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Can someone explain to me what is residency and moonlighting?

Discussion in 'Pre-Medical - MD' started by gongivittoya, Aug 13, 2015.

  1. gongivittoya

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    Sorry, I read about this stuff, but need some clarification.

    1. What exactly do you do during residency? Like is it the same thing you would do as a doctor but under supervision? For example, if you were doing a residency for a surgical program, would you perform surgery under supervision?
    2. What is moonlighting? (I hear this term that it is something residents do for extra money?)
     
  2. SirZaitsev

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    Residency is kind of like training for the field that you are entering (the job you will be doing), or a specialty. They last about 3-4 years depending on what type of residency program. Specialized programs will be longer with 1-2 fellowship years. You are payed for this, and salaries can range from 40-60k depending on the program. It is kind of like continuing school with a stipend (you are not making an attending salary), to pay for living expenses or the med school debt. It can be hard when you are working 60-80 hours a week. Moonlighting is a term used for people working extra hours, or working outside of their primary job for extra $$$$. Most residents don't make enough to live comfortably according to "their" standards, so right there is why they would moonlight. Hope this clarifies. Happy studying :)
     
  3. SirZaitsev

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  4. gonnif

    gonnif Only 695 Days Until Next Presidential Election
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    To clarify further, after your first year of residency (traditionally called internship) you are eligible for a limited medical license that allows you to work in institutional settings, such as clinics, prison, hospital ER, and other places. This was somewhat commons 30 years ago or more but is somewhat frowned upon and done quietly now
     
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  5. SirZaitsev

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    Can you explain why it is frowned upon now?
     
  6. gonnif

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    Because residency directors and attendings want their worker bees to spend their time and energy on the program and not spend their minimal days and hours off doing something else.
     
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  7. Cyberdyne 101

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    I think some residency programs allow moonlighting. Although, it might be more prevalent in fields with a lighter workload (ie psych).
    @mimelim @NickNaylor @SouthernSurgeon
     
  8. NickNaylor

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    1) Yes, you essentially operate as a physician with supervision. In contrast to medical school, you are generally allowed to perform procedures, write prescriptions, give orders to other staff, etc.. The degree of supervision will vary based on your competence. For example, PGY-1s will generally be more supervised than residents in their final year of training. There are specific levels of supervision that vary from direct, in-person supervision to indirect supervision. The goal of residency is to prepare you for independent practice in the field you're training in. A junior surgical resident will likely be closely supervised for a case, for example, while a senior surgical resident may do relatively simple procedures independently (with the attending in the room to help if needed; for example, while I was on surgery a PGY-5 did a cholecystectomy with me driving the camera while the attending was talking to another physician in the room and not at the table). In psychiatry, junior residents will be closely observed and should run all orders by their attendings while senior residents will be able to operate more or less independently and discuss questions or cases with attendings as needed.

    2) Moonlighting is performing additional work in your capacity as a physician outside of what your residency program expects of you. This work is paid. Moonlighting opportunities can range from being on-call at a hospital affiliated with your program under supervision of an attending to independent practice without supervision. Most states only require one year of residency training in order for you to be eligible for an unrestricted medical license, assuming you've passed all of the step exams. You will not be board-certified, but you are able to independently practice legally. Most people moonlight for the additional cash - which can be quite substantial (e.g., getting paid $100-150/hr for moonlighting would not be uncommon depending upon the job and the field; when I was in medical school, some IM residents had moonlighting gigs that paid $200/hr for an 8-12 hour shift) - but it also can function as a great learning experience as you may not have any supervision and will have to figure out things yourself. Residency programs have policies related to moonlighting which may range from "no moonlighting allowed" to "moonlighting allowed only during PGY-X years" to "moonlight to your heart's content." At my program, moonlighting must be approved by the program director but is otherwise unrestricted. Per ACGME guidelines, moonlighting (whether it occurs internally, i.e., within the hospital the resident is contracted at, or externally, i.e., at another facility the resident otherwise does have an affiliation with) counts toward the 80-hour limit. This can functionally limit a resident's ability to moonlight independent of a program's policies as with some programs you may be working in your role as a resident for near that amount, preventing you from doing any meaningful moonlighting. In other programs, it's very feasible to moonlight and many residents take advantage. However, this is program- and specialty-specific.
     
    #8 NickNaylor, Aug 13, 2015
    Last edited: Aug 13, 2015
  9. raindropx

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    The 80 hour limitation is dumb
     
  10. sovereign0

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    Why? Also, what experience do you have with it?
     
  11. raindropx

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    Didn't realize we needed personal experience to have opinions, but just google it and you'll gain insight.
     
  12. steelersfan1243

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    I think he was curious if you had personal experience you could share to help learn more, not that your opinion was invalid
     
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  13. raindropx

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    oh sorry! Well it's not my own experience but physicians shared with me while I was shadowing them how shuffling patients between so many different doctors adversely affected health care and residents could not stay long term with patients (negatively affects their education)
     
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  14. 7331poas

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    Ive seen alternate opinions that 100 hour+ work weeks affect their health significantly.
     
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  15. raindropx

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    the residents' health? I've heard more bad than good things about the rule personally and in research
     
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  16. 7331poas

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    yes the residents health. 100 hours is a lot of time.
     
  17. rocklobstr

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    The effects of sleep deprivation are well documented. There is a reason for the rule. With too many hours, productivity goes down and mistakes go up. It is for both the resident and the patients.
     
  18. raindropx

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    The shortened amount of time is detrimental to the training. Maybe an adcom can comment on their experience better.
     
  19. rocklobstr

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    You won't retain as much if you're too tired to pay attention. It has been commented on. ACGME didn't make the rule for funzies. I personally would not want to be treated by a doctor who has been on active duty for 24+ hours, with certain exceptions regarding continuity of care. It's dangerous.
     
  20. raindropx

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  21. rocklobstr

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    Chronic sleep deprivation and the resulting fatigue and stress can affect job productivity and the incidence of workplace accidents
    Kauppinen, Timo (2001). The 24-Hour Society and Industrial Relations Strategies. Oslo, Norway: European Industrial Relations Association.

    Medical residencies traditionally require lengthy hours of trainees. The public and the medical education establishment recognize that such long hours are counter-productive, since sleep deprivation increases rates of medical errors and may affect learning, however the phenomenon persists in order to create a higher entry barrier and reduce costs for medical facilities. This risk was noted in a landmark study on the effects of sleep deprivation and error rate in an intensive care unit.
    Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA (2004). "Effect of reducing interns' work hours on serious medical errors in intensive care units". N Engl J Med351 (18): 1838–48.


    Also, it has been reported that many residents still work the 80+ hours as reporting more can result in a loss of accreditation for the program, which would have negative consequences for the reporting resident. So, there is a possible problem with studies suggesting that there is no change, as there is often no actual change in hours worked.
     
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  22. raindropx

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    These studies are over a decade old...
     
  23. 7331poas

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    Is it really so hard to believe that 100 to 120 hour work weeks can be detrimental to patients.
     
  24. raindropx

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    I would like to hear opinions from those who are more experienced. @Goro @gyngyn @mimelim
     
  25. rocklobstr

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    .
     
    #25 rocklobstr, Aug 13, 2015
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  26. raindropx

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    Good choice deleting that
     
    #26 raindropx, Aug 13, 2015
    Last edited: Aug 13, 2015
  27. Goro

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    This is outside my knowledge base.

     
  28. gongivittoya

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    Thanks for the replies. Could you guys also provide me some insight on malpractice insurance if possible. My rough understanding is that it is insurance you pay just in case you are sued by a patient for making an error. So do you have to worry about this as a resident? What is academic vs private? Do you pay malpractice insurance for both? And do most doctors face malpractice lawsuits in their career at least once? Does it hurt your career as a physician permanently if you face a malpractice lawsuit?
     
  29. NickNaylor

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    Most programs will provide you with some form of malpractice coverage only for activities performed in the course of your duties as a resident. This would not include moonlighting gigs, where either your employer would need to provide you with coverage or you would need to purchase your own coverage.
     
  30. NickNaylor

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    The counterargument, however, is that patient hand-offs - transferring patient care from one provider to the next - are not benign and are themselves riddled with mistakes that result in poorer patient care if not harm. The question is whether these harms are more or less than what they would be with fatigued, over-worked residents.

    I can say being in residency now that while I enjoy the lifestyle afforded by duty hour restrictions, from both a learning and patient care perspective they are deleterious. It's difficult to assume care for a patient that you did not admit, have not worked with, and only receive a very brief sign-out on. You really don't understand what's going on with a patient by reading a sign-out or having a resident/attending discuss the patient briefly. You also don't have the opportunity to see a patient's course first-hand. This is less of an issue in my field since problems are typically chronic and slow-developing, but in something like medicine where a patient's course can change quickly over a night, you may very well miss the opportunity to either intervene a patient's course or see their decompensation first-hand. These are things which can contribute significantly to your education.

    The problems with experience are magnified in procedural fields, where limited hours may very well handicap your ability to complete cases and gain the experience necessary to be truly ready for independent practice.
     
    #30 NickNaylor, Aug 13, 2015
    Last edited: Aug 13, 2015
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  31. sovereign0

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    Interesting. Playing devil's advocate, I have a couple questions:

    1.) Do you believe this issue could be partially helped by better documentation or hand-off procedures? Or do you believe the issue can mostly be attributed to the increased frequency of handoffs?

    2.) I suppose this varies between department, but how much would relaxation of work restrictions benefit continuity of care where patients tend to stay hospitalized longer (perhaps ICU)? Wouldn't hand-off still be necessary?
     
    #31 sovereign0, Aug 13, 2015
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  32. NickNaylor

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    1) Maybe, but there is still the fundamental problem of the patient being new to you. This is not something that can be overcome with more words on a sign-out. The nature of hand-offs also invites the opportunity for seemingly minor points (or sometimes even major points) to be forgotten or lost in the shuffle. Sometimes these things can result in significant harm.

    2) Yes, however there were times when residents would remain in the hospital for 36-48 hours at a time. That kind of system results in significantly fewer hand-offs and, again, from the perspective of education, would be beneficial for residents from the perspective of simply spending more time on the hospital watching things unfold and having the opportunity to see more of a patient's course.
     
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  33. Cyberdyne 101

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    So what is the best way to achieve optimal training in procedural fields without working 120 hour weeks? Would a 90-95 hour cap improve continuity of care? What about mandatory limits on resident scut work? <- Might sound ridiculous, but I imagine it would help.
     
  34. NickNaylor

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    I have no idea. In fields like surgery, scut work is typically pawned off to interns, which gives the more senior residents more time in the OR and less time on the floor managing patients pre- or post-op. However, this is probably something that @mimelim could provide more insight on.
     
  35. bc65

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    The hospital or university program that employs you will take care of the malpractice insurance during residency. When you go into private practice, you or your medical group will be responsible for purchasing your own insurance. It can range in price from as little as $7,000 a year to over $100,000, depending on your specialty, and the malpractice law of the state you practice in.

    Academic means you are employed by a medical school or university hospital, and they pay your salary and provide you with an office, and will typically pay for your expenses. You will usually share office space with other employed physicians. The salary structure is often quite complex. There is often a base salary, and a formula which will allow you to earn more money, but my understanding is that it's quite difficult to earn more than the base due to how the salaries are structured.

    Private practice is in distinction to being employed. You can be employed by a university, in which case you are academic, or you can be employed by a hospital, or by a government agency, or another entity ( eg VA Hospital, US military, a school, a prison, a government health agency, etc ).

    Private practice can mean that you have your own completely private practice, alone or with partner(s). You get paid by patients, either paying cash or by accepting insurance. You get paid based on each patient visit or each procedure you perform.

    You can also work for a large HMO or large medical group, which can technically still be private practice, if you are in a large medical group, but practically speaking you are functioning as an employed physician, earning a flat salary, more or less.

    Yes

    Not usually, but it depends on what happened, if you actually did something wrong, what it was, and how often you get sued. Also, on the size of the community you practice in.

    I have heard people say this. Residents don't like the handoffs. However, very few people experienced residencies both ways, so as to be able to compare them. As someone who did a surgery residency before the 80 hour rule, I can tell you that it was no fun working those long hours. My residency schedule had long weeks and short weeks every month. The short week was about 80 hours. The long week was between 130 and 140 hours. The long weeks were not easy, and probably were not very educational. I would have loved an 80 week limit, despite the fact that now I get to talk about how hard it was back in the "days of the giants".
     
  36. sovereign0

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    Another question, sorry.

    Is the malpractice insurance provided by the hospital for residents considered sufficient? Or is it common practice for residents to get additional coverage? Is the situation the same for attendings?
     
  37. rocklobstr

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    Some of that does make sense, but at some point there has to be a limit. I mean, you can't be on duty for 100 hours for the sake of continuity. I guess the system still needs some work.
     
  38. NickNaylor

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    As a real-life example, I was on night float last week and was the resident responsible for covering two in-patient units with roughly 20-25 patients total as well as an in-patient residential substance abuse floor that houses ~20 patients. Even if I were to receive a one-minute sign-out on every patient (which is a complete joke), that would take 45 minutes to complete sign-out. That just isn't going to happen. I could also get the ultimate sign-out by reading a patient's chart, but it might take 10-15 minutes per patient to look through everything and really understand a patient's course, especially if they've been there for a while. Even excluding the residential unit (which rarely gets calls), for 20-25 patients at 5-10 minutes each, we're talking hours of reading through charts. Combined with sign-out, I could spend almost half of my 12-hour shift trying to understand these patients. That assumes that I'm not being called about issues, having to admit patients, etc..

    Of course, in most cases problems that I have to address don't require in-depth knowledge of a patient. If I'm called about something, it's usually benign and I can get the information I need by very quickly looking at a patient's chart. I also have an attending in the hospital that I call for issues that I'm uncomfortable with, but candidly they are more than likely even more clueless with respect to what's going on with any one patient and function more as a stop-gap to make sure I don't do anything overtly dangerous.

    Since your third question wasn't in your post when I originally replied, I'm in psychiatry.
     
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  39. NickNaylor

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    I imagine this is program- and institution-specific, but I would be pretty surprised if residents were required or felt the need to get additional malpractice coverage for their duties as a resident. That sort of thing is a pretty standard "benefit" of programs, at least the ones I saw and interviewed at.
     
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  40. bc65

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    I don't think there's much scut work any more, at least compared to what it was way back when.
    Most of our scutwork was doing admissions before surgery ( not done any more, as most admissions for surgery are the morning of surgery) , admissions for tests ( mostly outpatient now) trying to track down chest xrays ( now all on computer, back then, you needed to find the hard copy and have it read, and bring the xray to the OR. If it got lost, you had to drag the patient down to xray in the middle of the night and get it taken again) finding lab results on slips of paper, as there was no computerized system for getting results. If the paper got lost, you had to draw the lab yourself and get the results, hand carry back. Back then, every patient got an 6 and 12 and CBC, type and cross 2 units, and if anything was missing or off, it had to be fixed, whereas now those bloods aren't even ordered routinely on most patients,and if they are, they are on the computer.

    Pre and post op care is the backbone of surgery, not scut, although residents don't always see it that way.

    It's sufficient. It's essentially unlimited, and the resident might be named in the suit, but it's the hospital and the attending who are ultimately responsible and will be the primary targets of the suit.
     
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  41. raindropx

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    Well seeing as he is a resident, I'm sure he can give a better opinion on whether or not one can be on duty for that long.
     
  42. rocklobstr

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    I believe the general consensus of the human race is that it is inadvisable to stay awake for 100 hours.

    [​IMG]
     
  43. raindropx

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    ...If you used google, then you would know that these 100 hours are not consecutive. Please do your research before making accusations/forming ignorant opinions. Just because we disagreed does not make me a troll, but it's amusing seeing your immature way of handing it.
     
  44. rocklobstr

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    If you read my post, I said 100 hours on duty, as in in the hospital, not 100 hours in a week.
     
  45. raindropx

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    If you read Nick's post, he is referring to 100 hours a week. Not sure where you got the 100 hours on duty.
     
  46. sovereign0

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    This is great information. Thank you.

    How does the insurance stuff translate to attendings? I'm assuming it is specialty-specific as well, but is it generally offered by the employer? Is it still considered sufficient or is it common practice to get more coverage?
     
  47. rocklobstr

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    ...It was referring to how long one should be on a single shift to avoid handing off a patient. As in being on duty 24 hours vs. 36-48 hours vs. 100 hours. It was a hyperbole meant to highlight the fact that there needs to be a limit at some point for a single shift, and that finding a proper limit/improving the system would be beneficial for residents and patients.
     
  48. bc65

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    I did 80 hours straight once, which was a 3 day weekend on call plus the next day, but fortunately I did get some sleep each night. However, the cariothoracic fellows did a week straight in the hospital, on call every night for 7 night s straight, and they rarely slept more than a couple of hours a night. I have no idea how they did it.
     
  49. raindropx

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    ah, thank you for clarifying. It would be difficult to limit the time as I imagine it depends on various things including patients and treatment types.
     
  50. raindropx

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    :eek:
     
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