Do you moonlight?

[Rodney10]

Just curious to see how many resident do (did) moonlight. I am at a newer program and nobody has moonlighted at our program. Not really sure what my opinion of the moonlighting is right now. I get the whole board certification aspect and agree with it, but the surrounding rural areas have FP's, PA's and NP's covering them.

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[12R34Y]

I moonlight in a single coverage rural (critical access) hospital. 4 beds, one nurse, 8 inpatient beds.

I also moonlight at a subruban 40,000 volume ED as triple coverage.

so, far at has been the single most invaluable experience of residency. The first time going to a rural area and having a code come in or a sick kid and talk about pucker factor. It's a real test.

You definately learn to deal with autonomy and making your own calls. It can be a little scary at time, but good learning experience that I can't simulate at my residency with oversight constantly.

I also understand the problem with allowing non-boarded people to work in ER's, but on the other hand I'm getting check out from ortho residents and optho guys are covering an ER by themselves.

So, yes, I feel that EM residents are serving these communities in a good way because their other option is the 65 y/o FP guy who still uses keflex for abscesses or the ortho resident who hasn't read an EKG since medical school.

Do you need to moonlight to be competent.........absolutely NOT, but I haven't regretted one moment of it and thoroughly enjoy the cash as well.

later

 

[DrMom]

I moonlight in a double physician coverage ED with triple coverage by an NP.

I completely agree with 12R34Y's post above. Very valuable learning...not so much the content of EM, but being able to get more comfortable doing it without anyone looking over your shoulder or double checking you. It is also good to see how things are outside of academics.

Rodney, at my program we're strongly encouraged by our PD and attendings to moonlight and everyone PGY2 and up moonlights at least some amount.

 

[TysonCook]

We are allowed to moonlight in house only, with attending coverage.

 

[edinOH]

I did a good bit while I was a resident. Agree with the reasons above.

Each patient encounter you have either in your residency or moonlighting is an opportunity to learn and broaden your skills and experiential base. The more patients you see, generally the more competent and prepared you are.

As far as the question of residents should be moonlighting in the ED? The only reason they are offering moonlighting jobs in these EDs is because they can't find or afford EM trained physicians. It's my opinion that a partially trained EM resident in this setting is absolutely superior to a moonlighting resident of another specialty and usually better than a FM/GP type or PA.

 

[Hercules]

As far as the question of residents should be moonlighting in the ED? The only reason they are offering moonlighting jobs in these EDs is because they can't find or afford EM trained physicians. It's my opinion that a partially trained EM resident in this setting is absolutely superior to a moonlighting resident of another specialty and usually better than a FM/GP type or PA.

Agree wholeheartedly with this. In academic centers and large urban areas you will hear the argument of moonlighting cheapening the position of our specialty, but this is not a realistic position to take. Out in rural areas and states with less coverage, your 2nd, 3rd, and 4th year EM residents are often a vast improvement over the alternative.

I also agree that moonlighting, while not absolutely necessary, greatly enhances your training and the progression from resident to attending.

 

[kungfufishing]

I suspect my transition to attending might have been more difficult had I not moonlit frequently over the last 18 months of residency. Recommend it with the caveat that you pick your venue carefully.

 

[Dr.Evil1]

The decision to moonlight is a personal one. I did moonlight and I found it somewhat valuable. If you are in a residency program that has extensive attending oversight and you aren't allowed to function very independently then it is probably a good idea. Also if you are in dire need of the cash for your family then it is probably a good idea.

All that being said regardless of whether you moonlight or not your butt will still pucker the first real test when you are on your own. No matter when you start to see patients on your own you will be nervous the first time. For some people its not really going to matter if that occurs during residency or as an attending. People think that once you are graduated from residency you know everything and you stop learning. Let me tell you I felt very prepared leaving residency and I have still learned a TON in my first attending year.

There are significant licensing and credentialing costs to consider too. Also realize that it will take you several months to get credentialed once you get a moonlighting job. If you are going to only work for a month or 2 then skip it.

Lastly if you have a spouse and have EVER argued about not being home enough then I would skip moonlighting.

The matter is a personal choice. Not moonlighting is no big deal. You will get the pucker at sometime, who really cares if it happens when you are a resident moonlighting or as a brand new attending.

 

[Midwest Medic]

Our program encouraged moonlighting pretty hard. I did it my last 2 years of the 1-4 program, and the last year did it pretty heavily. I think that it definitely taught me quite a bit being on my own and making all the decisions without having an overbearing attending over me. Like the above poster said though, if your program gives you plenty of autonomy then it might not help as much as a program that has a lot of oversight.

 

[EctopicFetus]

FWIW i moonlight both at a single coverage as well as double coverage ED. Where I do double coverage we then get 3x coverage with PA's and for a few hours quadruple coverage.

 

[NewAndImproved]

Tangentially related question for you guys...

Say a board certified EM doc works for a few years then decides he'd rather have his own office. Can he hang a shingle and open up a family practice office or are there legal/license/other problems with that?

 

[Dr Roboto]

Tangentially related question for you guys...

Say a board certified EM doc works for a few years then decides he'd rather have his own office. Can he hang a shingle and open up a family practice office or are there legal/license/other problems with that?

You mean besides the fact that he's not licensed or trained to practice family medicine? Basically, not possible, unless he feels like going through residency all over again, which I'm not even sure is possible.

 

[docB]

Tangentially related question for you guys...

Say a board certified EM doc works for a few years then decides he'd rather have his own office. Can he hang a shingle and open up a family practice office or are there legal/license/other problems with that?

An EP should not do this as we are not trained in primary care, family medicine, etc.

Just for an idea of why that's important try to think of what your third line antihypertensive is in a black 60 yo diabetic man who is post MI, what the appropriate immunizations are for a 3 year old who missed a set and is allergic to eggs and how much you should lower the coumadin dose of a 40 yo woman who is post PE but whose last INR was 4.8. All three are in your clinic right now along with the other three you have to see to keep your 6/hour flow mandate so you don't have time to look anything up. Go!

You mean besides the fact that he's not licensed or trained to practice family medicine? Basically, not possible, unless he feels like going through residency all over again, which I'm not even sure is possible.

The license isn't the problem. With a medical license you can just declare your self a primary care doc. There are reimbursement problems associated with it but it's fine as far as the licensing board is concerned. You shouldn't do it. But you can legally.

 

[Dr Roboto]

The license isn't the problem. With a medical license you can just declare your self a primary care doc. There are reimbursement problems associated with it but it's fine as far as the licensing board is concerned. You shouldn't do it. But you can legally.

I think the word I should've used is boarded. But anyway, I'm surprised it's that easy.

 

[J.J.]

Received my perm. lic. yesterday. I absolutely plan on moonlighting... my ass off! Coverage or not!

 

[NewAndImproved]

An EP should not do this as we are not trained in primary care, family medicine, etc.

Just for an idea of why that's important try to think of what your third line antihypertensive is in a black 60 yo diabetic man who is post MI, what the appropriate immunizations are for a 3 year old who missed a set and is allergic to eggs and how much you should lower the coumadin dose of a 40 yo woman who is post PE but whose last INR was 4.8. All three are in your clinic right now along with the other three you have to see to keep your 6/hour flow mandate so you don't have time to look anything up. Go!

The license isn't the problem. With a medical license you can just declare your self a primary care doc. There are reimbursement problems associated with it but it's fine as far as the licensing board is concerned. You shouldn't do it. But you can legally.

Thanks for the answer, docB!

 

[8744]

We are allowed to moonlight in house only, with attending coverage.

Same here. And the pay is Okay but not that great. I don't do any moonlighting. After a brief burst of enthusiasm for it I got tired of being tired and either working on a rare day off when I wouldn't ordinarilly be tired or "stacking" shifts.

Oh my distinguished colleagues, being tired all the time sucks. Big time. Not only have I officially long passed the point where I am scared to go into work (come on, admit it, as interns and second years you are scared to death of not knowing what to do) but I am rapidly forgetting what it meant to be tired all the time like I was during intern year of which I did two. Being exhausted every day and all day is no way to live life and the heady allure of forty bucks an hour for seeing PA-level patients is not much of an incentive anymore.

Am I the only one whose family life and marriage has suffered from not being home and, when home, being an exhausted zombie?

 

[8744]

Tangentially related question for you guys...

Say a board certified EM doc works for a few years then decides he'd rather have his own office. Can he hang a shingle and open up a family practice office or are there legal/license/other problems with that?

Yes. Of course. But I would call myself a Consulting Physician or something like that to avoid the stigma of Family Medicine. You are perfectly capable of practicing general medicine, especially since the mid-levels with a fouth of your training, chiropractors, naturopaths, and everybody and his brother thinks they can do it.

 

[12R34Y]

Same here. And the pay is Okay but not that great. I don't do any moonlighting. After a brief burst of enthusiasm for it I got tired of being tired and either working on a rare day off when I wouldn't ordinarilly be tired or "stacking" shifts.

Oh my distinguished colleagues, being tired all the time sucks. Big time. Not only have I officially long passed the point where I am scared to go into work (come on, admit it, as interns and second years you are scared to death of not knowing what to do) but I am rapidly forgetting what it meant to be tired all the time like I was during intern year of which I did two. Being exhausted every day and all day is no way to live life and the heady allure of forty bucks an hour for seeing PA-level patients is not much of an incentive anymore.

Am I the only one whose family life and marriage has suffered from not being home and, when home, being an exhausted zombie?

i'm moonlighting for 120-140 bucks/hour. So financially for us (wife and 2 little kiddos) it is huge. I've virtually 4 times my monthly salary.

so for me it has actually IMPROVED the home life, because the stress of financial ruin is gone.

I do understand and appreciate the being tired part and having days off.

Since I'm a chief I get a shift break and don't work as much normally so it is like I'm a regular 3rd year and not that bad.

later

 

[DrJosephKim]

I used to do a lot of moonlighting. Depending on the types of shifts, you may end up doing more reading than working.

 

[45408]

Being exhausted every day and all day is no way to live life and the heady allure of forty bucks an hour for seeing PA-level patients is not much of an incentive anymore.

$40/hr? No wonder you don't think it's not worth it. That's what a nurse with a 2-year degree makes for overtime around here. I'd crawl into bed after an 80 hour week and ask my wife to pick up an extra shift.

 

[deleted109597]

Bringing this one back from the dead for the next wave of residents.

Although to me, it isn't do you or don't you, but how much do you moonlight?

 

[lucky_deadman]

Bringing this one back from the dead for the next wave of residents.

Although to me, it isn't do you or don't you, but how much do you moonlight?

A lot when it comes time to move and get set up in a new location.

It also helps when you're not going to be having a paycheck for ~1 month when starting up your new job.

 

[DocZ]

Curious if any resident from the NY programs moonlight/moonlit? Wouldn't think there is as much opportunity in the NY tri-state area.

 

[quinsy]

At my program there was a lot of moonlighting in the ICUs providing midlevel coverage. It was exactly what you would do there while rotating as a resident, but you get PAID for it! $75-85 an hour to mostly sit around, writing occasional orders to replete potassium and sometimes throwing in a central line. Numerous times got paid and got a good 4 hours of sleep on a night shift. What a deal. I would do it maybe 3 times a month so that's a good bunch of extra money to throw at the old student loans.

We also had moonlighting double coverage at outside EDs, for about $150 an hour, but I didn't do that, was not brave enough as a resident. Now as a fellow I am doing it, and it's nice.

 

[Venko]

Just a point to remember, when you are moonlighting, you are held to the standard of an EM attending with no exceptions. This is a risk from a malpractice standpoint, but if one is willing to take the risk there are benefits as well.

I personally did not moonlight and am happy with my choice, but know and respect that there is are definitely things to be gained from moonlighting.

 

[deleted109597]

As a resident, you are also held to the standard of an EM attending. You can't sit up there on the witness stand and say "well, I wasn't the attending". Your name is on the chart. If you **** up, you're getting sued. Hell, if you blink funny, you're likely to get sued. That being said, you'll be the only person on the lawsuit if you're moonlighting.
Moonlighting increases your risk of lawsuits as an absolute only because you see more patients. On average, EM physicians are sued once for every X patients (I can't remember or find the exact number). If you moonlight, you see more. It doesn't increase your relative risk unless you're actively doing something wrong.

Looking up at the poll, I laughed at the board certification. I'm guessing the implication was board eligible.

 

[Venko]

As a resident, you are also held to the standard of an EM attending. You can't sit up there on the witness stand and say "well, I wasn't the attending". Your name is on the chart. If you **** up, you're getting sued. Hell, if you blink funny, you're likely to get sued. That being said, you'll be the only person on the lawsuit if you're moonlighting.
Moonlighting increases your risk of lawsuits as an absolute only because you see more patients. On average, EM physicians are sued once for every X patients (I can't remember or find the exact number). If you moonlight, you see more. It doesn't increase your relative risk unless you're actively doing something wrong.

Looking up at the poll, I laughed at the board certification. I'm guessing the implication was board eligible.

I understand what you are trying to say, but I do think that working in the function of a resident, your chance of an error is lower as not only are you looking for it, but your attending is as well. Also, if you are sued when working under an attending, you definitely can say that you are the resident. It doesnt mean you have no responsibility, but trust me, the attending is shouldering significantly more responsibility than you are. Make no mistake, when you moonlight you are taking on significantly more risk...you take on the risk of litigation that any fully trained EM physician does, but without having had a complete set of training. It would be potentially serious mistake to think the risk is only related to the number of patients you see...the attendings you work with keep watch over what you are doing more than you think they are and they do provide safety in your practice. The other factor is that the more experience the physician has in EM the less likely (not zero), they are going to miss something and thus be sued...having an experienced attending behind you versus you and your 1, 2, or 3 years of residency training on your own are two different risks entirely.

 

[deleted109597]

The more we talk about it in the other thread, the more we distort the original meaning of it. So I'm taking the moonlighting discussion here.

It's not a matter so much of the care you provide being materially different, it's that single coverage with inadequate resources is risky for anyone. The question becomes: is the extra income worth the increased exposure to risk? The fact that you're a moonlighting resident is going to make defending bad outcomes more difficult. "So doctor, had you finished your training when you made the decision that killed Mrs. X and orphaned her 5 children?" If you don't need the cash, single coverage moonlighting is a relatively risky way to get experience.

I'm not sure you could blame letting someone die on inadequate resources. That's like blaming all your failed codes on your EMS guys. I mean, if only they could do more in the back of that truck. Critical access hospitals are just that. Everything that needs to be admitted still gets admitted. Just to a different hospital.
However, we don't take the risk lightly. I don't discharge people with chest pain. I don't not order things on people because it might take longer. I've had to transfer a vag bleeder for ultrasound. But not ultrasounding it was not an option. The care is not less, just where they receive it.

If you do need the cash or are willing to take that risk (the majority of residents will fall into one or both categories), make sure you communicate well with family. Patients that need to be admitted are sick and should be billed as such to family.

Of course. I've actually found I have to speak more with the patients and family, because it's not just "You want me to stay here overnight", it is "you want to send me 60 miles away to spend the night at another hospital?". It's not like I go in and say "If you were somewhere else I would admit you, but here you're just SOL. Sorry"

 

[deleted109597]

What type of places are you guys working?

7 beds. Annual volume 13K.

I started working midway through my PGY3 year (4 year program) at single coverage ERs with volums of 8-15K per year. Since July, I have stepped it up to the 30-35K per year size. These places are double covered and often a midlevel.

I like the larger places because I can admit near anything and dont have to screw with transfering. Its also nice to work with other doctors in the real world. The money tends to be double an hour, but I assure you that I work near twice as hard and have high acuity.

I will agree with this, and it's why I don't work at the much larger (70K volume) TeamHealth joint we can moonlight at which is only 15 minutes longer driving (in the complete opposite direction). They don't double the pay (135 an hour would be hard to double), but TH does pay 300 for driving, or 500 if you sleep there and work 2 in a row. However, even with double or more coverage, you pretty much get annihilated every day.

On the flip side, I'll hit the smaller places when they are in a pinch. Often you can get several hours of sleep at those places on a night shift...

Absolutely. Getting paid to sleep is pretty low risk. I had 0 patients for the last 7 of my 12 hour shift labor day night.

 

[xaelia]

I had 0 patients for the last 7 of my 12 hour shift labor day night.

Yep, 64 patients total scattered across three 12-hour nights and one 12-hour day...or fewer than what I see on a much higher acuity residency shift. If the TeamHealth facility paid like a true high-volume, high-stress/RVU facility, then I'd consider working there, but this is a fine place to start.

Seems like I replace the time I otherwise spend chasing down my attending etc by spending more time with the patient explaining the meanings of what I'm finding and involving them in the treatment decisions.