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Moonlighting: a tug-of-war between time and money

Opportunities abound, but work-hour rules and safety concerns are shrinking the pool of available residents

From the December ACP Observer, copyright 2005 by the American College of Physicians.

By Deborah Gesensway

As an internal medicine chief resident at Philadelphia's University of Pennsylvania, Jennifer A. Loh, ACP Associate, is trying to catch up financially before she starts an endocrinology fellowship—and a family. She plans to moonlight as much as she can on her off-hours—maybe a shift a week—and earn just shy of $60 an hour, more if she moonlights on holidays.

"If I wanted to work more I could easily get more," Dr. Loh said. "From what I've seen in our system, there are more opportunities for moonlighting" than ever before. Her one limitation? Fitting the extra hours she wants to work after her residency shifts end into the 80-hour limited workweek.

No one has studied the effects of the two-year-old residency duty-hour limitations on moonlighting, but everyone has an opinion. Many, like Dr. Loh, see a dramatic increase in moonlighting opportunities—and say that residents now have more time to pursue those opportunities than ever before.

But others claim that fewer residents are interested in moonlighting. They point to the fact that in-house moonlighting now counts toward the 80-hour total that residents can work every week and that program directors are keeping closer tabs on how moonlighting might affect Associates' performance.

"Moonlighting has definitely decreased," said Lawrence M. Phillips, ACP Associate, a cardiology fellow at North Shore University Hospital in Manhasset, N.Y., and the Chair-elect of ACP's Council of Associates. Internal moonlighting, where residents work extra shifts in their own training hospitals, has been cut back by residency program directors, he explained. At the same time, external moonlighting—where residents work at other, often community hospitals—is now more complicated because residents have to get extra malpractice coverage and some hospitals have complex rules governing licensure and credentialing.

What all agree on is that duty-hour limitations, which address the major time problems residents face, are also shining a new light on another big issue: money, specifically stipends and debt.

"People are desperate for money so they will work as much as they can, and not because they want to live a luxurious life" said Dr. Loh. "It's just simply to support ourselves."

Money matters

Since the Accreditation Council for Graduate Medical Education (ACGME) enacted new rules in July 2003 that limit residents to an 80-hour workweek, housestaffs' financial problems have only gotten worse.

According to a 2004 report on young physician indebtedness by the Association of American Medical Colleges, more than 80% of medical school graduates are in debt, with median debt exceeding $100,000. At the same time, the median stipend in 2004-05 was a modest $40,788 for interns, $44,491 for third-year residents.

The College, which supported the work-hour rules, also acknowledged the corresponding financial dilemma in a 2003 position paper. According to that paper, the "loss of opportunities for moonlighting will need to be evaluated with regard to implications for the need for higher resident stipends and on the financial situation of teaching hospitals."

Moonlighting is the time-honored means many residents have used to convert spare time into extra cash and experience. While the ACGME doesn't track moonlighting, some observers claim that at one time as many as 40% of senior residents were moonlighting.

According to one set of anecdotes, more residents now have time on their hands to moonlight. Attendings at academic medical centers complain they now have to work longer and harder because residents must work less—only to bump into those same residents moonlighting in the hospital on a different service, instead of going home to read and rest. Pushing residents to moonlight is the fact that many are married to other physicians, who likewise come with their own $100,000+ debt burden.

But another set of anecdotes leads to the opposite conclusion. Some programs prohibit moonlighting outright. In others, different laws and regulations—targeting when residents are eligible for an unrestricted medical license, for instance, or the credentialing process hospitals must use to maintain accreditation—means a shrinking pool of potential moonlighters.

According to Michael A. Weisz, FACP, internal medicine program director at the University of Oklahoma in Tulsa, Okla., and Governor for ACP's Oklahoma Chapter, fewer residents in his program are choosing to moonlight.

"That's partly due to the new duty-hour rules, which have focused everyone on the issue of not working too much," Dr. Weisz said. The ACGME rules have likewise hit non-citizen residents hard, he pointed out. While they may not have as much educational debt to pay off as many American medical school graduates, they often need to send money back to families overseas—and if they are in this country with certain types of visas, they are forbidden to moonlight externally.

At the same time, pointed out Ingrid Philibert, ACGME's director of field activities, the makeup of the resident population has changed. Dr. Loh notwithstanding, women in general tend to do less moonlighting than men, Ms. Philibert said—and women now make up 40% of the resident population. In addition, she noted that this generation of residents may put more value on time than on money, compared to older physicians.

And hospitals that depend on moonlighters say they are now coping with a shrinking pool of potential workers. That's taking place while inpatient censuses are on the rise and as academic centers are creating and expanding their non-teaching services. During the day, teams of nurse practitioners, physician assistants, hospitalists or private physicians can handle the increased load. But with staffing shortages, many hospitals count on hiring internal medicine residents and fellow moonlighters to augment after-hours coverage—and they are coming up short.

Michael F. Beers, MD, associate professor of medicine at the University of Pennsylvania, has for 15 years run a company that recruits moonlighters. Over the years, he said, he has watched as both the demand for high-quality, academically based moonlighting residents has shot up—while the supply of potential workers keeps falling.

He has now stopped trying to recruit residents and fellows to moonlight as house doctors at some community hospitals in suburban Philadelphia. He is even having a tough time finding a big enough internal pool of fellows to guarantee coverage for cardiology and oncology non-teaching services at two of University of Pennsylvania's teaching hospitals.

"We are saturated, given the size of the fellow pool, and there is no way to accommodate another service," Dr. Beers said. "If everyone were to turn around and say they don't want their fellows moonlighting, that would be the death knell."

Out of the shadows

In addition to focusing attention on educational debt, the duty-hour rules have brought moonlighting under official scrutiny. For decades, moonlighting was something that many senior residents did but didn't talk about. Now they're obligated to report it.

The 2003 ACGME duty-hour rules mandate that program directors discuss moonlighting with their trainees. Residents must now get written permission from their program directors before taking any internal moonlighting job. At the same time, any moonlighting that takes place within the residency program's clinical sites must be counted toward the 80-hour limit.

External moonlighting at other hospitals or clinics does not technically have to be included in that 80-hour count. But many residents' contracts now require them to report external moonlighting activities to their program director, due to concerns about the effects of sleep deprivation and overwork.

At the same time, program directors are trying to be sensitive to residents who need extra money. At Ohio State University in Columbus, Ohio, Catherine R. Lucey, FACP, internal medicine program director, said she's tried to deal with that problem by adding an educational component to moonlighting.

"We ask them to really think about what their job is going to entail, if they have the skill sets that they will need," she said. For instance, she discourages residents from taking moonlighting shifts in some community hospital emergency rooms because they may not have the proper skills—and may put themselves at greater risk for being sued. She said she draws on her experience as a moonlighting resident in an urgent care clinic that treated both children and adults.

"I realized I didn't have the skills to take care of kids, and it wasn't fair for me to put myself forth as a doctor who could," she said. "We try to encourage our residents to think of that."

To help housestaff who want to moonlight, she has put together a list of good and less taxing moonlighting opportunities in the community that she can point residents to. (Also see "Tips for moonlighters.")

"We've tried to find jobs like monitoring people at a local imaging center that we think are particularly good fits for residents," she said. Other teaching hospitals now use external moonlighting as a way to educate residents about practice opportunities and to help them find permanent positions. (See "State uses moonlighting as recruitment tool.")

In the meantime, while moonlighting continues to pose an ethical and financial dilemma for residents, the jury is out on how heavily it should be regulated.

"There isn't enough research being done on the opportunities for moonlighting, how to use moonlighting appropriately and what education could or should be done with those venues--and there should be," said ACGME's Ms. Philibert. "We understand that we have no right to tell people how to spend their spare time, but we also have this notion that hospitals have an obligation to provide safe and effective care."

Deborah Gesensway is a freelance health care writer in Toronto.

The information included herein should never be used as a substitute for clinical or business judgment and does not represent an official position of ACP.

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State uses moonlighting as recruitment tool

Almost 15 years ago, family physician Daniel Derksen, MD, began trying to match moonlighting supply with demand at the University of New Mexico (UNM) in Albuquerque. On the supply side were residents, fellows and young physicians who needed extra income, but were already tired from working long hours.

On the demand side were practicing doctors and hospitals in rural and medically underserved areas that needed staff and had nowhere to turn for affordable relief.

So Dr. Derksen, now director for UNM's Center for Community Partnerships and professor and vice chair in the department of family and community medicine, joined with many of his colleagues to help found an academic locum tenens program. The idea was to have the school control moonlighting opportunities so it could limit the hours people worked.

"I'm a big proponent of work-hour limits," Dr. Derksen said. "We know that if our residents work more than 80 hours, there is a much higher rate of depression, substance abuse, divorce and impairment."

As part of their resident contracts, UNM residents agree to use UNM's locum tenens service exclusively for moonlighting. The service reports back to program directors on how many hours trainees are working.

Dr. Derksen points to two other big advantages of the program. One, it boosts recruiting possibilities for private practitioners who use the service. About 75 residents who have moonlighted over the years have taken jobs in one of the practices where they served.

And because the service helps attract physicians to the state's rural and medically underserved areas, it now receives a state subsidy. This year, that subsidy totaled nearly half a million dollars, which allows physicians to discount services in health professional shortage areas—and provides better pay for the residents who moonlight.

"That ensures," Dr. Derksen said, "that residents are paid fairly."

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Tips for moonlighters

  • Understand the Accreditation Council for Graduate Medical Education regulations. In addition to the 80-hour rule, residents must have one day off in seven, cannot be on call more than once every three nights, and cannot be continually on duty for more than 24 hours plus six additional hours for patient hand-offs and paperwork.

  • Know what type of moonlighting situation you're getting into and make sure you have the skills to handle whatever comes through the door.

  • If you're considering an external moonlighting job, find out what your liability insurance situation will be. You may, for instance, have to purchase your own tail coverage.

  • To bill for services delivered outside the scope of your residency practice, you must enroll in Medicare and receive a unique physician identification number.

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