ED Moonlighting

[iridesingltrack]

Not too long ago I was having a discussion with an EM attending at my medical school about moonlighting. He felt that it was inappropriate for residents to moonlight, unsupervised, in the ED because he believed that it undermines the specialty-that is, if an incompletely trained EM resident is permitted to independently practice EM then the argument for rigorous training and board certification is substantially weakened. He took it even further stating that non-EM residents were often moonlighting independently which of course, to his way of thinking, weakens further the argument that EM is unique and requires specific training. His take home point was, moonlighting is unsafe for the patient, and is bad for the maturation of the specialty.

However, in talking to EM residents about this, I find that there is both a substantial financial incentive and educational incentive toward moonlighting. The financial incentive is obvious so I won't belabor it. But, I was surprised by the comments about the educational advantages. I heard comments that independent practice forces one to galvanize their knowledge base and also leads to many discussions with attendings about particular cases that substantially facilitate learning.

What are your thoughts on residents moonlighting in the ED?

BTW, I did a quick search about this topic and didn't really find what I was looking for. If this has already been discussed at length please excuse me and point me in the right direction. Additional disclaimer, I'm not attempting to argue a point but am genuinely interested in what people think about this issue. Personally, I see both sides and as an incoming EM resident I like the idea of being able to make extra money doing what I enjoy and what I am in training for...but, on the other hand...Thoughts?

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[theCamel]

Not too long ago I was having a discussion with an EM attending at my medical school about moonlighting. He felt that it was inappropriate for residents to moonlight, unsupervised, in the ED because he believed that it undermines the specialty-that is, if an incompletely trained EM resident is permitted to independently practice EM then the argument for rigorous training and board certification is substantially weakened. He took it even further stating that non-EM residents were often moonlighting independently which of course, to his way of thinking, weakens further the argument that EM is unique and requires specific training. His take home point was, moonlighting is unsafe for the patient, and is bad for the maturation of the specialty.

However, in talking to EM residents about this, I find that there is both a substantial financial incentive and educational incentive toward moonlighting. The financial incentive is obvious so I won't belabor it. But, I was surprised by the comments about the educational advantages. I heard comments that independent practice forces one to galvanize their knowledge base and also leads to many discussions with attendings about particular cases that substantially facilitate learning.

What are your thoughts on residents moonlighting in the ED?

BTW, I did a quick search about this topic and didn't really find what I was looking for. If this has already been discussed at length please excuse me and point me in the right direction. Additional disclaimer, I'm not attempting to argue a point but am genuinely interested in what people think about this issue. Personally, I see both sides and as an incoming EM resident I like the idea of being able to make extra money doing what I enjoy and what I am in training for...but, on the other hand...Thoughts?

i have no experience with moonlighting, and i'm also curious about it. i agree with the attending in that it doesn't look too great for the field when residents are basically doing the full job of an attending without finishing their training. that being said, when you moonlight in EM, do you have full independence, or are you mostly independent. i.e. is there anybody with more experience there to run things by or oversee your work at all? even after the shift, to review your shift's work or answer any questions about the day?

i'm all about moonlighting, financially and experience-wise - but i wonder about the points brought up in the OP, and hope that this generates interesting discussion. i hope that this topic hasn't already been beaten to death.

 

[MasterintuBater]

Moonlighting is, indeed, an educational opportunity and important step in the transition from resident to attending physician. OUr program encourages moonlighting in the 3rd year for this very reason.

My own anectodatal experience:

As PGY3 I moonlight mostly at a rural community hospital ED with 9 beds and single coverage. A group of attendings at my training hospital own the contract to this hospital and placed me there with a good degree of confidence. That being said, when I work, I have a list of ALL their cell phone numbers to discuss cases as needed or when I get in a "jam" or my sphincter tone is inappropriately tight. I have called several times or faxed an EKG or discussed a dispostion and it has been MOST educational.

The OP was spot on when he said that moonlighting will "galvanize" your confidence while at the same time exploiting your fund of knowledge. If you don't moonlight during residency, you could be in for a rude awakening your first day as an attending. It doesn't weaken the perception of our training. It emphasizes the fact that we have SUPERIOR training that prepares us to care for patients independently well before the last day of our residency.

Also, the Benjamins are nice. Mo' money, Mo' problems.

Good luck

 

[polygonal]

I see both sides to the argument. Personally, I'm for it. I'm not sure what its like where you are, but around here the people that staff the EDs where we moonlight are rarely EM trained. I think a 2nd or 3rd year EM resident is more qualified than say a pathologist or radiology resident (no offence) or a PA/NP. EM boarded physicians simply don't work at these places so its the next best thing.

 

[DeLaughterDO]

I see both sides to the argument. Personally, I'm for it. I'm not sure what its like where you are, but around here the people that staff the EDs where we moonlight are rarely EM trained. I think a 2nd or 3rd year EM resident is more qualified than say a pathologist or radiology resident (no offence) or a PA/NP. EM boarded physicians simply don't work at these places so its the next best thing.

Agree with what has been said above (this post and the rest).

I am personally looking forward to moonlighting in 3rd year, both for the educational and the monetary benefits. There are several hospitals in our area where our residents moonlight. Every one has only great things to say about it - both for the taste of the "real world" you get, and for the $$$

 

[roja]

ACEP has a policy that your attending is reiterating. I can definately see the incentive to moonlight (financial). I would guess, that while you can learn from almost anything, the true educational value is less. If your residency isn't training you to galvanize your knowledge, that is a problem in your residency. I also think it is important that residents spend thier time off, OFF.

If you are moonlighting single coverage, then you can't learn *as much* because you have no one to bounce your thoughts off of. Not to mention, you will probably be learning 'trial by fire.' From a patient standpoint, I wouldn't want a resident practicing solo on me or my loved ones.

For the same reason I really don't want individuals who aren't trained in EM taking care of me in the ED.

So, both sides have valid points. But in the end, I marginally end up on the 'no moonlighting' side.

 

[anonymousEM]

I did some moonlighting only in my last 6 mo of residency. I didn't really feel ready personally before that though others in our class started at the beginning of 3rd year. In the rural area where one of us was working at that hospital at least several days a week. I saw a guy returning for followup of his cellulitis seen by another guy from my program earlier in the week and the patient was happy to see me and said "oh, i have so much more confidence in you docs from...." Much better an almost graduated EM resident than a nephrologist running their ATV rollover....

I agree that it was worthwhile to practice some of the private medicine we didn't see much in the county hospital...calling private docs, arranging transport for emergent sub specialty stuff, pushing thrombolytics vs striaght to cath, figuring out what can wait until clinic for a call vs. call in the middle of the night....that said, I never worked any single coverage shifts. Glad I didn't have to, though many of my classmates chose to do so.

Also, be sure to look at the finances. If you are hired as an independent contractor, your tax burden will be higher than you may realize as you have to pay your own "employer contributed 7.5%" for social security. One attending told us to plan on one check for me, one check for uncle sam. After the first year self-employed you also have to pay estimated taxes.

I fall on the moonlighting but not too much side of the fence...and god-help-the-resident who gets caught missing conference to moonlight!!! You must keep up with residency education and shouldn't be working so much you never get to relax!

 

[GeneralVeers]

I disagree concerning patients getting inferior care with moonlighting residents. At my program we are allowed to moonlight, but only at the outer "rural" hospitals about 30 minutes outside of town. Prior to our arrival these hospitals were staffed solely by FP-certified physicians, and to tell the truth some of the workups they do (we get all their transfers) are scary. If my family had to go to one of these smaller hospitals, I'd much rather have a 3rd year EM resident see and treat them than some FP physician with no formal training in EM.

 

[kungfufishing]

I'm in a 4 year program. I've been moonlighting since november of my pgy3 year, so perhaps a slightly different perspective, but I think it has been very positive. There is no way to simulate autonomy. I think it is telling that all of the potential employers I spoke with inquired about and encouraged moonlighting experience. I do see the point about cheapening the specialty and patient care, but given the motley assortment of non EM trained physicians staffing many EDs I dont know that upper level residents are doing much damage and in many instances may be an improvement.

 

[deleted109597]

Here is the thing that always got to me.
Many of the people who are against moonlighting (ACEP,etc) are filled with people who moonlighted themselves in residency. Far be it from me to state that they might be using some hindsight, but it seems that they are.
In reality though, there are positions out there. When PGY2-3 FM residents get to moonlight in the EDs, but EM residents can't, there is a serious problem, but this does exist in places. It seems ironic.

 

[12R34Y]

I agree with the whlole "can't simulate autonomy" in your residency.

Nothing can replace being completely by yourself and making independent decisions.

I start moonlight July 1st at two different hospitals and cannot wait (beginning of my 3rd year). Not only is the money amazing. It's a great educational/confidence-building opportunity. At least that's what the seniors doing it this year have said.

I'll let you know in 1.5 months.

later

 

[jbar]

There is something to be said for hindsight. People who say "I did this and it was a bad idea" often know what they are talking about. I'd trust someone who used to moolight who says they were in over their head rather than someone who has never done it but thinks it's a good idea.

 

[dchristismi]

It's not really an option at my program... but we have a sweet ICU moonlighting gig set up to make up for the benjamins. And it's ICU medicine, in system at a smaller hospital (no extra malpractice and the cash goes into the regular paycheck), with an attending intensivist by phone if needed. (You run codes, manage any ICU issues, and call to let them know you admitted someone to the unit once you've stabilized and managed whatever is going on.) While it's not in the ED, it's a nice compromise. And honestly, it's nice to get paid to sleep.

In Florida, there is an ongoing board certification issue, wherein an outside group snuck an addendum onto a state legistature bill allowing them administer a test to non-EM trained docs to be "board certified." This has FCEP up in arms, and to make a long story short, it would undermine the argument too much. I see both sides, but will be moot for me in a month. (My new boss is big into ACEP and knows my program well, so it never came up - in fact, moonlighting wasn't really emphasized at any of them.)

 

[Aloha Kid]

I DO NOT WANT TO MOONLIGHT. I like being OFF. I work hard enough as it is and don't care about money. I have enough autonomy, and feel comfortable enough not moonlighting.

This is my issue. The widely held belief that moonlighting = a better prepared resident is screwing residents like me over. You see it everywhere and unfortunately as some of you have mentioned, some employers naively look on it as favorable. To believe even for a second that moonlighting is a right of passage to graduation undermines every single one of us. I have respect for those who want to moonlight. But don't force unproven speculations & opinions on all of us. Most of all, please don't undermine our ability to get jobs with unfounded beliefs that moonlighting is requisite as part of a normal education/training process.

If you want to moonlight then by all means go ahead. But be considerate in thought and words about those of us who chose not to moonlight, or one day, we just might have a 5th year EM residency dedicated to moonlighting before anyone can graduate. If there is a confidence problem, then it should be addressed with your program and training. We deserve not to have to moonlight because we lack confidence, need more galvanizing of our abilities, lack skills and knowledge (YIKES), or need it to solidify our resumes so we can get a job.

 

[McDoc]

I couldn't agree more. I'm still working 19-21 10 hour shift as a PGYIII- why the hell would I want to work on my days off??

We have supervised (still work under staff as a resident, just get paid extra for working more than required) moonlighting shifts available in our ED, but I don't pick any up.

As far as single coverage moonlighting at outside hospitals, not an option for my program. Resident salaries are getting paid by CMS. If you work outside independently and bill CMS for your services, you are actually doubling billing them in some ways. Some health systems view this as fraud and don't allow independent resident moonlighting because of it.

 

[AmoryBlaine]

Good points on all sides, but speaking as someone who has taken a loved one to the ED I would much rather find out that I was talking to a senior EM resident from a solid program than an FP.

Plus in my limited discussions with EM residents on this issue it seems like moonlighters do a sort of self-selection. I asked one guy who was a rising PGY-4 if he did it and he said, "nah, I don't feel ready." That struck me as a very responsible thing to do given that he had some pretty lucrative options.

 

[lucky_deadman]

Resident salaries are getting paid by CMS. If you work outside independently and bill CMS for your services, you are actually doubling billing them in some ways. Some health systems view this as fraud and don't allow independent resident moonlighting because of it.

But while resident salaries are funded by CMS, we are not "paid" by CMS. The hospitals are paid by CMS and they pay residents. Semantics, but really a huge difference legally.

As far as moonlighting goes; you are not billing CMS. You are paid a salary/hourly rate (usually as an independent contractor) by the group who has the contract (sometimes the hospital itself). The hospital is the one who bills CMS and other insurance companies. So you are not committing fraud.

Basically it's no different than any other physician working at 2 different places.

 

[Arcan57]

If you are an independent contractor, many groups have it set up so you are billing CMS. Although you may not send out the actual bill, its your Medicare number. There's usually language in the contract that you are allowing the group to bill and collect CMS on your behalf.

However, CMS usually only gets upset when you are trying to bill them twice for the same service. Resident physician acting as a licensed physician at OSH billing CMS is ok. Resident physician acting as resident and submitting a bill to CMS is bad. Resident physician acting as attending at home institution and billing CMS? I honestly don't know.

 

[BADMD]

As far as moonlighting goes; you are not billing CMS. You are paid a salary/hourly rate (usually as an independent contractor) by the group who has the contract (sometimes the hospital itself). The hospital is the one who bills CMS and other insurance companies. So you are not committing fraud.

Only the physician can bill CMS. So even though you are paid at an hourly rate and the group keeps the billing, the bill goes out with your name on it. In fact, if the billing company does shady stuff, YOU are on the hook for the fraud.

 

[docB]

Ah the old moonlighting debate. A very sticky issue for EM, a specialty trying to convince the world that you have to be boarded in EM to practice EM. One of the most interesting things about the whole debate is that the most vocal proponents of the "EM Boarded Only!" side, EM residents, are also the ones who argue to dilute that stance by advocating moonlighting by EM residents.

Here’s the AAEM position on it:
http://www.aaem.org/positionstatements/pre_fsmb.php
AAEM has been the leader on the anti-moonlighting for the sake of purity side.

If residents who want to moonlight were to write a position statement it would be more like:
We strongly believe that the independent practice of Emergency Medicine is best conducted by a specialist board certified in Emergency Medicine or a non BC/BE EM resident who feels that they are experienced enough to know that they can do it.

I disagree concerning patients getting inferior care with moonlighting residents. At my program we are allowed to moonlight, but only at the outer "rural" hospitals about 30 minutes outside of town. Prior to our arrival these hospitals were staffed solely by FP-certified physicians, and to tell the truth some of the workups they do (we get all their transfers) are scary. If my family had to go to one of these smaller hospitals, I'd much rather have a 3rd year EM resident see and treat them than some FP physician with no formal training in EM.

Be careful with this argument. I hear what you're saying and you can certainly say that some of the workups you see done by the FP docs are not what you would consider adequate but when you try to extrapolate that across the board you are discounting experience totally. I would agree that I expect a Boarded EP to do a more appropriate work up than an FM doc but an experienced FM in the ED will usually be better (more directed and efficient) than a fresh EP.

Here is the thing that always got to me.
Many of the people who are against moonlighting (ACEP,etc) are filled with people who moonlighted themselves in residency. Far be it from me to state that they might be using some hindsight, but it seems that they are.
In reality though, there are positions out there. When PGY2-3 FM residents get to moonlight in the EDs, but EM residents can't, there is a serious problem, but this does exist in places. It seems ironic.

I am one of those guys who did moonlight during residency and I certainly felt stronger for it. I’m not against moonlighting now but I do think it creates a problem for our specialty as far as the “Only BC/BE EPs!” argument.

I think that everyone should understand the glass house we live in as a specialty with this issue and to temper their stone throwing.

On a side note

Many of the people who are against moonlighting (ACEP,etc) are filled with people who moonlighted themselves in residency.

What the hell is the proper past tense of “to moonlight?” Is it “moonlighted”, “moonlit?” I don’t know. We should be able to figure this out.

 

[jazz]

i trained a place where you weren't allowed to moonlight b/c they felt that it diminished the field. in a way i agree, iif after 2 years of training, you can be an ER doctor, then why is our specialty 3 years?

but i wanted to comment on a few other things...

If you don't moonlight during residency, you could be in for a rude awakening your first day as an attending.

I do not agree with this. If you're in for a rude awakening as an attending on day one then you will be in for an even ruder awakening as a resident (who hasn't finished residency) moonlighting. The first few months of being an attending is always challenging but you will be ready, that's why you do a residency.



Also while I am the strongest supporter of EM as its own speciality, don't discount FP/IM trained physicians who have had years of practice in emergency medicine.

The best advice I can give, is when you are in your last year of residency, each case, have a plan and disposition in mind before presenting to your attending. If s/he agrees with you most of the time, you're set.

Finally, if you do plan to moonlight... a word to the wise. In addition to the whole income tax/self employement thing that may hit you, make sure you are covered by good malpractice insurance. You don't want to be hit with a lawsuit with sh**ty coverage prior to even beginning your career.

 

[crewmaster1]

The best advice I can give, is when you are in your last year of residency, each case, have a plan and disposition in mind before presenting to your attending. If s/he agrees with you most of the time, you're set.

Agree, but I would suggest you start doing this as a 4th year med student. You will learn a lot more when you come up with your own plan and figure out why people agree or disagree with YOUR plan. Anybody can take a history and do a physical.....in the ER where my wife works they have "surgical assistants" with a 2 year community college degree that do the entire H&P to help speed the MD up. Yeah, the MD has to verify the key details, but doesn't do the whole thing over. Crazy.

 

[dhb]

Nothing has been mentioned about the acuity level of the particular ED you moonlight at which is generally pretty low at the "rural" ED.
I'm a year and a half into my residency and i started moonlighting at a rural ED in january. Considering the kind of cases we see i don't think anyone is going to do a much better job than me.
Level 3 trauma is a different beast i wouldn't want to be managing 10 acute patients at the same time.
For those who don't feel ready to moonlight after 3 years of residency i wouldn't want them taking care of me.

 

[deleted109597]

As far as single coverage moonlighting at outside hospitals, not an option for my program. Resident salaries are getting paid by CMS. If you work outside independently and bill CMS for your services, you are actually doubling billing them in some ways. Some health systems view this as fraud and don't allow independent resident moonlighting because of it.

No you aren't. Your resident hospital is billing them as a resident. You, while moonlighting, have a full license, and are billing them as a physician. Because the patients are different, there is no double billing.
I have never heard of a hospital saying that they don't allow moonlighting because they are afraid of fraud (except for maybe inhouse stuff). That's like saying the hospital has a non-compete clause because of fraud.

 

[n2b8me]

 

[lucky_deadman]

How credible is someone's opinion as an attending if they have only worked at a single institution for the last 20 years? As a senior resident, I definitely appreciated the opinions of the attendings that worked primarily in the community and moonlit in our academic/county ER. I felt they had so much more experience with real life experience in the ED than many of the esteemed professors that never left the academic world.

Wow, you hit the nail on the head.