Moonlighting without programs approval

[notdeadyet]

I don't think moonlighting against residency rules is"lying".

Only if you don't know that there are rules prohibiting moonlighting.

Most programs have a moonlighting policy. It's usually communicated in the policies and procedures. Every intern is typically given a contract to sign in which the terms and conditions entail agreeing to follow the policies and procedures. Lack of awareness is not a defense.

No offense, but it's convenient for someone without much student loan debt to take this position on a residency banning moonlighting. Some people actually have bills to pay and families to support.

I don't know whopper's financial situation (and am not asking), but I didn't hear him take a position at all on residencies banning moonlighting. He took a position on the dishonesty and lack of ethics that are reflected when a resident chooses to not follow rules they are contractually obligated to follow.

The ethics of programs banning moonlighting is another issue entirely. Personally, I think the most common approach is for programs to allow moonlighting assuming the resident is in good standing with the residency program. I know several programs that essentially require residents to report if they are moonlighting at an external site and the program has the right of refusal if the resident is in jeopardy.

Some people actually have bills to pay and families to support.

Bills and families only seem special when they're yours. We all have 'em.

By the time someone is finished with medical school, they are typically at least 26yo. Regardless of recent trends in helicopter parenting, I think by the age of 26, folks should be accountable for knowing their financial situation. Medical students should look at their monthly nut, plan for setting aside a small savings for emergencies, plan for family changes, and figure out what they need to make each month.

When they look at programs, if they can't live on the residency salary alone, they need to inquire (from the PD and existing residents) what the moonlighting policy and opportunities are. If they can't get a good answer to that question that will let them earn that number, they should drop that program from their list. If they get a reassuring answer, they need to read over the policy documents that they are about to sign and make sure it jibes. And Saplingo's advice about emergencies is right on: talk to your PD. Going around behind his/her back and then talking about emergencies when caught is not going to get you far. See whopper's ethics discussion above.

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[michaelrack]

I don't think moonlighting against residency rules is"lying". .

Agree that it is not lying; it's not immoral as long as one isn't moonlighting so much that it impairs their functioning during residency/fellowship. It is breaking an arbitrary rule and there is a significant likelihood of getting caught with potentially drastic consequences, so don't do it if it is against the rules.

 

[deleted736562]

Agree that it is not lying; it's not immoral as long as one isn't moonlighting so much that it impairs their functioning during residency/fellowship. It is breaking an arbitrary rule and there is a significant likelihood of getting caught with potentially drastic consequences, so don't do it if it is against the rules.

It's always a red flag when people bring ethics into a discussion like this one. It's just a way to further infantilize and bully residents. Not that it's a good idea to violate your residency contract.

 

[whopper]

, but it's convenient for someone without much student loan debt to take this position on a residency banning moonlighting.

How is this not rationalization? Yeah I agree it sucks but you signed on to this program and you have contractual obligations.

IMHO programs should allow for moonlighting, and if a program doesn't allow it the residents should try to change it from within, not break the rules. You can address this issue with the GME, the chief resident or program director. Also this should be factored in when making your match list. When medstudents interview feel free to complain to the applicant that they don't allow moonlighting. Hey it's honest. It'll also put a flame under the butt of the PD to make him consider allowing moonlighting. I don't find this unethical at all because applicants have the right to an honest opinion on the residency.

I don't know whopper's financial situation (and am not asking), but I didn't hear him take a position at all on residencies banning moonlighting. He took a position on the dishonesty and lack of ethics that are reflected when a resident chooses to not follow rules they are contractually obligated to follow.

You understood me right. Personally I do think a resident should be allowed to moonlight especially since many programs have easy hours during the 4th year and the mounting debt of medstudents, but like I said again you should not violate the program's rules.

 

[whopper]

Why would a psych residency not allow moonlighting?

I've seen it happen and I didn't like it one bit. One argument I heard was it would prevent the resident from seeking opportunities in research and academics. I don't like the argument because it ignores that many residents are in debt. Further with the shortage of psychiatrists we're not helping the community.

Lack of working was not the reason in the once place I've seen. Heck most residencies I've seen go real easy on PGY 4s.

 

[notdeadyet]

It's always a red flag when people bring ethics into a discussion like this one. It's just a way to further infantilize and bully residents. Not that it's a good idea to violate your residency contract.

If I remember correctly, the original post basically said, "I want to moonlight. My program doesn't allow moonlighting. How serious of an infraction would it be if I did moonlighting anyway?"

How on earth can you address this without bringing ethics into it? It was an ethics question! I understand that programs can use "professionalism" as a hammer sometimes, but when you ask a professionalism question...

Medicine is a funny world, particularly when you're an older traveller. Any time things about how to act like a professional and how to be ethical are discussed, it is inevitably followed by complaints of The Man infantilizing, condescending, bullying, badgering, etc. It's kind of an odd reaction when this discussion occurs in the context of folks asking about how they can be unprofessional or if it's okay to be unethical.

I don't know what it is about medicine. I worked in several other industries before and never had so much exposure to lectures about things like ethics and professionalism. But I also never worked in environments where folks needed it so much. I attribute it to the Special Snowflake/I Know It's the Rules But I'm Different-vibe that comes when folks have been coddled either via enviable academic success or enviable bank balances growing up.

 

[OldPsychDoc]

I feel that if we forbade moonlighting, it would just mean that residents would have to sneak around us and would do it anyway. Having a policy and asking for disclosure allows us to maximize the value of the experience to the resident, both from a training perspective and an ethics perspective.

Guess it's kind of like making sure your kids are using birth control--so you can at least have some opportunity to guide their decision-making...

 

[deleted736562]

If I remember correctly, the original post basically said, "I want to moonlight. My program doesn't allow moonlighting. How serious of an infraction would it be if I did moonlighting anyway?"

How on earth can you address this without bringing ethics into it? It was an ethics question! I understand that programs can use "professionalism" as a hammer sometimes, but when you ask a professionalism question...

The OP was asking about repercussions, and not necessarily moral judgements. For one thing, discussing ethical considerations is almost impossible without considering the actual circumstances. For another, violating rules is not always unethical, and in this case, it may very well end up benefitting patients and make the resident a better psychiatrist.

 

[notdeadyet]

The OP was asking about repercussions, and not necessarily moral judgements. For one thing, discussing ethical considerations is almost impossible without considering the actual circumstances. For another, violating rules is not always unethical, and in this case, it may very well end up benefitting patients and make the resident a better psychiatrist.

This is the Special Snowflake/I Know It's the Rules But I'm Different-vibe I was alluding to.

You sign a contract and give your word that you will follow the rules outlined, one of which pertains to moonlighting.
Saying it's not unethical to break the agreement that you made because you want to real bad is the sort of truthiness that has lead to there being so much professionalism discussions in the residency curriculum. The "we don't know all the facts" things is splitting hairs that are fine intact; this is not a question about jaywalking to perform CPR.

The honesty thing is huge in medicine (or any real professional field, really). If folks are going to not follow their word on agreeing not to moonlight, it's hard to trust them to follow rules in other domains.

I think we should be able to trust our residents enough to moonlight and still place their education and residency service requirements first. But I also think we should be able to trust our residents enough to take them at their word.

 

[hamstergang]

For the record, the residents that I know that did moonlighting without permission were in a program that allows moonlighting. They just didn't bother with the process as far as I know.

Edit: though I don't know how credentialing would work without the program being aware so maybe I was misled. I'm fairly sure 1 person in fellowship did get away with this since their residency was elsewhere, but now I'm less sure.

 

[Madden007]

This is the Special Snowflake/I Know It's the Rules But I'm Different-vibe I was alluding to.

You sign a contract and give your word that you will follow the rules outlined, one of which pertains to moonlighting.
Saying it's not unethical to break the agreement that you made because you want to real bad is the sort of truthiness that has lead to there being so much professionalism discussions in the residency curriculum. The "we don't know all the facts" things is splitting hairs that are fine intact; this is not a question about jaywalking to perform CPR.

The honesty thing is huge in medicine (or any real professional field, really). If folks are going to not follow their word on agreeing not to moonlight, it's hard to trust them to follow rules in other domains.

I think we should be able to trust our residents enough to moonlight and still place their education and residency service requirements first. But I also think we should be able to trust our residents enough to take them at their word.

Love the wonderful insight in this post, from both sides of the argument. I'm sure we all understand that not all rules/consequences are weigh the same. Jay walking is not a dwi, and their repercussions are vastly different as well, and im sure we've all broken the rules by Jay walking. Simply put, as one seeking wisdom, i wasnt sure if inappropriate moonlighting was a jaywalk or dwi lol

 

[notdeadyet]

I'm sure we all understand that not all rules/consequences are weigh the same. Jay walking is not a dwi, and their repercussions are vastly different as well, and im sure we've all broken the rules by Jay walking. Simply put, as one seeking wisdom, i wasnt sure if inappropriate moonlighting was a jaywalk or dwi lol

That's the spirit I got from your original post. It's a very valid question, and you won't know if you don't ask. All good.

 

[deleted736562]

This is the Special Snowflake/I Know It's the Rules But I'm Different-vibe I was alluding to.

It's just that actual circumstances matter when one is willing to make sweeping moral judgement or use words like "unethical" for breaking a rule. But this is the sort of parenting behavior one could get away with in systems with huge imbalances in power.

It doesn't mean that rules should be selectively applied, which I think your "Special Snowflake" statement implies. When you sign anything, you take responsibility for breaking it.

You sign a contract and give your word that you will follow the rules outlined, one of which pertains to moonlighting.
Saying it's not unethical to break the agreement that you made because you want to real bad is the sort of truthiness that has lead to there being so much professionalism discussions in the residency curriculum. The "we don't know all the facts" things is splitting hairs that are fine intact; this is not a question about jaywalking to perform CPR.

Well, not sure what sort of an agreement this is, when you don't get to negotiate your actual contract and refusing it is tantamount to "career over". How much of a choice or say do you actually have? Furthermore, work contracts are not exactly Hippocratic Oaths. They are meant to define legal responsibilities for both parties to guarantee its validity.

A question for you: do you think it's "unethical" to break any work contract? If not, why then residency?

 

[nancysinatra]

how? aside from winning the lottery etc - any additional work whether clinical or related to medicine or not counts as moonlighting. I had to fill in a moonlighting form to teach a class

Seems like there's gotta be an antitrust case here somewhere...

 

[ProfMD]

If you are in such dire financial circumstances that you need to moonlight to get by, I suggest you reevaluate your finances. Plenty of residents do just fine on resident salaries, some for much longer than you.

As someone who sits on his hospital's medical staff committee, I would strongly discourage you from moonlighting if it is against your program's policies. If you are caught, you PD will have to report it to every hospital and state medical board you apply to. These comments are taken very seriously because, fair or not, they reflect on your character. People will assume that if you couldn't follow a simple moonlighting rule, that you may play it fast and loose with other policies as well. Not worth it for a few extra bucks during residency/fellowship.

 

[keifernny2]

My understanding is also that there are Medicare rules regarding moonlighting that also affect the hours and locations that you are eligible to moonlight (i.e. You can't bill Medicare while Medicare is paying your full time residency salary during business hours, as that could be seen as double dipping with Medicare). If a hospital double dips with Medicare it turns into a big compliance and $$ issue for them (and you, since you are officially benefitting and it is all happening under your NPI number, you don't get to plead ignorance). I could be wrong at this, but this is what was explained to me by the clinic financial people when I started moonlighting.


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[Salpingo]

how? aside from winning the lottery etc - any additional work whether clinical or related to medicine or not counts as moonlighting. I had to fill in a moonlighting form to teach a class

I assumed the definition of moonlighting was acting in the capacity of a physician, since we had to be licensed and have malpractice insurance to do it. That may vary based on program.

As for alternative sources of income, I realize it's not easy, but I've known some very entrepreneurial residents who have done well. Granted, they started their business or developed their skills before residency. Again, it's not ideal (and you'll still want to make sure it's kosher with your PD if it's a big time commitment), but if things are so dire with finances, there are options.

 

[Crayola227]

My understanding is also that there are Medicare rules regarding moonlighting that also affect the hours and locations that you are eligible to moonlight (i.e. You can't bill Medicare while Medicare is paying your full time residency salary during business hours, as that could be seen as double dipping with Medicare). If a hospital double dips with Medicare it turns into a big compliance and $$ issue for them (and you, since you are officially benefitting and it is all happening under your NPI number, you don't get to plead ignorance). I could be wrong at this, but this is what was explained to me by the clinic financial people when I started moonlighting.


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the very possibility of this is a thread ender - you don't know how moonlighting without approval can **** you until you ask your PD - therefore, ask your PD

is it really worth losing your career over? I don't care if some people get away with it

 

[OldPsychDoc]

My understanding is also that there are Medicare rules regarding moonlighting that also affect the hours and locations that you are eligible to moonlight (i.e. You can't bill Medicare while Medicare is paying your full time residency salary during business hours, as that could be seen as double dipping with Medicare). If a hospital double dips with Medicare it turns into a big compliance and $$ issue for them (and you, since you are officially benefitting and it is all happening under your NPI number, you don't get to plead ignorance). I could be wrong at this, but this is what was explained to me by the clinic financial people when I started moonlighting.


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An apt reminder to be aware that someone else is paying our salary, and that we all have to alter our behavior one way or another to satisfy them...
e.g. EVERYBODY has a Boss.

 

[michaelrack]

An apt reminder to be aware that someone else is paying our salary, and that we all have to alter our behavior one way or another to satisfy them...
e.g. EVERYBODY has a Boss.

Some of my work is salaried. I have a boss, not a master. I try to have several positions going at once so I can walk away from one if I need to (or so I can survive being terminated).

Ultimately, I am answerable to the boards of medicine in the states which I am practicing.

 

[notdeadyet]

A question for you: do you think it's "unethical" to break any work contract? If not, why then residency?

To me, "breaking" a contract means leaving it before the date of expected completion. There's a lot of reasons folks do this, some ethical and some ethical. This can be done ethically or unethically in residency and elsewhere.

But if you're asking me if it's unethical to intentionally violate the promises made in a contract, not disclose the fact, and hope you don't get caught? Yes, this is unethical. In any business, including residency.

Well, not sure what sort of an agreement this is, when you don't get to negotiate your actual contract and refusing it is tantamount to "career over". How much of a choice or say do you actually have?

Yup. This is why folks repeatedly have recommended asking about any deal-breakers before choosing programs.

It's really not that hard. Folks ask these kinds of questions all the time. Yes, the system favors the programs in many ways, but you can hedge your bets by asking questions that are important to you before selecting programs. It beats saying "it's not fair" and looking for ways to violate a contract you've signed.

There are a lot of injustices in our field and with our training. Not liking a moonlighting policy that you could have learned about how you asked before you signed a contract is not one of the biggies.

 

[666357]

what your program doesn't know won't hurt them. And if they do find out somehow, just don't be brazen about it and tell everyone "Im not supposed to moonlight but am anyways and they know so **** them" and they will probably just look the other way to not make waves. Don't let your program dictate bs rules to you.....just be smart about it.

Agreed. I ML'd without my program knowing. I was worried until I started getting those paychecks which well exceeded my residency salary. I was a really good resident too and wasn't worried about getting the boot if I did get caught. I know other residents, including the chief, knew what I was up to. No one said anything. Start making some bank.

PS, if you do get caught, just pull a Hillary and state that you had no intention of violating the rules...

 

[MacDonaldTriad]

Agreed. I ML'd without my program knowing. I was worried until I started getting those paychecks which well exceeded my residency salary. I was a really good resident too and wasn't worried about getting the boot if I did get caught. I know other residents, including the chief, knew what I was up to. No one said anything. Start making some bank.

PS, if you do get caught, just pull a Hillary and state that you had no intention of violating the rules...

Really, loaded gun here? "Do you feel lucky punk"? If you want to gamble on how good a resident your program thinks you are, take the above advice. How many of you "gatsta know". Probably a lot of you are good enough to get away with this, but the ones who aren't seem to be the least aware of it. It just seems like a bad idea if there is an established policy. I suggest asking or looking it up when selecting programs. It can derail your efforts if it is in writing.

 

[nancysinatra]

If you are in such dire financial circumstances that you need to moonlight to get by, I suggest you reevaluate your finances. Plenty of residents do just fine on resident salaries, some for much longer than you.

As a person who once had over $300K of med student debt, I find your attitude offensive.

 

[ProfMD]

As a person who once had over $300K of med student debt, I find your attitude offensive.

I still have debt, so what? I still wouldn't risk my career on moonlighting against policy.

As I said, there are plenty of residents who don't moonlight and mange to get by. I don't think most surgical programs allow moonlighting. These people do 5-10 years of residency and fellowship. You think they were all born with silver spoons and graduated without debt?

 

[nancysinatra]

If I remember correctly, the original post basically said, "I want to moonlight. My program doesn't allow moonlighting. How serious of an infraction would it be if I did moonlighting anyway?"

How on earth can you address this without bringing ethics into it? It was an ethics question! I understand that programs can use "professionalism" as a hammer sometimes, but when you ask a professionalism question...

I disagree. The question asked by the OP was not, in a philosophical sense, an ethics question. It was a question about rules, and what happens if you break them.

In philosophy, ethics and morals are not the same. I do not recall the official distinction between ethics and rules, but there has to be one. To me, a "rule" implies a requirement made by a governing authority. That's it. It has no other quality. Whereas ethics has a quality about "goodness" and "badness" to it, which the OP did not mention.

Some people have a hard time questioning authority of any kind, and as a result of this they fail to perceive that not all rules set down by the authorities are equally good, or moral, or valid. These people tend to flourish in medical training, often rising to high levels of administration. (Fortunately people with such a mindset did NOT flourish in the American Revolution, which is why we don't live in a totalitarian state. Imagine if the American Constitution had been written by a medical school professionalism committee chair, or a residency program director! We'd have no rights!)

But it's hard to see what could be wrong with this obedient, unquestioning attitude, because our field has so many examples where being obedient leads to success. However anyone who wants to argue that ethics and rules are the same ought to keep in mind places like North Korea and Saudi Arabia. North Korea has rules against criticizing its leader, even anonymously (come to think of it, so did my own residency program). Saudi Arabia prohibits adult women from making many important life decisions without the approval of a male guardian.

Is it unethical to break those rules? It's dangerous, for sure, but unethical? We all will say, of course it's not unethical to break such offensive rules. So then, there must be a difference between rules and ethics.

Hence it follows that the OP's question was not about ethics, since he/she only asked about the rule and the consequences of breaking it, and did not refer to any other qualities, such as goodness or badness.

how? aside from winning the lottery etc - any additional work whether clinical or related to medicine or not counts as moonlighting. I had to fill in a moonlighting form to teach a class

I'm sorry but that could not possibly hold up in court. If I write a winning book of poetry, I can sell it to a publisher and get royalties. That has nothing to do with medicine. If residencies are simply trying to curb ALL the income generating abilities of their residents, then some needs to sue them.

Another example - what if I'm earning money from a trust fund?

 

[nancysinatra]

I still have debt, so what? I still wouldn't risk my career on moonlighting against policy.

As I said, there are plenty of residents who don't moonlight and mange to get by. I don't think most surgical programs allow moonlighting. These people do 5-10 years of residency and fellowship. You think they were all born with silver spoons and graduated without debt?

First of all, some surgery residents get contracts from future employers where the employer pays the debt off while they are in residency. Neurosurgery does this. Second, surgeons make more than psychiatrists. And if they do the income based repayment program, they can get a lot of that debt forgiven. This is not exactly as true for psychiatry graduates, for complicated reasons.

But look, you apparently like the idea of a significant number of your colleagues having large amounts of debt (your smug tone implies it, that's for sure). I never advised moonlighting in violation of program policy; I merely said your words were offensive, which they are.

 

[nancysinatra]

People who tend to play by the rules(especially when the rules are stupid and represent admin bs from people with nothing useful to do) tend to fall behind the ones who seize the moment and do what is in their best interests.

Yes, but the most Machiavellian people of all will follow the rules, knowing they are asinine, rise up the chain, and gain power over the peons who spend their lives yammering about how unethical it is to break rules.

 

[Salpingo]

It seems like the main assumption for breaking the rule is that residency is like any other job. You have an employer/PD/da Man who has their self-interest to serve, and then we have our own self-interests. The next assumption is that our self-interests are just as valid as theirs. That's also been the general trend with millenials (as opposed to previous generations' mentality of keeping your head down, holding a job and collecting pension).

The thing is, residency isn't purely employment. It's still governed by an educational body, staffed by people who have taken paycuts to be teachers and functions by shielding residents from serious repercussions if something goes wrong. It's in a grey zone between "real work" and school, with an assumed honor code.

Also, as has been previously mentioned, medicine is not a great field of you're an iconoclast. Even if you're self-employed, there are medical boards and malpractice lawyers. I'm sure the majority of people who are caught sleeping with patients or similar bone headed moves held vistaril's belief that rules are for other people and the only way of getting what you deserve is by taking it.

That being said, a strict no moonlighting policy seems dumb, and hopefully they open up something for the next year.

 

[deleted736562]

It seems like the main assumption for breaking the rule is that residency is like any other job. You have an employer/PD/da Man who has their self-interest to serve, and then we have our own self-interests. The next assumption is that our self-interests are just as valid as theirs. That's also been the general trend with millenials (as opposed to previous generations' mentality of keeping your head down, holding a job and collecting pension).

The thing is, residency isn't purely employment. It's still governed by an educational body, staffed by people who have taken paycuts to be teachers and functions by shielding residents from serious repercussions if something goes wrong. It's in a grey zone between "real work" and school, with an assumed honor code.

That's because we still have an outdated, abusive system with a large imbalance of power. The term "residency" itself has its own implications. It's purely a job almost everywhere else in the Western world. It works everywhere. Why shouldn't it work here? I have experience in some of those places, and maybe that's why my perspective is a little different. There's no difference between a resident employee and an attending employee, except one requires less supervision in the workplace. That's it.

The powers that be don't want to treat residents as working employees because that can open the floodgates of revamping the match system, dismantling the hospital monopoly and giving more power to the residents to negotiate their contracts, leave and find other places of employment. So we're stuck with a monopolized system with a huge power differential, and the consequences that come with it. And that's what is unethical to me: treating a working relationship in this manner. I believe residents need to be made aware of this reality and it does not help when they buy into it. This sort of system is also precisely why residents need to be nannied and sometimes are short on professionalism.

But thank you for putting your thumb on the wound.

 

[ProfMD]

First of all, some surgery residents get contracts from future employers where the employer pays the debt off while they are in residency. Neurosurgery does this. Second, surgeons make more than psychiatrists. And if they do the income based repayment program, they can get a lot of that debt forgiven. This is not exactly as true for psychiatry graduates, for complicated reasons.

But look, you apparently like the idea of a significant number of your colleagues having large amounts of debt (your smug tone implies it, that's for sure). I never advised moonlighting in violation of program policy; I merely said your words were offensive, which they are.

Some, but not even close to all, get some kind of remuneration during residency from future employers. There are plenty of neurosurgeons for whom this does not apply as well. And surgeons do make more, but start making it 1-6 years later than psychiatrists. Now, I am not a huge fan of large amounts of debt. I would love for medical school to be cheaper and graduate with little or no debt, but that is s different discussion. However, there are plenty of threads elsewhere discussing finances as a resident. This is not to say that people should not moonlight if their programs allow it - by all means, do it. The fact remains that plenty of residents are able to live within their means. I am sorry that you find this offensive, but it does not make it any less true.

That's because we still have an outdated, abusive system with a large imbalance of power. The term "residency" itself has its own implications. It's purely a job almost everywhere else in the Western world. It works everywhere. Why shouldn't it work here? I have experience in some of those places, and maybe that's why my perspective is a little different. There's no difference between a resident employee and an attending employee, except one requires less supervision in the workplace. That's it.

The powers that be don't want to treat residents as working employees because that can open the floodgates of revamping the match system, dismantling the hospital monopoly and giving more power to the residents to negotiate their contracts, leave and find other places of employment. So we're stuck with a monopolized system with a huge power differential, and the consequences that come with it. And that's what is unethical to me: treating a working relationship in this manner. I believe residents need to be made aware of this reality and it does not help when they buy into it. This sort of system is also precisely why residents need to be nannied and sometimes are short on professionalism.

But thank you for putting your thumb on the wound.

The other major difference besides requiring additional supervision is that residents do not bill for services rendered (except for the primary care exception). Also, the degree of supervision required can be substantial (for interns) or minimal (for senior residents).

 

[hamstergang]

There's no difference between a resident employee and an attending employee, except one requires less supervision in the workplace. That's it.

And that's a huge difference. I don't get how you can just write it off. In addition, there's the whole educational piece too.

The powers that be don't want to treat residents as working employees because that can open the floodgates of revamping the match system, dismantling the hospital monopoly and giving more power to the residents to negotiate their contracts, leave and find other places of employment. So we're stuck with a monopolized system with a huge power differential, and the consequences that come with it. And that's what is unethical to me: treating a working relationship in this manner. I believe residents need to be made aware of this reality and it does not help when they buy into it. This sort of system is also precisely why residents need to be nannied and sometimes are short on professionalism.

You think that the match gives the hospital powers? The real issue is that the medical degree in the US is useless without a residency. Because of that, just allowing individual residents-to-be to make contracts with individual hospitals would be disastrous for the med students. We'd be the ones who couldn't afford to walk away and therefore we'd have no leverage for our contract negotiations.

As it is now, programs have to try to look good in order to get decent med students to rank them. So they're incentivized to be resident friendly to some degree. And this all isn't just something I made up -- the match didn't always exist, and it came about due to the power hospitals had without it.

So in the end, if moonlighting is important to you, there are more than enough programs that allow moonlighting that you don't have to rank any that don't. If you otherwise do rank a program that doesn't allow moonlighting, then you've agreed that that is ok and should stick to your agreement.

 

[Salpingo]

There's no difference between a resident employee and an attending employee, except one requires less supervision in the workplace. That's it.

First of all, you would then have to explain the uptick in morbidity and mortality that occurs in July (and can last until December). Second, we get didactics and teaching that is worth hundreds if not thousands of dollars (when you consider the cost of the time of the people teaching). Third, you would have to ask patients if they're comfortable being treated by a resident vs. a supervised resident. That's ultimately what dictates policy in the US, for better or worse. It also provides an enormous layer of protection for the resident.

The powers that be don't want to treat residents as working employees because that can open the floodgates of revamping the match system, dismantling the hospital monopoly and giving more power to the residents to negotiate their contracts, leave and find other places of employment. So we're stuck with a monopolized system with a huge power differential, and the consequences that come with it.

Hamstergang already mentioned this, but the match system has been inordinately beneficial to medical students and residents. Yes, there is a spectrum. Someone matching into psychiatry from a US allopathic school is going to have more leverage than an IMG applying for a competitive specialty, and the latter is going to be more vulnerable to abuse. Yes, once you're in a program you have much less flexibility to leave compared to the private industry, but the same can be said for medical school itself. Fortunately, its time limited and there are ways out.

But thank you for putting your thumb on the wound.

I'm sorry to hear you've had such a negative experience with the US post-graduate system. My training hasn't been all rosy, but my overall experience has been that programs will go to great lengths to keep residents happy and well-trained, since they do have a strong incentive to provide good patient care and maintain their brand as a training institute.

 

[deleted736562]

And that's a huge difference. I don't get how you can just write it off. In addition, there's the whole educational piece too.

"huge" in terms of what? It doesn't and shouldn't stop anyone from being considered a regular employee with rights. You're doing actual work and getting paid for it. It's precisely this whole you're half employee, half kid/student/trainee/slave or whatever you want to call it, that would be considered outrageous almost everywhere else in the developed world and has actually no good rationalization.

You think that the match gives the hospital powers? The real issue is that the medical degree in the US is useless without a residency.

Of course it does. It is essentially a monopoly of program directors and hospitals that continues all throughout residency and that allows to define all the rules according to their interests, and then of course stick a little bit of "ethics" to them because they can.

An MD could only allow you to work under supervision and you would be free to work independently once you meet certain criteria. That's how it also is everywhere in the world, and is not unique at all to the US.

Because of that, just allowing individual residents-to-be to make contracts with individual hospitals would be disastrous for the med students. We'd be the ones who couldn't afford to walk away and therefore we'd have no leverage for our contract negotiations.

How is that? You could walk away and find another contract. Again, this system works almost everywhere else.

I'm sorry to hear you've had such a negative experience with the US post-graduate system.

There are good and bad things about the US post-graduate system. I used that analogy only to say you touched on the right point, not anything else.

 

[HarryMTieboutMD]

I'm sorry but that could not possibly hold up in court. If I write a winning book of poetry, I can sell it to a publisher and get royalties. That has nothing to do with medicine. If residencies are simply trying to curb ALL the income generating abilities of their residents, then some needs to sue them.

Another example - what if I'm earning money from a trust fund?

Agreed. Plenty of people do non clinical things outside of residency and don't need to disclose it as moonlighting.

 

[Salpingo]

How is that? You could walk away and find another contract. Again, this system works almost everywhere else.

You can talk to people who got their residency or fellowship outside of a March (which is thankfully less common). The general trend is that they felt compelled to sign the first contract they were offered rather than rolling the dice and risk not getting a spot anywhere (often at a much weaker program).

You can also talk to the people who had to scramble into a surgery transition spot. That's probably much closer to slave labor than anything I've seen. They get all the grunt work on the floors, rarely get to participate in ANY cases (much less interesting ones) and there's no incentive to teach them. At the end of the year, they just have to hope they did enough that a spot opens for them.

I'm not saying we should be beggars content to take whatever offal is thrown our way, but the system could be (and has been) much worse.

 

[Salpingo]

well you'd have to be careful, many universities have clauses in their contracts basically taking ownership of all intellectual property developed during employment

Yeah, I've actually heard of some residents who took off time from residency to develop an app/software to insure they kept full rights to the patent