Community EM Moonlighting while in training

[inspirationmd]

So I need a little advice. Still a resident/fellow and will be for few more years. In order to reduce the financial pain and gather experience making the final decision I have been moonlighting for about a year now and will continue to do so until my training is finished. Lots of opportunities in the immediate region and lot of people kicking down the door begging. I started doing this for experience initially and it is still about that but the financial component is becoming more relevant now that I have started paying my loans and have become conscious of maximizing my bottom line. Will actually do quite well this year.

At the same time I do not want to be exposed to an excessive amount of risk. PA/NP supervision seems concerning but my friends have consistently told me that finding a job without having to supervise is becoming exceedingly rare - consistent with my own limited experience working in the community and with emailed job offers.

Here are the most appealing ED moonlighting opportunities I have done:

1) $170 hr for solo coverage in 12 bed rural ED with good ability to transfer to two tertiary hospitals and strong Hospitalist service and OB/Surgery back-up on phone that can come in. Other specialty back-up is spotty. Have to supervise PA. Drive 1.5 hours. Low acuity. Small amount blunt trauma. Haven't seen penetrating here yet.

2) $175 hr for multiple coverage with MDs and 2-3 NP/PA (have to supervise PA/NP for few hours each shift). Moderate to High acuity. Not uncommon to intubate, code, give TPA for STEMI/CVA, manage NSTEMI, a fib w RVR, etc or some combination every shift. Fair amount of blunt trauma, small but present penetrating trauma. Spotty specialty back-up though in house Surgery most hours of day, Hospitalist in house, and OB-Gyn by phone and can be there within 1 hour or less. Quasi-urban. 40+ bed ED. 2 hours away.

3) $125 hr for double coverage of 14 bed rural ED with moderate acuity. Surprisingly busy actually but it is manageable with the double coverage. Hospitalist strong support. No dialysis. Easy transfer availability. Some blunt, very rare penetrating trauma. No PA supervision. 30 min away.

What do you guys think?

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[link2swim06]

Out of curiosity, where do you live at?

 

[Aesculapius]

Seems pretty generous. What is the average pay like for moonlighting out there, out of curiosity?

 

[Tiger26]

I didn't moonlight for anything less than $200/hr during residency. That was the risk vs reward equilibrium point for me

 

[Groove]

So I need a little advice. Still a resident/fellow and will be for few more years. In order to reduce the financial pain and gather experience making the final decision I have been moonlighting for about a year now and will continue to do so until my training is finished. Lots of opportunities in the immediate region and lot of people kicking down the door begging. I started doing this for experience initially and it is still about that but the financial component is becoming more relevant now that I have started paying my loans and have become conscious of maximizing my bottom line. Will actually do quite well this year.

At the same time I do not want to be exposed to an excessive amount of risk. PA/NP supervision seems concerning but my friends have consistently told me that finding a job without having to supervise is becoming exceedingly rare - consistent with my own limited experience working in the community and with emailed job offers.

Here are the most appealing ED moonlighting opportunities I have done:

1) $170 hr for solo coverage in 12 bed rural ED with good ability to transfer to two tertiary hospitals and strong Hospitalist service and OB/Surgery back-up on phone that can come in. Other specialty back-up is spotty. Have to supervise PA. Drive 1.5 hours. Low acuity. Small amount blunt trauma. Haven't seen penetrating here yet.

2) $175 hr for multiple coverage with MDs and 2-3 NP/PA (have to supervise PA/NP for few hours each shift). Moderate to High acuity. Not uncommon to intubate, code, give TPA for STEMI/CVA, manage NSTEMI, a fib w RVR, etc or some combination every shift. Fair amount of blunt trauma, small but present penetrating trauma. Spotty specialty back-up though in house Surgery most hours of day, Hospitalist in house, and OB-Gyn by phone and can be there within 1 hour or less. Quasi-urban. 40+ bed ED. 2 hours away.

3) $125 hr for double coverage of 14 bed rural ED with moderate acuity. Surprisingly busy actually but it is manageable with the double coverage. Hospitalist strong support. No dialysis. Easy transfer availability. Some blunt, very rare penetrating trauma. No PA supervision. 30 min away.

What do you guys think?

Depends on your needs and if you have a family or not. #2 is good experience but sounds busy... I would demand $200/hr at the very least, especially when you compare it to #1. Unless you really feel the need to get loads of experience in a high acuity environment (you should be getting that in residency...), I'd minimize your risk and take #1 or #3. I'd probably lean towards #1 unless the drive really hampers your personal life/family, etc.. It would probably be worth it in the long run unless you can talk #3 into upping their pay. Get used to supervising/signing MLP charts. I moonlit for 2yrs in residency and supervised PAs the entire time.

 

[sum dude]

So I need a little advice. Still a resident/fellow and will be for few more years. In order to reduce the financial pain and gather experience making the final decision I have been moonlighting for about a year now and will continue to do so until my training is finished. Lots of opportunities in the immediate region and lot of people kicking down the door begging. I started doing this for experience initially and it is still about that but the financial component is becoming more relevant now that I have started paying my loans and have become conscious of maximizing my bottom line. Will actually do quite well this year.

At the same time I do not want to be exposed to an excessive amount of risk. PA/NP supervision seems concerning but my friends have consistently told me that finding a job without having to supervise is becoming exceedingly rare - consistent with my own limited experience working in the community and with emailed job offers.

Here are the most appealing ED moonlighting opportunities I have done:

1) $170 hr for solo coverage in 12 bed rural ED with good ability to transfer to two tertiary hospitals and strong Hospitalist service and OB/Surgery back-up on phone that can come in. Other specialty back-up is spotty. Have to supervise PA. Drive 1.5 hours. Low acuity. Small amount blunt trauma. Haven't seen penetrating here yet.

2) $175 hr for multiple coverage with MDs and 2-3 NP/PA (have to supervise PA/NP for few hours each shift). Moderate to High acuity. Not uncommon to intubate, code, give TPA for STEMI/CVA, manage NSTEMI, a fib w RVR, etc or some combination every shift. Fair amount of blunt trauma, small but present penetrating trauma. Spotty specialty back-up though in house Surgery most hours of day, Hospitalist in house, and OB-Gyn by phone and can be there within 1 hour or less. Quasi-urban. 40+ bed ED. 2 hours away.

3) $125 hr for double coverage of 14 bed rural ED with moderate acuity. Surprisingly busy actually but it is manageable with the double coverage. Hospitalist strong support. No dialysis. Easy transfer availability. Some blunt, very rare penetrating trauma. No PA supervision. 30 min away.

What do you guys think?

I've worked at all 3, and can tell you, 1) can be the toughest to work at when stuff hits the fan. #3 sounds like best option for moonlighting if you want more cush place. #2) seems like best mix of action/pay, though 2 hrs is a rough drive. I'm assuming you are a fellow or #2 is really rural (given that high acuity centers in cities usually aren't going to take non-grads), in which case, that can be pretty tough. Having back up is the most important when you are a moonlighting resident/fellow (though you learn the most when you're hanging out in the breeze by yourself without specialty back up). I made more than $125 5 years ago a rural, small ER, where I saw the craziest and scariest cases of my life, without any back up, but that' where I learned how to be a real community ED doc.

PA/NP's are a reality in Community practice--be real nice to them, encourage them to ask questions any time, tell them to be very conservative with plans (yes admit, yes get d-dimer, yes scan, yes give antibiotics). Experienced ones are better than young, fresh residents for cookie-cutter stuff, IMO, b/c they better know their limitations better. They will save your life when it gets busy and 3 drunken idiots come in at 2 am with a giant facial lacs.

Just remember when you moonlight--scan everyone, be nice to everyone (staff, patients, consultants, etc), be liberal with abx and pain meds, admit anyone you feel uncomfortable about, and CYA all day. Remember you are an unboarded doc in a place which couldn't get a Boarded docs to work there (ie it is less desirable hospital or location)...moonlighting is not the place to dig your heals and practice state of the art clinical EBM

 

[inspirationmd]

Thanks for those that responded. Sorry I have been MIA. String of nights in the ED has kind of wrecked me and limited time.

I'm in the VA/NC area for those who asked and all of these are essentially rural community hospitals. Lots of demand in the SE USA though. The relatively low salaries are a direct result of not being BE/BC at this point at least for two of the locations for sure. Not sure I have a lot of negotiating power since this is what moonlighters from my program and beyond have taken for several years.

I get plenty of experience in residency so thats not the problem. Very satisfied with my exposure in training. CYA is definitely the name of game while moonlighting. If I even have a question then the study gets ordered (CT/US/MRI, etc). I have a cowboy streak to me but I'm not that crazy...yet.

Good to hear about the PA/NP question. I was a little bothered by it but I suppose it is just part of the specialty and community practice. Will just pay very close attention.