the Association of Program Directors in Internal Medicine. "We need to find some financial relief for residents."

Liability concerns

Residents who do put in extra hours outside their program must make sure they are protected from legal liability. While housestaff are no more likely to be sued when moonlighting than attendings, Boston malpractice attorney Lee Dunn, JD, said that they must make sure their malpractice insurance applies no matter where they are working. Because your residency program covers you for work only in your own institution, you need to protect yourself for services you perform outside your training program.

Clinics and physician offices may offer additional malpractice insurance to moonlighters, but beware of coverage in the "claims-made" category. Claims-made insurance protects you from malpractice claims only if the insurer that covered you at the time of the alleged incident is the same company you are using when the claim is actually filed. If that's not the case, you won't be covered unless you have purchased "tail insurance," which is designed to cover such after-the-fact claims. The only catch is that tail insurance can cost up to twice as much as standard malpractice insurance.

Legal experts also say that to be on the safe side, you should thoroughly document your services when you moonlight outside of your training program. Documentation can be a huge help if any questions are raised down the road.

Even with your legal back covered, experts say residents should consider moonlighting very carefully. "You only have one chance to learn during a residency," said Marvin R. Dunn, MD, director of ACGME's residency review committee activities.

Besides, he added, the answer to the enormous debt load is not moonlighting but finding a way to better finance medical education. Unfortunately, he said, that is not likely to happen soon. "We have to make some major changes for the residents of tomorrow," he explained, "but that doesn't help them today." *

Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.

Five things to think about before you start moonlighting

Planning to moonlight? Here are some tips to get you started:

  • Look in-house. The hospital emergency room is traditionally the place where many residents moonlight. One advantage is that you probably already are covered by the institution's liability insurance. As emergency medicine grows as a specialty, however, you may find yourself competing for spots with emergency medicine residents.

Other areas of your institution such as outpatient clinics may also need coverage. As chief resident of internal medicine, Kim Esh Russell, ACP­ASIM Member, helped internal medicine residents find work in a private group practice that needed extra coverage. "We covered admissions, morning consults and in-house emergencies," said Dr. Russell, who now practices in Greenwood, S.C.

  • Go into the community. Residents often find opportunities in local hospitals that don't have training programs. These hospitals can usually provide you with malpractice insurance. Local school districts also need physicians to do sports physicals for their students.
  • Consider the dot-coms. The growth of Web sites that allow readers to "ask the doctor" means telecommuting opportunities for physicians. Your institution also may have a Web site with this function or be willing to set one up.
  • Work in large chunks. Residents who have been there suggest moonlighting when you have large blocks of time. Try working through a free weekend or during a vacation to quickly earn a lump sum of cash.
  • Be cautious. Out on your own, you may come across situations you don't feel equipped to handle. Educators and residents alike say that you should be cautious, particularly when you're unsure of yourself.

Don't be afraid to consult specialists when confronted with medical problems outside your area of expertise. If your two-month medical school pediatric rotation didn't prepare you to treat a child in the emergency room, call for a consultant. "If you feel uncomfortable with something, make sure you should be doing it," said third-year Johns Hopkins resident Erik N. DeLue, ACP­ASIM Associate. "It's nice to have the cash, but you don't want to start out your career with a lawsuit."

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