Pro/Con of moonlighting

[Gamergirl]

Hey all,

I was wondering what people's experiences were in moonlighting in the emergency department (I suppose possibly also in the ICU-though I doubt less of those opportunities exist) as an EM resident (2nd or 3rd year). Our staff seems largely against it, given that you are probably in a much weaker place in terms of legal defense later down the line (and likely bc it does undermine our specialty to some extent). That being said, our non-EM residents -ie. radiology residents- do moonlight in our outlying emergency departments (I know this b/c I get their disastroma pts sometimes as referrals/follow-ups).

If you have had experience moonlighting as a resident:

-Did you think it enhanced your training? (Or was it primarily just good for money)
-How legally vulnerable do you feel you were?
-Are their stipulations to the situations in which you would recommend it?

My primary interest in moonlighting would be to get the extra experience. I am training at a huge academic center, and I think it would be helpful to get extra hours in the community/extra autonomy while I still have attendings to bounce cases off of etc. Perhaps that is unrealistic. I wouldn't mind extra dollars either.

Thank you in advance for any advice you can provide!

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[mauricekenter]

I am currently in my last year of residency and moonlight under the residency guidelines. We are able to do 4 shifts a month if we meet clinical, admin and performance benchmarks. Our moonlighting is incredible and we typically manage a 10-14 bed ER by ourselves in the "rurals" with a NP or PA managing the "fast-track."

1) It has enhanced my training beyond anything I could get during the residency. You grow up fast and make your own decisions, plus where we moonlight you see 20% pediatrics (no daily peds at our base hospital) as well as super sick patients. Also the money is great!

2) I don't feel vulnerable at all, but I am in a favorable malpractice state. However, I never feel comfortable signing a mid-level's chart on a patient I've never seen…which we do. However, we are supposed to supervise a certain amount, I think this varies from state to state.

3) I would only recommend moonlighting if you are not in-house (I don't feel like it would be true "moonlighting," but I'm sure somewhere it acts the same), you are at least as equivalent or better than the current care they get (so you don't "undermine" the specialty) and you are managing a real ER, not just some urgent care.

I honestly can't think of anything that well help you "grow up" fast than moonlighting, if it meets the above standards. You definitely put your big-boy pants on and really learn/experience any incredible amount.

 

[Venko]

Likely mine is an unpopular view but I offer it as a counterbalance…

First, ask yourself if you feel that you are able to provide expert level care for the patients? If you can, you should have no real need to moonlight as a learning opportunity. If you cannot provide expert level emergency care, you are short-changing the patients who are trusting you with their health. I don't think its fair if myself or my loved one comes to an emergency department expecting to see an expert in emergency care and I see someone who isn't able to provide that. Especially if I am not made aware of the discrepancy, and if I am paying for an expert.

Everyone is right that seeing patients independently is a great learning curve. It is one you will travel when the time is right (i.e. after completing residency thus demonstrating that you have acquired all the tools necessary to embark on this stage). You will learn tremendous amount when you come out of residency and its the right time to gain this kind of learning. If you are looking to augment your residency education, why not spend the time shoring up your clinical weaknesses. If you feel reading ECGs is difficult go tag along with cardiology, if you want to see more ED patients, just go work more clinically in your home ED under direct supervision, etc.

If you absolutely need the money to help keep your financial health, find ways to use your degree safely and augment your income. My wife spent time doing chart review for the government performing disability or workers compensation review. It was boring, but it was safe, and it paid well.

I really want to emphasize that if you are not able to see patients independently without having attendings modify your plans in your own department, its really not fair to the patients for you to go and pretend to be an expert in emergency medicine worthy of their trust, their time, and their money. The "growth," is a sad excuse to do it when you are doing it at the expense of people in need of emergency care. As the other poster said, they moonlight in a place where people are quite sick….they don't need a resident masquerading as an attending, they need an attending who may or may not be teaching a resident.

I recognize my views are unpopular, but it hits home with me after I saw a 2 year old hypothermic drowning victim, brain dead, because the moonlighting resident did not provide optimal and timely resuscitation. The kid had not chance, and her parents lost their daughter so the resident could, "grow up."

 

[The White Coat Investor]

Hey all,

I was wondering what people's experiences were in moonlighting in the emergency department (I suppose possibly also in the ICU-though I doubt less of those opportunities exist) as an EM resident (2nd or 3rd year). Our staff seems largely against it, given that you are probably in a much weaker place in terms of legal defense later down the line (and likely bc it does undermine our specialty to some extent). That being said, our non-EM residents -ie. radiology residents- do moonlight in our outlying emergency departments (I know this b/c I get their disastroma pts sometimes as referrals/follow-ups).

If you have had experience moonlighting as a resident:

-Did you think it enhanced your training? (Or was it primarily just good for money)
-How legally vulnerable do you feel you were?
-Are their stipulations to the situations in which you would recommend it?

My primary interest in moonlighting would be to get the extra experience. I am training at a huge academic center, and I think it would be helpful to get extra hours in the community/extra autonomy while I still have attendings to bounce cases off of etc. Perhaps that is unrealistic. I wouldn't mind extra dollars either.

Thank you in advance for any advice you can provide!

I did 10 shifts of moonlighting total in residency, all in the last 6 months. The money was nice, but at $80 an hour, was probably less than $10K total. It did enhance my training, but I think I was very legally vulnerable. I wouldn't feel like you were at a huge disadvantage either way. How much of a difference could 10 shifts have made?

 

[Arcan57]

Moonlighting as a concept is a definite win. Academic medicine /= community medicine and moonlighting is probably the best way to explore that difference. If moonlighting is an option (especially for 3yr programs), doing 2-3 shifts a month can give you a marked advantage in being a new attending. The con's all come out of specific situations. A short list would be:
1) They don't provide a tail for malpractice. A significant chunk of your income can vanish (usually in a lump sum) to pay for a tail if you're purchasing your own.
2) The hospital/patient population sucks. I moonlit 3 shifts at a hospital that had meth involved in roughly 75% of it's ED visits. My last shift there, the on-call doctor was refusing to come in on an unstable patient and told me to either let the patient die in the ED or force the family to make them DNR. Fortunately it was double coverage so I went to the assistant director working with me and explained the issue. I was met with a shrug and literally having him turn his back on me.
3) Hours - 24 hr shifts can be sweet from a $$$ - sleep angle but can also turn ugly. A lot of hospitals in rural areas are on the cusp of needing to switch to 12s but the docs like only having to work 6-7 shifts/month. Seeing 50-60 patients in a day is not as fun as it sounds, especially since there's a 99% chance you'll be hourly pay only.

 

[Venko]

Moonlighting as a concept is a definite win. Academic medicine /= community medicine and moonlighting is probably the best way to explore that difference. If moonlighting is an option (especially for 3yr programs), doing 2-3 shifts a month can give you a marked advantage in being a new attending. The con's all come out of specific situations. A short list would be:
1) They don't provide a tail for malpractice. A significant chunk of your income can vanish (usually in a lump sum) to pay for a tail if you're purchasing your own.
2) The hospital/patient population sucks. I moonlit 3 shifts at a hospital that had meth involved in roughly 75% of it's ED visits. My last shift there, the on-call doctor was refusing to come in on an unstable patient and told me to either let the patient die in the ED or force the family to make them DNR. Fortunately it was double coverage so I went to the assistant director working with me and explained the issue. I was met with a shrug and literally having him turn his back on me.
3) Hours - 24 hr shifts can be sweet from a $$$ - sleep angle but can also turn ugly. A lot of hospitals in rural areas are on the cusp of needing to switch to 12s but the docs like only having to work 6-7 shifts/month. Seeing 50-60 patients in a day is not as fun as it sounds, especially since there's a 99% chance you'll be hourly pay only.

Arcan, you have often brought wisdom to threads here. I read your post and am trying to temper my reaction because you have often proven yourself to be thoughtful and rational.

Reading your points, I can't help but feel they are all meant to serve the resident / provider, and none relate to the patient. This seems directly at odds with our specialty in that we are generally the only group who consistently cares about the community when other folks in medicine have given up or want to look the other way. Your point about the unstable patient discussion is a perfect example. I would argue that to truly care for the welfare of the community is to wait to provide them independent care until you have mastered all the skills of residency (recognizing that there is still tremendous learning to be had).

After the first six months out of residency the moonlighting graduate and the non-moonlighting graduate will be essentially equal in clinical excellence. I would argue that for the time that was spent moonlighting, the dedicated learner can use the time learning in other ways that would make any advantage coming out of residency a wash between the two groups.

Also watch out for work hour violations with such long moonlighting shifts.

 

[e30ftw]

ThymeLess, what type of EDs in your experience offer resident moonlighting?

In our region typically these shifts are covered by non-EM trained physicians or mid-levels. I would not say these practitionars are giving "Expert level Emergency Care" to their patients in the first place. IMO a crashing patient is better served by a PGY-3/4 resident who has spent the last 2.5 years taking care of crashing patients in a tertiary care facility (where there are lots of them) versus a non EM-trained physician who doesn't know pressors outside of dopamine, can't use U/S, knows nothing EBM, treats all tachyarythmias as afib, etc.. these places exist, and I would argue a moonlighting EM resident has done more EM procedures and rescus in the past 2 years than the majority of staff providers at critical access hospitals.

 

[mauricekenter]

Thyme,

I agree with you if you don't take into account my #3 in which you must be equal or better than the care the patients typically get. Which in my situation, if you know how to put a chest tube in (not backwards), can treat any facial laceration, peritonsillar abscess or even know how to intubate or place a central line, you are providing much better care than the patients are currently getting.

The lists could go on and on, but the fact of the matter is I will have worked an equivalent of 3 months on my own by the time I am done with residency. I am absolutely providing better care for my patients out there than they are getting when I am not working. The money is great (more than $80), but this isn't the driving factor.

If the only opportunity you have to moonlight is to take a spot from an already board certified ER physician, don't do it. If you will take the spot of someone who has no business working the ER in the first place because they cannot find anyone else to fill the spot….moonlight away.

 

[Arcan57]

Arcan, you have often brought wisdom to threads here. I read your post and am trying to temper my reaction because you have often proven yourself to be thoughtful and rational.

Reading your points, I can't help but feel they are all meant to serve the resident / provider, and none relate to the patient. This seems directly at odds with our specialty in that we are generally the only group who consistently cares about the community when other folks in medicine have given up or want to look the other way. Your point about the unstable patient discussion is a perfect example. I would argue that to truly care for the welfare of the community is to wait to provide them independent care until you have mastered all the skills of residency (recognizing that there is still tremendous learning to be had).

After the first six months out of residency the moonlighting graduate and the non-moonlighting graduate will be essentially equal in clinical excellence. I would argue that for the time that was spent moonlighting, the dedicated learner can use the time learning in other ways that would make any advantage coming out of residency a wash between the two groups.

Also watch out for work hour violations with such long moonlighting shifts.

Similar to e30ftw, the bulk of my moonlighting was done at an institution were I am confident that I provided a higher level of care then the "native" docs. I was a early PGY-4 when I started moonlighting, so that may be skewing my view of the overall competence of moonlighting residents. I don't think residents that aren't up to practicing independently should moonlight but I don't think there's something magical that happens the 12th month of third year that transforms incompetent EPs into competent solo practitioners. From someone that's interviewing and living with the consequences of the job offers that come from those interviews, residents that have moonlighting experience seem to have an easier time adjusting to our shop than those that didn't. I think of moonlighting as polishing your metagame, not your medical knowledge.

 

[Venko]

Interesting take. So if people are doing it because it is better for the community, why stop when you graduate? Why not continue to work in those areas even if it is a few shifts? Why not do it for free? Why not work in an underserved clinic instead? If this is truly for the benefit of the community why have I not met any attendings continuing to pick up extra shifts in these locations?

Also, I would not discount the experience of those non-EM trained folks. After all, each of us can be traced to attendings who were not trained in EM if you take us back far enough. I am not sure I would not take a 15 year veteran family practitioner over a 2nd, 3rd, or 4th year resident. After all, the family practitioner will likely recognize when they need help and in my experience are very quick to transfer or call for help, whereas my experience with most senior residents is that they are generally over confident in their abilities and think they have mastery of every situation. I do agree that if I could make sure that all working in ED's around the country are EM residency trained and board certified, I would do that. I disagree about whether a partially trained EM resident is better than a physician who is experienced in a system and has been working there for years.

In any case, I am pretty sure my view on this is not shared by most, but it just feels wrong to me.

 

[mauricekenter]

I don't claim to only moonlight because I am helping the community. No one is going to go work a 12 hour shift, which is one hour outside of town and assume the risks of practicing medicine without "fair" compensation. Some of our residency docs still go out there to help out, but I suspect the lack of this is mostly because of the travel time and since they are already working full time at our shop.

I definitely agree with you about experience prevailing over most anything else, but there is always a spectrum. Someone who uses their experience to improve is much different than someone who has a lot of experience, but doesn't learn from any of it. Nothing is black and white and even though where you have trained/worked might be less than ideal for moonlighting, it is doubtful this can be a blanket approach to everywhere in the country.

This will always come down to personal preference and the ideology of the specialty. There are definitely some residents I would rather have take care of my family than some of the long time non-boarded docs out there, and vice versa.

 

[deleted547339]

Interesting take. So if people are doing it because it is better for the community, why stop when you graduate? Why not continue to work in those areas even if it is a few shifts? Why not do it for free? Why not work in an underserved clinic instead? If this is truly for the benefit of the community why have I not met any attendings continuing to pick up extra shifts in these locations?

Also, I would not discount the experience of those non-EM trained folks. After all, each of us can be traced to attendings who were not trained in EM if you take us back far enough. I am not sure I would not take a 15 year veteran family practitioner over a 2nd, 3rd, or 4th year resident. After all, the family practitioner will likely recognize when they need help and in my experience are very quick to transfer or call for help, whereas my experience with most senior residents is that they are generally over confident in their abilities and think they have mastery of every situation. I do agree that if I could make sure that all working in ED's around the country are EM residency trained and board certified, I would do that. I disagree about whether a partially trained EM resident is better than a physician who is experienced in a system and has been working there for years.

In any case, I am pretty sure my view on this is not shared by most, but it just feels wrong to me.

I don't understand your logic at all. If your argument is that it's not best for the patient, that's fine; but now you're changing your argument. I know that our residents can often provide better care than what is currently available at a lot of local EDs. Now you're saying that if you're improving care you have to keep working there or work at an underserved clinic?

Residents' don't moonlight because it's good for the community, and I don't think anyone said they do; they moonlight because it's good for them (educationally and financially). The fact that you can often provide better care for patients can make it a win-win.

 

[Groove]

Everyone moonlit in my residency program. It was very moonlighting heavy and we started near end of PGY2 year (4 yr program). It was some of the best (and most harrowing) learning experiences that I had during training. I probably had more critical peds experience than anything else. I can remember a newborn arrest, an infant head trauma with SDH that herniated, postured and stopped breathing as the mother ran through the doors to place the kid in my arms. Most was the run of the mill type of stuff, but I had some really interesting cases while out on my own that I had to learn to creatively deal with without the assistance of an attending (although they were always a call away...technically...). The money DEFINITELY helped. I had malpractice with tail coverage. Hell, I worked for Weatherby all through residency and would fly 2 states over and moonlight weekends, holidays, vacation time, you name it. I worked in a variety of EDs and highly recommend the experience during residency for at least 2+ years. It's not just the experience along with being out on your own, but also within the framework of a residency program where you can discuss cases during conference each week or with your colleagues or even with your attendings. Are you more liable from a medmal standpoint? I don't know. Probably? I don't think you would be liable to the point of fault as there are plenty of other GPs who never finished residency that practice medicine in the occasional ER or clinic. No resident was approved for moonlighting that wasn't ready and those privileges hinged on certain criteria, ITE scores and attending discretion. It could also be revoked at any point.

Anyway, I think all residents should moonlight if they have the chance. It's a great confidence builder. All our guys did it and were better for it IMO.

 

[Khaos]

I will be honest. I did a lot of moonlighting my 3rd year, much more than I should have. I also did some in my 2nd year. I can say that it had a huge impact when I left and started my "first job real job." I had very little trouble transitioning and everyone noticed this. I am now a nocturnist and am about to leave my group. My partner that I regularly work with keeps making the comment that he does not want someone fresh out of residency to be the one replacing me. I have to remind him that I was fresh out of residency and he says I am an exception secondary to the experience I had prior.

I have learned some things. The most vulnerable places for you to work are usually the easiest places for you to get into. The small little ED about 1 to 2 hours away from your residency that is single coverage in the middle of nowhere. It is usually staffed by GP's and as some have said people like radiology residents. You were the only doctor in the entire hospital, if the sh** hit the fan you were the only one there covering the hospital. I had a code on the floor and a code in the ED at the same time. I had the phone talking to the nurses in the ED while working the one on the floor also. The one that I was present on was called, BTW. Was the malpractice risk in this place higher, I don't know because when you compare to what they normally had I was above that by far. I, however, still think the risk was significant when I think back on it now.

My third year, I started moonlighting in a place that I would highly recommend everyone doing. It was atleast double coverage at all times. You always had someone else that you could go to for help, bounce ideas off of, and it was a more prepared and experienced ED staff.

Last is the patient to be scared of. In the small emergency departments, I was not afraid of the obviously sick patient. I was afraid of the little old little that had belly pain. The sick patients were easy to transfer. The little old lady with negative labs, negative CT, negative everything would be a hard sell anywhere and those were the ones that made me worry. Hell, they still make me worry now.

I think moonlighting can be a great experience. You grow so much when you don't have an attending over your shoulder giving you the OK to discharge someone home. You learn to become efficient and confident in your abilities.

 

[inspirationmd]

My personal opinion is that it is a way to supplement your residency salary/stipend while gaining invaluable experience and helping pts who frequently are being seen by someone with less relevant training than you. Personally don't feel its a loss to anyone.

So a personal question I would like some insight on. Is it better to:

1) Moonlight within your hospital system where familiar with EMR and single coverage in 15K/year or so ED for 12 hour shifts. Pay very good per hour. Distance about 1-1.5 hours away. Generally low acuity and about 30 pts per shift.

2) Moonlight at outside history that has a great reputation with your residency (ie people moonlight there every year). Double coverage with a board certified ED attending in a ED with a separate fast track section with PAs you never see but have to say you were available for consultation if needed or something like that when you sign the PA charts (kind if worried about the liability personally). Total visits like 75K a year. Pay is even better. Less sophisticated EMR. Takes 2-2.5 hours to get there but if you work two days in a row or more then they give you a gas stipend and put you up in a hotel. Unsure how many pts per shift.

 

[SoCuteMD]

I'm sure the money from moonlighting is nice - but the places that pay well pay well for a reason. They can't attract anyone else. If it's an environment that board certified, experienced folks don't want to work in, then I'd take a serious look at whether it was a situation I was willing to take on as a resident.

You're going to have your first day working independently at some point. Doing so before the end of residency probably gives you a little head start on your first job as an attending, but that's a transient thing and very short-lived over a 20-30 year career.

 

[deleted128562]

I don't think there is anything generally "wrong with" these places that keeps them from attracting board certified docs, except for the fact that they are in Bumblefrack Village where no one wants to live and work full time. Remember, there is a shortage of board certified EM docs.

 

[inspirationmd]

Main issue with the places is that these places represent true rural living. It's not that the environment is toxic but you aren't going to want to raise a family in these places generally if you prefer city living with the educational and cultural options. Gonna have a hard time convincing board certified MDs to live there w families. That's why there is always need for locums/moonlighting.

I'm sure the money from moonlighting is nice - but the places that pay well pay well for a reason. They can't attract anyone else. If it's an environment that board certified, experienced folks don't want to work in, then I'd take a serious look at whether it was a situation I was willing to take on as a resident.

You're going to have your first day working independently at some point. Doing so before the end of residency probably gives you a little head start on your first job as an attending, but that's a transient thing and very short-lived over a 20-30 year career.

ssues

 

[SoCuteMD]

Main issue with the places is that these places represent true rural living. It's not that the environment is toxic but you aren't going to want to raise a family in these places generally if you prefer city living with the educational and cultural options. Gonna have a hard time convincing board certified MDs to live there w families. That's why there is always need for locums/moonlighting.


ssues

Some of them, but others are a different story. There was a place that was paying big money to moonlighting residents here. It is in a city an hour from several larger cities in a desirable state. Without getting into too many details - there was a reason they had to offer that much and still no one was taking the bait.

In any case, I stand by my statement that the few months of head start that moonlighting might give you is somewhat irrelevant in the context of a 20-30 year career. I'm not anti-moonlighting, but I think some people are overstating the benefits.

 

[deleted109597]

Some of them, but others are a different story. There was a place that was paying big money to moonlighting residents here. It is in a city an hour from several larger cities in a desirable state. Without getting into too many details - there was a reason they had to offer that much and still no one was taking the bait.

In any case, I stand by my statement that the few months of head start that moonlighting might give you is somewhat irrelevant in the context of a 20-30 year career. I'm not anti-moonlighting, but I think some people are overstating the benefits.

Eh, I'm on your side on this. I don't think that moonlighting is what makes or breaks anyone. It shouldn't be an expected money pipeline either. Don't get me wrong, nobody would do it for free, but quintupling your residency salary is probably overdoing it.
However, there is absolutely something to be said for moonlighting within the gravitational pull of your mothership, especially when it's on the same system. The vast majority of MD and DO residencies are at tertiary shops, so most places within a reasonable distance would refer to them. It is much easier to call your own guys for a transfer than it is to call people you aren't familiar with. Also, most faculty are realistic and will help out a resident in the sticks, but once you've graduated, that lifeline evaporates quickly.
I wouldn't force anybody to do it, but I wouldn't discourage doing it when they're ready.

 

[Hercules]

I moonlit a lot during residency. It was a good experience for me and I can honestly say that I provided vastly superior care for my patients compared to some of the doctors I relieved.

Now that I'm out in the community I can also tell you that whether people like to hear it or not, it's something that my SDG looks for if we hire a new grad.

 

[Apollyon]

3) Hours - 24 hr shifts can be sweet from a $$$ - sleep angle but can also turn ugly. A lot of hospitals in rural areas are on the cusp of needing to switch to 12s but the docs like only having to work 6-7 shifts/month. Seeing 50-60 patients in a day is not as fun as it sounds, especially since there's a 99% chance you'll be hourly pay only.

I've been thinking of this post for months, but didn't get to it until just now. 60 patients in 24 hours is 2.5/hour. Every hour. Really? That is enough to have 3 docs working an 8 hour shift - that would be CRAZY for one, moonlighting resident, to do it. To say "on the cusp" is, I believe, overstating it. They need to go to 12's, posthaste!

 

[EctopicFetus]

Ill chime in. I moonlit at 2 facilities.

Facility 1) 24 hour shifts $80/hr. Average 15 patients in 24 hours. I would guess I did 1-2 shifts a month and probably did 10 total shifts there. I never slept less than 5 consecutive hours except 1 time. NO BC/BE ED docs. 1 doc there was an ob/gyn.

Facility 2) 80+% non EM, mostly IM/FP. Busy place 12 hour shifts and residents had to work mid shift so there was another doctor on.

Personally, I learned to manage patients when I didnt have all the resources available at a large academic center. One of the things I found as the best was the learning. I went back and discussed cases with my attendings.

I wont pretend otherwise. I did this for money. I found the experience to be excellent. I personally would recommend anyone with an interest to do this. You are prepared. Will you be as good as someone who finished residency? NO. Is that guy who finished at the bottom of his residency as good as a chief resident moonlighting 3 months before he graduates? NO.

Nothing magical happens after 36 months.

 

[sum dude]

Pros (besides the obvious money one):
--Learn a lot more than you will 3rd or 4th year of residency in academic center with attendings and consultants at your fingertips
--Learn how to do transfers properly (and it is an art, what to say and not to say), which you won't get at a tertiary center
--Learn how to deal with urgent but not acute patients by talking to consultants on phone (eg 6 mm ureteral calculus, stable ectopic, difficult to reduce distal radius fx, etc.)
--learn how to manage post-code patients when there are no ICU docs to be found
--learn what you don't know, and what you have to focus on when you get back to your residency shifts
--refine your community medicine skills, which will help you stand out when you start your post-residency career

Cons:
--liability risk, malpractice risk
--very stressful
--eats up time which you could spend relaxing during your 3rd/4th year
--probably going to have to drive far
--scheduling could be issue depending on your residency
--as my rural-ED director told me my first day moonlighting, "you have to get used to going from having every consultant available at your fingertips to being the only doctor awake in the entire county on a given night."

I'm now 5 years out of residency--I can without a doubt a Resident who moonlights is a better doctor coming out than one who does not. Is it for everyone? No, but honestly, until you feel the pressure of practicing out on your own, you will never be able to simulate it at your home program, no matter what your program tells you. You will be a better doctor by moonlighting, and people hiring know this. Now whether you'll be a better doctor in 2-3 years, might remain to be seen, but hiring groups want someone they can plug in now, not in 2-3 years. As for the comment that you are providing "sub-standard care", that person probably has not been at a rural/understaffed ED any time in the past 10 years, where Family Practice/IM/Surgeons are practicing regularly EM without formal training.

If you want to know if your "ready" for moonlighting--just ask your PD/Assistant PD's, and some of your clinical faculty who worked at a Community centers. Most of them will be honest with you, and keep you from starting too early. Scary--yes, but worth the experience, even without the money. If you are really nervous, than pick a place which has more than 1 doc on at a time, so you at least have someone to lean on in a pinch.