Moonlighting does not count toward 80 hours

Pilot Doc · Oct 21, 2004

I want to dispel a bit of misinformation that has been running around the boards about the ACGME duty hour regulations. Various posters have said that all moonlighting counts toward the 80 hour/week rule. This is NOT true.

The full text of the ACGME duty hour regulations can be found here. The section of interest is V.F.4.c

Moonlighting that occurs within the residency program and/or the sponsoring institution or the non-hospital sponsor's primary clinical site(s), i.e., internal moonlighting, must be counted toward the 80-hour weekly limit on duty hours.

The key distinction here is between internal and external moonlighting. Consider the following example of a city with three hospitals 1) Academic U, 2) The VA and 3) St. Community. Residents at the Academic U program rotate at their hospital and the VA.

Radiology residents taking extra paid call at Academic U - 80 hour limited
Surgery residents moonlighting at the VA ER - 80 hour limited
ER Residents moonlighting at St. Community - unlimited
Medicine fellows working weekends at Dr. Bob's urgent care - unlimited

Many surgery programs - mine included - have never allowed clinical residents to moonlight, but the ACGME has no policy restricting external moonlighting!

fourthyear · Oct 21, 2004

More and more Surgery programs are outlawing moonlighting because of the 80 hour work week though. They are changing their policies, so it's becoming harder and harder to find a program that allows moonlighting now. I guess they don't want us all taking advantage of the hours limit at our primary job to allow us to just make more money in our spare time and still end up not being well-rested at our primary job or having any study time (which is the point of the 80 hour workweek anyway)

Winged Scapula · Oct 22, 2004

yes, that is the letter of the law. Our trouble is a) moonlighting banned - regardless of site and even on vacation and weekends off and b) we rotate at all local sites, so everything is essentially affiliated. If I wanted to commute I suppose I could moonlight in another community/state (close by) according to ACGME regs, but it would be disallowed by my program.

droliver · Oct 22, 2004

Moonlighting has been effectively banned for the Surgery residents here as well, except for during your vacation. There is such tremendous liability for a program re. this issue that I expect most programs to prohibit it at some point (if the ACGME doesn't do it first). Can you imagine when this comes up in court or in pretrial depositions @ some point that a hospital/training program will be able to defend this illogical position that outside work hours aren't "real"?

dr.evil · Oct 23, 2004

I don't think the issue lies in the fact that outside work hours aren't "real". The fact lies in the matter that residents can do whatever the hell they want outside of that 80 hours. Whether you wan't to go get sloppy drunk on your night off or if you want to moonlight doesn't matter. I personally would rather a resident moonlight and possibly learn a little more medicine than get free time to go get a little crazy (although we all need to get a little crazy sometimes).

Now that we have 80 hour weeks, I'm a little bitter that the programs don't allow moonlighting. Family practice residents double their salary by moonlighting yet surgery residents are forbidden. I guess the family practice guys are a little tougher than us and can handle the extra work.

yeah, i'm bitter (and a little strapped for cash)

droliver · Oct 23, 2004

dr.evil said:
I don't think the issue lies in the fact that outside work hours aren't "real". The fact lies in the matter that residents can do whatever the hell they want outside of that 80 hours.

On the contrary, what is now the de facto standard in place is that a resident physician (or it could be argued to include ANY physician) who works beyond this arbitrary 80 hours is negligent due to impairment. There will be NO defense with any complication that can plausibly be tied to residents who can be shown to have exceeded the black letter rules of the ACGME, whether some of these hours were "on the job" at the training program or out moonlighting. This is the liability that has been dropped on programs by the new rules & is causing the curtailing of moonlighting. The situation is not new of course, but now there are regulations which a plaintiff can point to which clearly outline what maximum duty requirements are. These cases are sitting ducks for malpractice claims.

Winged Scapula · Oct 24, 2004

I agree with droliver - on a civil liberties POV, residents should be able to do whatever they want after work hours, while on vacation. HOWEVER, as he points out, moonlighting after 80 hrs is a undefensible position and ripe for malpractice suits (especially here in PA where anything goes 😀 ).You cannot defend yourself, nor will your program do so.

We have some rotations in which residents work less than 80 hrs (we have a few) and I wish we were able to moonlight up to that limit on those rotations and vacation. But as it stands now, we are not permitted to do so, largely for the reasons stated above and concerns over record keeping/"proving" hours.

dr.evil · Oct 24, 2004

I see your points, all of which are related to malpractice/lawyers and nothing to do with resident life or even patient care. Medicine is just too screwed up.

This hasn't really been a problem in the past with the residency programs who do moonlight. Do you think that the ACGME simply placing an arbitrary 80 hour work week will now instill more lawsuits? And in these lawsuits the lawyers will track down all of the resident's hours outside of the primary institutions? Has the ACGME simply given the lawyers another avenue to come at us?

It's really all just interesting. I'd like to find out how many times an attending has been sued and the primary offense was care while working too many hours. It's interesting how residents may be held at higher standards.

I'm jabbering but it does make you think.

BTW, I often stay post nightfloat (taboo now) to teach ATLS and then start another "shift". Am I setting myself up for a lawsuit? I hate our court system.

droliver · Oct 24, 2004

dr.evil said:
This hasn't really been a problem in the past with the residency programs who do moonlight. Do you think that the ACGME simply placing an arbitrary 80 hour work week will now instill more lawsuits? And in these lawsuits the lawyers will track down all of the resident's hours outside of the primary institutions? Has the ACGME simply given the lawyers another avenue to come at us?

Yes, Yes, & Yes.

Prior to these rules it was really quite a gray area & while fatigue has been intoduced in lawsuits before, it was a pretty circumstancial argument. Now there is a bright red line drawn in sand. This avenue of liability is going to be investigated in every case involving teaching hospitals. It's why so many programs are getting stricter & stricter on documentation & why eventually you will likely have to clock in/out (to leave a paper trail for a program's defence)as malpractice carriers demand it

Moonlighting does not count toward 80 hours

Pilot Doc

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fourthyear

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Winged Scapula

Cougariffic!

droliver

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dr.evil

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droliver

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Winged Scapula

Cougariffic!

dr.evil

Senior Member

droliver

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