List of EM Residencies that Allow Moonlighting

[Got Em]

Anyone know where to find a list for this? If not, do you think it's a good idea to have a "master" list of programs that allow moonlighting to help future applicants? I know only 26% last year considered this when applying to programs, but it may be another helpful factor. I was thinking something like:

Name of Program: allow, after 2nd year, internal + external, >50% moonlight

Any residents/attendings think this is a good idea and want to contribute?

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[da8s0859q]

I think the list of EM programs which don't allow some sort of moonlighting would be shorter.

Don't forget state law issues (some states have different FMG requirements, some prohibit permanent licensure until completion of two postgrad years and not just one, etc).

 

[Cinematographer]

You can probably find this info on FREIDA. Or better yet, wait until you actually start getting interview invitations and then decide which ones to attend based on your priorities. Kind of pointless at this stage of the 2016-2017 application cycle. I think this early in the game you should be focusing on your sub-I and completing your ERAS app.

 

[racerwad]

Anyone know where to find a list for this? If not, do you think it's a good idea to have a "master" list of programs that allow moonlighting to help future applicants? I know only 26% last year considered this when applying to programs, but it may be another helpful factor. I was thinking something like:

Name of Program: allow, after 2nd year, internal + external, >50% moonlight

Any residents/attendings think this is a good idea and want to contribute?

My personal bias is the moonlighting is important, but it is hard to gauge how important that $$$ is versus your free time, especially when you don't know what residency is like. Honestly, I can't recall a program that didn't allow moonlight, most just handled it in the same way with various outliers mixed it. I don't think that it should be a variable that makes or breaks your rank list.

No one is going to let you moonlight first year and the percentage of other residents that moonlight doesn't tell you much.

Honestly, I think how much money the program contributes to your food allowance is more important in terms of day-to-day happiness.

 

[Tenk]

Bad idea. Ask programs when you interview. If they say nobody moonlights, just say you think you just got paged, stand up and leave.

 

[canigetawhatwhat]

I am probably the poster child for being against moonlighting.

You go as a less than adequate late 2nd year and practice in IMO the hardest setting (rural ****ty critical access hospitals). You work 18-20 days a month normally, and not including conferences and other stuff. It is pretty much being an attending too soon, while you were already overworked. Why not wait until you are an actual attending and well-trained before you go out in the world? I never saw the appeal been working 22 shifts a month

 

[gro2001]

I am probably the poster child for being against moonlighting.

You go as a less than adequate late 2nd year and practice in IMO the hardest setting (rural ****ty critical access hospitals). You work 18-20 days a month normally, and not including conferences and other stuff. It is pretty much being an attending too soon, while you were already overworked. Why not wait until you are an actual attending and well-trained before you go out in the world? I never saw the appeal been working 22 shifts a month

It is a very unpopular opinion here on SDN, but is more common IRL.
I am also against moonlighting, for several reasons.

1) It undermines our specialty. We keep saying EM residency is absolutely crucial for practice, and there is no way that someone with an FM residency and 2 year fellowship should be allowed to staff an ER, but then we let PGY2s moonlight. Either its possible to learn everything necessary to practice EM at a baseline level of competency in <2 years or it's not. We should pick a side and stick to it. I think it's not, which is why I am both against FM fellowships and against moonlighting.

2) It is not as educationally useful as people claim. Once again, almost everyone here on SDN seems convinced moonlighting is a crucial component of EM education. I disagree because there is practice and there is mindful practice. The latter comes from feedback on how you did, which ideally should come from your attending, residents you are supervising and RNs/other staff you are working with. Moonlighting just does not give you that feedback. If anything, it takes up a significant amount of mental energy which (for me at least, but I suspect for most people too) is a limited resource. There are many more educationally high yield things you can do with that time and energy.

3) It comes with an unquantifiable expense. Usually the expense is in the form of quality of life/mental health. Might be in quality of your education too. If your residency gives you so much free time that you can easily take on more clinical shifts without compromising your family time and post-shift recovery time, then either you are fooling yourself or residency was extremely different where you did it.

 

[deleted547339]

It is a very unpopular opinion here on SDN, but is more common IRL.
I am also against moonlighting, for several reasons.

1) It undermines our specialty. We keep saying EM residency is absolutely crucial for practice, and there is no way that someone with an FM residency and 2 year fellowship should be allowed to staff an ER, but then we let PGY2s moonlight. Either its possible to learn everything necessary to practice EM at a baseline level of competency in <2 years or it's not. We should pick a side and stick to it. I think it's not, which is why I am both against FM fellowships and against moonlighting.

2) It is not as educationally useful as people claim. Once again, almost everyone here on SDN seems convinced moonlighting is a crucial component of EM education. I disagree because there is practice and there is mindful practice. The latter comes from feedback on how you did, which ideally should come from your attending, residents you are supervising and RNs/other staff you are working with. Moonlighting just does not give you that feedback. If anything, it takes up a significant amount of mental energy which (for me at least, but I suspect for most people too) is a limited resource. There are many more educationally high yield things you can do with that time and energy.

3) It comes with an unquantifiable expense. Usually the expense is in the form of quality of life/mental health. Might be in quality of your education too. If your residency gives you so much free time that you can easily take on more clinical shifts without compromising your family time and post-shift recovery time, then either you are fooling yourself or residency was extremely different where you did it.

You're just plain wrong on point 2. I learned more moonlighting during my final year of residency than I did in my program. You learn for a lot of reasons:

1) new system - you have to think about/learn what to do when you don't have an obs unit, or a neurosurgeon or whatever.
2) the "second-guess" effect - even when you have seen something 100 times, when you don't have someone to bounce someone off of it makes you think harder. This results in more reading. You think a lot harder about taking someone's airway, discharging, etc.
3) new consultants - I have learned a lot from my consultants, and a fresh new group is great
4) learn how to fight your own battles - it was easy for me to turf a fight to my attending as a resident. When you have a consultant who doesn't want to come in and see a patient, it takes a lot of growing up to say "listen, I need you to come in now. You're on call, if you think it's still inappropriate after you get here, we can talk about it then. Otherwise I'm going to have to ship the patient to a hospital where a surgeon will actually see the patient and email the CMO explaining why you're refusing a consult"
5) makes you have a little more respect for the attendings who are more conservative.

Plus a lot more. The money was a great plus, but I got a lot better education because of moonlighting. I think I got more out of my final year because I would have tough cases then go ask senior faculty what they would had done.

 

[RustedFox]

Terrible idea.

When I applied, this data was on FREIDA, but we all know that the data there is not always accurate.

If you're a MS 3/4.... chill. Focus on the task in front of you.
If you're a PGY 2/3... chill. Focus on the task in front of you. If moonlighting exists, great. - If not... pfft.

I never moonlit. I'm not "behind the curve" when it comes to decision-making, or systems whatever.

Chill. It will come. The system is designed a certain way for a reason.

 

[pianoman511]

I will go ahead and take the middle ground. The opportunity for moonlighting for me was at urgent care which was perfect. It helped with decision making, routine procedures but generally low acuity. When someone was sick it was a pretty easy call what to do and I called faculty a few times with the "what do I do" questions. The money was helpful... For sure...

Sent from my SM-G925P using SDN mobile

 

[gro2001]

You're just plain wrong on point 2. I learned more moonlighting during my final year of residency than I did in my program. You learn for a lot of reasons:

1) new system - you have to think about/learn what to do when you don't have an obs unit, or a neurosurgeon or whatever.
2) the "second-guess" effect - even when you have seen something 100 times, when you don't have someone to bounce someone off of it makes you think harder. This results in more reading. You think a lot harder about taking someone's airway, discharging, etc.
3) new consultants - I have learned a lot from my consultants, and a fresh new group is great
4) learn how to fight your own battles - it was easy for me to turf a fight to my attending as a resident. When you have a consultant who doesn't want to come in and see a patient, it takes a lot of growing up to say "listen, I need you to come in now. You're on call, if you think it's still inappropriate after you get here, we can talk about it then. Otherwise I'm going to have to ship the patient to a hospital where a surgeon will actually see the patient and email the CMO explaining why you're refusing a consult"
5) makes you have a little more respect for the attendings who are more conservative.

Plus a lot more. The money was a great plus, but I got a lot better education because of moonlighting. I think I got more out of my final year because I would have tough cases then go ask senior faculty what they would had done.

Points 1) and 3) are basically the same (new place) and points 2) and 4) are basically the same (on your own).

New place: true, but this can be learned just as well by doing residency at a place that has more than one primary site with different resources and personnel. Being exposed to multiple environments is very useful, but this is why I think that residencies with more than one site have a big plus to them.

On your own: true, you don't really get this until you either moonlight or take your first job. My argument wasn't that branching out on your own isn't going to make you grow as a clinician. Of course it will. I just think the best time to do that is once you are fully baked, training wise, not before. There is a reason we do this training instead of just letting whoever practice in the ER.

Let me frame my argument in a different way. There has been a lot of interest in comparing the healthcare industry to the airline industry to see what lessons we can learn to improve safety and quality. Think of the way pilots are trained, for example. Or really any highly skilled professional in an industry where, to use a cliche, lives are on the line. They are given gradually increased levels of responsibility until they are deemed ready to operate solo under supervision and THEN they are graduated and work on their own. We don't let pilots moonlight before they complete their training. We don't deploy soldier before they finish boot camp and then bring them back to complete their training. Training first, then practice.

 

[deleted547339]

Points 1) and 3) are basically the same (new place) and points 2) and 4) are basically the same (on your own).

New place: true, but this can be learned just as well by doing residency at a place that has more than one primary site with different resources and personnel. Being exposed to multiple environments is very useful, but this is why I think that residencies with more than one site have a big plus to them.

On your own: true, you don't really get this until you either moonlight or take your first job. My argument wasn't that branching out on your own isn't going to make you grow as a clinician. Of course it will. I just think the best time to do that is once you are fully baked, training wise, not before. There is a reason we do this training instead of just letting whoever practice in the ER.

Let me frame my argument in a different way. There has been a lot of interest in comparing the healthcare industry to the airline industry to see what lessons we can learn to improve safety and quality. Think of the way pilots are trained, for example. Or really any highly skilled professional in an industry where, to use a cliche, lives are on the line. They are given gradually increased levels of responsibility until they are deemed ready to operate solo under supervision and THEN they are graduated and work on their own. We don't let pilots moonlight before they complete their training. We don't deploy soldier before they finish boot camp and then bring them back to complete their training. Training first, then practice.

We don't let pilots fly solo half way through training, sure. But wouldn't a 75% trained pilot be better than letting a bus driver continue to fly the plane? Because that's what is happening now in rural EDs.

 

[gro2001]

We don't let pilots fly solo half way through training, sure. But wouldn't a 75% trained pilot be better than letting a bus driver continue to fly the plane? Because that's what is happening now in rural EDs.

I hear you. That may be an argument in favor of the practice (although not one I'd agree with... to paraphrase an attending I know: there is nothing more dangerous in a hospital than a second year resident). But its still not an argument that it's educational. Saving patients in rural America from being seeing by FPs and PAs may be a noble cause, and perhaps all of us should have been farmed out to rural ERs for that purpose in our PGY2 year, but that's a (flawed) argument for patient safety, not for resident education.

 

[Daiphon]

I hear you. That may be an argument in favor of the practice (although not one I'd agree with... to paraphrase an attending I know: there is nothing more dangerous in a hospital than a second year resident). But its still not an argument that it's educational. Saving patients in rural America from being seeing by FPs and PAs may be a noble cause, and perhaps all of us should have been farmed out to rural ERs for that purpose in our PGY2 year, but that's a (flawed) argument for patient safety, not for resident education.

Somewhat agree. Our R2's do most of their heavy critical care months at this time, so when in the ED "no one's sick" - but this is situational biased as when they're coming off a 30 bed ICU where they're the only resident, their frame of reference shifts.

That said, there is something to be said for the educational aspect of being on your own. The finances are nice, true, but they can also screw with your IBR if one starts too soon.

I typically recommend UC moonlighting, as soul crushing as it is, because the money's not bad but not as situationally dangerous IMHO... plus, I agree with the "residency trained only" argument, but an R2 is orders of magnitude better than an APN, so seems to me like a win for UC.

-d

Semper Brunneis Pallium

 

[gro2001]

Somewhat agree. Our R2's do most of their heavy critical care months at this time, so when in the ED "no one's sick" - but this is situational biased as when they're coming off a 30 bed ICU where they're the only resident, their frame of reference shifts.

That said, there is something to be said for the educational aspect of being on your own. The finances are nice, true, but they can also screw with your IBR if one starts too soon.

I typically recommend UC moonlighting, as soul crushing as it is, because the money's not bad but not as situationally dangerous IMHO... plus, I agree with the "residency trained only" argument, but an R2 is orders of magnitude better than an APN, so seems to me like a win for UC.

-d

Semper Brunneis Pallium

Yeah, Urgent Care is fine in my opinion too exactly because it is nothing like moonlighting in an ER. It's almost impossible to outright kill someone there and we as a specialty aren't making the argument that all UCs should be BC/BE staffed.

 

[fahimaz7]

I'm glad I did a hefty amount of moonlighting as a resident. For one, I felt way more prepared to make the leap to my first attending gig. Second, it's the only way that I didn't go 20k in additional debt when I graduated, moved across the country, and had no paycheck for nearly two months. Finally, I really don't think there is that much difference between a pgy3 in his last few months of residency and a new,y minted graduate. On top of that, I felt better prepared for sick patients than he rural ED docs that hadn't incubated a patient in a year or performed any other significant procedures.

You're well trained as a pgy3. Do you know everything? Of course not, but let's be honest... No one does.

 

[gro2001]

I'm glad I did a hefty amount of moonlighting as a resident. For one, I felt way more prepared to make the leap to my first attending gig. Second, it's the only way that I didn't go 20k in additional debt when I graduated, moved across the country, and had no paycheck for nearly two months. Finally, I really don't think there is that much difference between a pgy3 in his last few months of residency and a new,y minted graduate. On top of that, I felt better prepared for sick patients than he rural ED docs that hadn't incubated a patient in a year or performed any other significant procedures.

You're well trained as a pgy3. Do you know everything? Of course not, but let's be honest... No one does.

1) You weren't better prepared for your first attending job. You were better prepared for your second attending job. Your first attending job was your moonlighting gig.

2) The financial argument is solid. But that's the only argument for moonlighting that holds water.

3) Probably nothing wrong with a PGY3 in the last few months of residency moonlighting. Big difference from many people who are drooling over moonlighting as a PGY2 at a 4 year program.

 

[deleted109597]

I've honestly never personally seen a place where the 2s can moonlight externally. My site of training, as well as the two I've worked at since have all required it to be a 3. And yes, there are some bad ones out there, but lets not pretend like moonlighting residents are out causing numerous deaths.
Consider that what we consider moonlighting is what the GME environment in many other countries practice for EM. And it's exactly what ALL OTHER RESIDENCIES do in the hospital. There's no IM attending for those PGY2 seniors admitting and making all the decisions overnight. Sure, they're available by phone, but so are ED attendings when you're moonlighting (unless it's a super ****ty program).
Does it increase your risk? Sure. Does it pay well, usually. Are there bad places to moonlight, absolutely. But there are good ones as well. Each person needs to individualize to their own situation.

 

[gro2001]

I've honestly never personally seen a place where the 2s can moonlight externally. My site of training, as well as the two I've worked at since have all required it to be a 3. And yes, there are some bad ones out there, but lets not pretend like moonlighting residents are out causing numerous deaths.
Consider that what we consider moonlighting is what the GME environment in many other countries practice for EM. And it's exactly what ALL OTHER RESIDENCIES do in the hospital. There's no IM attending for those PGY2 seniors admitting and making all the decisions overnight. Sure, they're available by phone, but so are ED attendings when you're moonlighting (unless it's a super ****ty program).
Does it increase your risk? Sure. Does it pay well, usually. Are there bad places to moonlight, absolutely. But there are good ones as well. Each person needs to individualize to their own situation.

I don't mean to beat a dead horse, but the first point I made about it undermining our own specialty still stands. The issue of 'who can be a hospitalist' is not nearly as important to IM as the issue of 'who can be an EP' to EM. We, as a specialty, have taken the position that to provide great ED care you have to be EM residency trained. It seems that we have finally brought people, though not everyone, not even in medicine, around to that way of thinking. Letting residents moonlight chips away at that. In fact, this was one of the arguments that lead to the initial ABEM application to ABMS for board status to be turned down: ED care was seen as a side gig for moonlighters, not a specialty.

I don't mean that if we continue to let residents moonlight we will somehow lose our status as a specialty, but it certainly doesn't help our argument at FPs after 2 year fellowship or independent PAs should not be staffing ERs. You may see a difference (in favor of the EM resident) between them, but I am sure most people (including most people in other specialties) will not.

Regarding all other specialties doing it: they don't have to convince anyone they are a specialty. We kinda do. ENTs don't have to convince the other docs, the public, the hospitals and the policy makers of the value of ENT training. We do.

 

[gman33]

I could have moonlit, but didn't for several reasons.
I already worked too much. You need some downtime.

The extra shifts would have cut into my education.
It's hard enough to find time to read etc, but if you are working all the time this would never happen.
Now if you aren't going to do this anyway, then I guess you will learn more from working than from playing video games.

As for making decisions on your own, you might have a slight learning advantage by moonlighting.
And by slight I mean you might feel more comfortable in your first couple of weeks.

I think it's pretty much a non issue.
If you want to do some moonlighting great, if you don't or it's not allowed, no big deal.

This might be more of an issue if you train at a 4 year program, but that's a whole other topic.

 

[future_dr_house]

I personally only moonlit my last 6 months of residency. I worked in an FSED at 125/hr. It worked great. I was able to read for residency, learn possible weaknesses and ask attendings on shift about issues that would come up. It adds a whole new level of learning at the end of residency. By third year you know your system so well that many treatment plans are on autopilot. I'm sure I would have been fine without moonlighting but it sure made my transition at my first job out better.

Also, the FSED owner read all of our charts and would bring up important issues regarding charting to a level that most academicians never did because it did not impact their bottom line.

YMMV.


Sent from my iPhone using Tapatalk

 

[deleted109597]

I don't mean to beat a dead horse, but the first point I made about it undermining our own specialty still stands.

No it doesn't. The moonlighting residents aren't preventing other, more qualified people from doing it. If they are, then show me where. They're simply filling a void. Once there is saturation, then certainly we can argue that letting them moonlight is counter to our stated goals. Otherwise, we need to increase residency positions by 400% or so.
Think of it like the FP guys out there doing C sections and endoscopies. Are they as qualified as board certified physicians of those specialties? Probably not. Are those specialists beating down the doors of the family guys out in there in the sticks? No.

OTOH, if we banished it as a specialty, I wouldn't lose a lot of sleep. Well, actually, I probably would, because we would have multitudes of uncovered shifts in my neck of the woods, and I could make tons of money filling them.

 

[gro2001]

No it doesn't. The moonlighting residents aren't preventing other, more qualified people from doing it. If they are, then show me where. They're simply filling a void. Once there is saturation, then certainly we can argue that letting them moonlight is counter to our stated goals. Otherwise, we need to increase residency positions by 400% or so.
Think of it like the FP guys out there doing C sections and endoscopies. Are they as qualified as board certified physicians of those specialties? Probably not. Are those specialists beating down the doors of the family guys out in there in the sticks? No.

OTOH, if we banished it as a specialty, I wouldn't lose a lot of sleep. Well, actually, I probably would, because we would have multitudes of uncovered shifts in my neck of the woods, and I could make tons of money filling them.

What I mean when I say it's undermining our specialty is not that they are preventing more qualified people from filling those shifts. It's that we, as a specialty, seem to be of two minds of what it means to be qualified.

PGY2 EM resident: 2 years is plenty of time to learn enough EM to be a competent EP. You are basically on autopilot. Sure, go moonlight.
FP + 2 year fellowship: Are you crazy? 2 years is definitely not enough time to learn enough EM to be a competent EP!

 

[deleted109597]

PGY2 EM resident: 2 years is plenty of time to learn enough EM to be a competent EP. You are basically on autopilot. Sure, go moonlight.
FP + 2 year fellowship: Are you crazy? 2 years is definitely not enough time to learn enough EM to be a competent EP!

But moonlighting residents aren't arguing they're equivalent to board certified docs. FM fellows are. And moonlighters are relegated to rural, lower census hospitals (or the fasttrack areas of bigger ones), same as the FM fellows. But FM fellows are arguing they should be eligible to work in those shops that only take BC/BE EPs. I know it sounds like sacrilege, but there really are tiers of emergency departments out there. Should there be? That's a different discussion, but ignoring it doesn't make it not a fact.

Of note, the tea steeping model of GME is probably not the best model. Sure, 2 years probably isn't enough, but not everyone needs exactly 3, and some need more. However, we are stuck with the model we've been using for decades.

 

[Tenk]

I'm probably one of the biggest supporters of moonlighting ever but I don't think pgy-2s should be running a rural ED. Urgent care or internal, sure why not. Full ED should be pgy-3 only and at a lot of programs that's how it is.

For anyone who says moonlighting doesn't help your education, I have a question for you: do you work academics and have you worked with a pgy-3 who has been moonlighting versus one who hasn't. I'm going to go out on a limb here and say you have not. It is basically night and day. It's not even close. The gap is huge and noticeable within a couple months. As one of my attendings told me in residency: "I can always tell when you guys start moonlighting, everyone suddenly gets a hell of a lot sicker."

After what I have seen by most FP docs in rural EDs I can truthfully say if my mother needed emergent care and I had to choose between a PGY-3 EM resident or a FP attending, I would pick the EM resident. What would you choose? I don't think residents moonlighting undermines the specialty, hell I think it proves how badass we are as a specialty. We should not be better at our job during residency than someone who has been working EDs for 20 years. But for a lot of rural EDs, that is the sad truth.

 

[sum dude]

I think every resident should moonlight after 2.5 years of residency (with PD's being in charge of who is allowed to moonlight). There is no reason a REsident should not moonlight the last 2 months of their Residency. I went to a great residency in NC, but my experience was made exponentially better by moonlighting. I moonlit at a tiny, garbage county hospital, and that's where I really learned to be an emergency physician. By the time I started my first attending job, I didn't skip a beat due to my experience moonlighting

You don't know what you don't know, till you do it on your own. The reason so many people quit their first jobs in ED is b/c they don't have eyes open on just how hard and stressful it can be on the outside. Believe it or not, Residency, no matter how good, cannot replicate the lack of safety net you have once you become an attending. Also, most hospitals don't have every specialty at your beckon call, as residencies do. I worked at a dinky county hospital where I saw some of the sickest patients who walked in. I had a surgeon and a hospitalist. No ICU. No anesthesia, no Cards. No ortho. I had to transfer every patient requiring cards/ICU/specialist. If you can make it there, you can make it any where.

I can tell you hiring in hiring Residents in a community hospital, moonlighting trumps anything else as a positive. You were published in NEJM--good for you. Fellowship--great! You went to House of God Residency--cool! Now can you run an ER with 12 beds filled, 6 more in the waiting room while trying to transfer an intubated patient? That's the doctor you want working at your group (obviously academics is another beast, but most residents don't go on to work academics). Outside of liability or lifestyle, there is no reason why a resident in their last 2 months cannot moonlight (and the liability will be there the second you get out, so best to learn to live with it).

As for screwing our specialty--the other doctors at that county hospital were FP's or moonlighting from other specialties. There are more jobs than EP's in this country (who here doesn't get 5 job offers emailed daily as spam?) Some were solid but many were complete duds. As above, I would rather have a 2.5 EM resident caring for my family than a FP on his 5th different job moonlighting at a hospital he's been to twice. If a program doesn't let you moonlight, they are doing you a disservice. Plus, the $ doesn't hurt either.

 

[gro2001]

I think every resident should moonlight after 2.5 years of residency (with PD's being in charge of who is allowed to moonlight). There is no reason a REsident should not moonlight the last 2 months of their Residency. I went to a great residency in NC, but my experience was made exponentially better by moonlighting. I moonlit at a tiny, garbage county hospital, and that's where I really learned to be an emergency physician. By the time I started my first attending job, I didn't skip a beat due to my experience moonlighting

You don't know what you don't know, till you do it on your own. The reason so many people quit their first jobs in ED is b/c they don't have eyes open on just how hard and stressful it can be on the outside. Believe it or not, Residency, no matter how good, cannot replicate the lack of safety net you have once you become an attending. Also, most hospitals don't have every specialty at your beckon call, as residencies do. I worked at a dinky county hospital where I saw some of the sickest patients who walked in. I had a surgeon and a hospitalist. No ICU. No anesthesia, no Cards. No ortho. I had to transfer every patient requiring cards/ICU/specialist. If you can make it there, you can make it any where.

I can tell you hiring in hiring Residents in a community hospital, moonlighting trumps anything else as a positive. You were published in NEJM--good for you. Fellowship--great! You went to House of God Residency--cool! Now can you run an ER with 12 beds filled, 6 more in the waiting room while trying to transfer an intubated patient? That's the doctor you want working at your group (obviously academics is another beast, but most residents don't go on to work academics). Outside of liability or lifestyle, there is no reason why a resident in their last 2 months cannot moonlight (and the liability will be there the second you get out, so best to learn to live with it).

As for screwing our specialty--the other doctors at that county hospital were FP's or moonlighting from other specialties. There are more jobs than EP's in this country (who here doesn't get 5 job offers emailed daily as spam?) Some were solid but many were complete duds. As above, I would rather have a 2.5 EM resident caring for my family than a FP on his 5th different job moonlighting at a hospital he's been to twice. If a program doesn't let you moonlight, they are doing you a disservice. Plus, the $ doesn't hurt either.

I understand the importance of being on your own. What I don't understand is why it is so much better to do it 2 month before you finish residency as opposed to right after. It's still a shock, it's still a big learning leap. If moonlighting in the last few months of residency is enough to get you to be the 'doc you want working at your group', then you should be able to get to that level after the first few months of your first job.

 

[swamprat]

PGY3 here. It blows my mind we have 4 year programs.. very happy I am not at one. I think the length of residency is arbitrary. Maybe I am talking out my ass as an overconfident PGY3 but if they took the training wheels off right now I'd be fine. I know enough to practice safe. I think I'll learn a ton when I'm an attending, no doubt. I will also learn a ton the rest of this year. With that being said.. its arbitrary. 3 years? so what? There is no evidence that says you must train for so many years in order to practice Y or you won't know what you are doing or practice safely. I'll continue the grind the rest of the year, learn a ton, be more prepared to practice in 10 months, but I still think it is possible to practice EM independently in 2 years of residency if you are good and dedicated to learning the field. Obviously there will be stragglers, and those not ready to practice in 3. But they will graduate regardless and they will go practice. We as a specialty should stop training mid levels to do our jobs (i.e. EM PA "fellowships", solo rural PA coverage) rather than argue about what trained, fully licensed physicians undergoing EM training should be allowed to do with their free time. Just my .02. Hate to see this field go the way of anaesthesia with the crnas, what a joke.

 

[gro2001]

PGY3 here. It blows my mind we have 4 year programs.. very happy I am not at one. I think the length of residency is arbitrary. Maybe I am talking out my ass as an overconfident PGY3 but if they took the training wheels off right now I'd be fine. I know enough to practice safe. I think I'll learn a ton when I'm an attending, no doubt. I will also learn a ton the rest of this year. With that being said.. its arbitrary. 3 years? so what? There is no evidence that says you must train for so many years in order to practice Y or you won't know what you are doing or practice safely. I'll continue the grind the rest of the year, learn a ton, be more prepared to practice in 10 months, but I still think it is possible to practice EM independently in 2 years of residency if you are good and dedicated to learning the field. Obviously there will be stragglers, and those not ready to practice in 3. But they will graduate regardless and they will go practice. We as a specialty should stop training mid levels to do our jobs (i.e. EM PA "fellowships", solo rural PA coverage) rather than argue about what trained, fully licensed physicians undergoing EM training should be allowed to do with their free time. Just my .02. Hate to see this field go the way of anaesthesia with the crnas, what a joke.

But your argument is part of the problem though. If 2 years is enough time to train for EM, why can't those 2 years be the FM fellowship? To be clear, I don't think FM+2 year fellowship provides sufficient training for high quality ED care, but if you are convinced 2 years of residency is enough to be out on your own, then 3 years of residency and 2 years of EM fellowship should definitely be enough. Basically if you are good enough as is, imagine how much better you would be if you also had 3 years of FM training behind you. This is the argument the FM fellowship folks are making. We would have a much more united front and a more solid argument against midlevel and FP encroachment if we as a specialty agreed that overconfident PGY2s aren't ready to staff EDs by themselves.

 

[deleted547339]

But your argument is part of the problem though. If 2 years is enough time to train for EM, why can't those 2 years be the FM fellowship? To be clear, I don't think FM+2 year fellowship provides sufficient training for high quality ED care, but if you are convinced 2 years of residency is enough to be out on your own, then 3 years of residency and 2 years of EM fellowship should definitely be enough. Basically if you are good enough as is, imagine how much better you would be if you also had 3 years of FM training behind you. This is the argument the FM fellowship folks are making. We would have a much more united front and a more solid argument against midlevel and FP encroachment if we as a specialty agreed that overconfident PGY2s aren't ready to staff EDs by themselves.

We get it. You're against moonlighting. Thanks for derailing the thread....

 

[swamprat]

But your argument is part of the problem though. If 2 years is enough time to train for EM, why can't those 2 years be the FM fellowship? To be clear, I don't think FM+2 year fellowship provides sufficient training for high quality ED care, but if you are convinced 2 years of residency is enough to be out on your own, then 3 years of residency and 2 years of EM fellowship should definitely be enough. Basically if you are good enough as is, imagine how much better you would be if you also had 3 years of FM training behind you. This is the argument the FM fellowship folks are making. We would have a much more united front and a more solid argument against midlevel and FP encroachment if we as a specialty agreed that overconfident PGY2s aren't ready to staff EDs by themselves.

Yeah that is true. However how intense is the FM EM fellowship? If it's like most fellowships outside of IM they probably aren't seeing enough patients and acuity to be as good as us. At the same time, maybe we should be piloting these programs so we could make it up to our standards. There are combined 5 year FM/EM residencies right now that lead to board certification in both fields. On the other point.. There is no reason to be training our replacements with non-physician providers. We should end all pa fellowships they are PAs and should assist us with **** we don't want to do like lacs and low acuity patients. I'd rather have a non-EM trained family doc rural coverage than a PA. We need to stop watering down the quality of care bad providers of our field with all these short cuts.


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[Makati2008]

Yeah that is true. However how intense is the FM EM fellowship? If it's like most fellowships outside of IM they probably aren't seeing enough patients and acuity to be as good as us. At the same time, maybe we should be piloting these programs so we could make it up to our standards. There are combined 5 year FM/EM residencies right now that lead to board certification in both fields. On the other point.. There is no reason to be training our replacements with non-physician providers. We should end all pa fellowships they are PAs and should assist us with **** we don't want to do like lacs and low acuity patients. I'd rather have a non-EM trained family doc rural coverage than a PA. We need to stop watering down the quality of care bad providers of our field with all these short cuts.


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Honestly I just want the best person taking care of the rural communities patients although I personally prefer a well trained PA vs a poorly trained FP (I am biased due to my previous background).

Limiting a PA to lacs and sore throats is a bit drastic and won't ever happen extensively. Also thinking you won't work with midlevels is becoming harder by the day....


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[deleted109597]

I understand the importance of being on your own. What I don't understand is why it is so much better to do it 2 month before you finish residency as opposed to right after. It's still a shock, it's still a big learning leap. If moonlighting in the last few months of residency is enough to get you to be the 'doc you want working at your group', then you should be able to get to that level after the first few months of your first job.

Because you're calling the mothership for transfers. People you know and have worked with, instead of at a new place, with new procedures. It's like attending training wheels.

 

[DetectiveAlonzo]

I personally only moonlit my last 6 months of residency. I worked in an FSED at 125/hr. It worked great. I was able to read for residency, learn possible weaknesses and ask attendings on shift about issues that would come up. It adds a whole new level of learning at the end of residency. By third year you know your system so well that many treatment plans are on autopilot. I'm sure I would have been fine without moonlighting but it sure made my transition at my first job out better.

Also, the FSED owner read all of our charts and would bring up important issues regarding charting to a level that most academicians never did because it did not impact their bottom line.

YMMV.


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Quick question. What state was this in? Also, were most of these FSED owners physicians as well and did they do an active work with consults and patients themselves? Appreciate it.

 

[HooliganSnail]

I am probably the poster child for being against moonlighting.

You go as a less than adequate late 2nd year and practice in IMO the hardest setting (rural ****ty critical access hospitals). You work 18-20 days a month normally, and not including conferences and other stuff. It is pretty much being an attending too soon, while you were already overworked. Why not wait until you are an actual attending and well-trained before you go out in the world? I never saw the appeal been working 22 shifts a month

Money bro. it's just about the money