Moonlighting outside of anesthesia

[minwoo]

As a CA-1+ with a valid medical license, is it at all possible to do some moonlighting in the ER or an Urgent Care center? I know many will find this incredulous as most go into anesthesia to avoid having to deal with this type of work, but my goal has always been medical missions along with being a physician of versatility that can treat as wide a range of patients as possible. While there are many opportunities in anesthesia for this, it would also be nice to retain some of the more "basic" skills of draining an abscess, suturing up a laceration, treating common bacterial/viral infxns, etc..

Btw, I'm a 4th year student towards the end of the interview season and am totally psyched to have been able to interview at some amazing programs!!

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[Noyac]

Good idea. Good luck.

 

[deleted171991]

As a CA-1+ with a valid medical license, is it at all possible to do some moonlighting in the ER or an Urgent Care center? I know many will find this incredulous as most go into anesthesia to avoid having to deal with this type of work, but my goal has always been medical missions along with being a physician of versatility that can treat as wide a range of patients as possible. While there are many opportunities in anesthesia for this, it would also be nice to retain some of the more "basic" skills of draining an abscess, suturing up a laceration, treating common bacterial/viral infxns, etc..

Btw, I'm a 4th year student towards the end of the interview season and am totally psyched to have been able to interview at some amazing programs!!

I hope you realize that working as an attending, especially in an urgent/emergent care setting, brings all kinds of malpractice risks. I would tread VERY carefully, if I were you. After one year of internship, you will have very little practical experience. You need to miss just one diagnosis and your career might become history, including your anesthesia residency.

 

[Morzh]

I have wondered the same. Not sure about covering the ED, but maybe a low acute urgent care place in a semi-rural area. Maybe not as a resident, but perhaps once or twice a month as an attending.

I love so much about anesthesiology and at this point (ms3) am almost certainly going into it, despite all the doom and gloom I read here. The only competitor is EM, for precisely the reasons stated. I want to be able serve family/friends from time-to-time with simple "doctoring" skills like minor lac repairs, looking at the neighbor kid's ears/throat, going on high-adventure camping trips with the boy scouts as the medical guy, medical mission trips, etc.

In the hospital, as a career, I want the be a physician anesthesiologist. Outside the hospital, though, I still value being able to be just "a doc".

 

[minwoo]

I hope you realize that working as an attending, especially in an urgent/emergent care setting, brings all kinds of malpractice risks. I would tread VERY carefully, if I were you. After one year of internship, you will have very little practical experience. You need to miss just one diagnosis and your career might become history, including your anesthesia residency.

Good advice, much appreciated~

Would still like to know if this is possible and if anyone here has attempted this?

 

[minwoo]

I want to be able serve family/friends from time-to-time with simple "doctoring" skills like minor lac repairs, looking at the neighbor kid's ears/throats, going on high-adventure camping trips with the boy scouts as the medical guy, medical mission trips, etc.

In the hospital, as a career, I want the be a physician anesthesiologist. Outside the hospital, though, I still value being able to be just "a doc".

THIS. Couldn't have said it better myself, thank you~

 

[deleted171991]

Where I trained, it was impossible to moonlight outside anesthesia. There are definitely places where you can, but my advice is to try and stay either within anesthesia (as a trainee doing paid weekend calls etc.) or within your competence level (as an attending doing medical H&P for psych etc.). A low acute urgent care place where you can run stuff by more senior docs can also qualify.

 

[deleted171991]

Outside the hospital, though, I still value being able to be just "a doc".

I hope you realize that you shouldn't treat your family at all, and your friends only at your place of work, just like any other patient. There are ethical and legal regulations about these.

 

[ZzzPlz]

It's relatively common to moonlight in the Midwest. Most places I interviewed at had residents who did it.

I know that it can be done and the residents that do it can make BANK over a weekend. At least it is until we finish residency.

 

[Morzh]

I hope you realize that you shouldn't treat your family at all, and your friends only at your place of work, just like any other patient. There are ethical and legal codes regulating these.

Yes, of course. I'm not talking about actually treating chronic diseases or anything major, or even prescribing a short-course abx (although there are many who do this). And officially what you said is always the right answer, I know. Just little things, for select people, and done with caution and wisdom. Like my sister calling to ask if I could swing by to look at her kid who has had a sore throat/runny nose for a few days, and wanting to know if I think he needs to visit his pediatrician or can just wait it out with Tylenol. Or the next-door neighbor kid with a minor knee lac whose parents would be eternally grateful if I could save them an ER visit by injecting a little lido, cleaning it out, and throwing 3 simple sutures in. Of course a mission trip or something would be more involved but would also be more official with paperwork/insurance.

I just think it's sad if you spend 8+ years in school and training to be a doctor and can't even do little things like that from time-to-time.


Edit: lol at the Christmas Eve Fools' gimmick where "it i--s" is auto-changed to 'tis

 

[deleted171991]

I just think Tis sad if you spend 8+ years in school and training to be a doctor and can't even do little things like that from time-to-time.

I completely understand. Where I trained abroad, it was unimaginable to not be able to care for your friends and family at home, without any paper trail. It was considered extremely rude to invite them to get an appointment with you.

Here I can't even ask a friend to renew my chronic medication, not to speak about self-prescribing. I have to go see a "doctor".

 

[Random Anesthesiologist]

I hope you realize that you shouldn't treat your family at all, and your friends only at your place of work, just like any other patient. There are ethical and legal regulations about these.

Some can do it ethically, like the family physician who returns to their small hometown to practice and may be related to half the population in some way.

And let's be real, it's not entirely unethical or illegal to give your kid antibiotics for strep throat.

It's about judgment. And most of us use it wisely.

 

[deleted171991]

And let's be real, Tis not entirely unethical or illegal to give your kid antibiotics for strep throat.

AFAIK, it is actually illegal in certain states without a medical record, and a bona fide patient-practitioner relationship.

http://www.pharmacistsletter.com/pl/detaildocuments/250412-1422.pdf

 

[Random Anesthesiologist]

AFAIK, Tis actually illegal in certain states.

I'm curious... Which ones? I'm not talking about scheduled drugs, of course.

 

[deleted171991]

I'm curious... Which ones? I'm not talking about scheduled drugs, of course.

See the pdf I just added to the post.

 

[Random Anesthesiologist]

See the pdf I just added to the post.

As I suspected, controlled substances are the ones not kosher.

 

[deleted171991]

As I suspected, controlled substances are the ones not kosher.

Not always. See South Carolina or Virginia. Also see Illinois, Indiana, Minnesota, Mississippi, Missouri, Montana, New York, North Carolina, Oregon, Wyoming and probably others.

Let me just say that I have been refused benign non-controlled substances because the prescription was from a family member.

 

[B-Bone]

Where I did residency, the main medical institution had a number of smaller satellite hospitals where residents from various specialties moonlighted in the EDs and urgent cares. The main institution puts residents who wish to moonlight through a formal preparation program that reviews various EM/urgent care topics. Some of these EDs have no permanent staff and depend on moonlighting residents 100% to cover. They also provided malpractice insurance for the residents. I never did this, but most of my anesthesia colleagues did, as well as most EM and FM residents. Some IM, surgery, and other specialty residents (even rads and path!) also did this. A few people who moonlighted often made upwards of $100,000/year above their resident's salary. The usual rates were around $100/hour, but frequently also included shift bonuses of upto $1000-1500 per 12 hour shift in addition to the hourly wage, if the shift was at an undesirable time (usually weekends). There were some residents who would pay another resident to take their calls (for like $500) then moonlight during that time and pull in like $2500. PDs put a stop to this when they found out, but it was a gravy train for some for a while.

 

[deleted547339]

So hey, I'm EM. You think I could moonlight in anesthesia? I mean, not the big, cardiac cases, but little hospitals doing appys and hernias? That'd be cool, right?

 

[IlDestriero]

Do you think your malpractice insurance that covers your anesthetic practice will pay out when the neighbors kid's strep throat becomes an abscess and he ends up in the PICU after emergency surgery? How about when he gets a septic knee from his little cut that you put some lido and a couple stitches in? How about that bump that you didn't notice and didn't get followed up on that was actually a sarcoma?
You think the families will still thank you for playing doctor in their kitchen, or sue you for not meeting accepted standards of care, like keeping records, following up, having documented proper training, etc.

 

[G0S2]

I moonlighted at an LTAC for 2.5 yrs during residency. Great experience. Burned the midnight oil.

 

[deleted171991]

Do you think your malpractice insurance that covers your anesthetic practice will pay out when the neighbors kid's strep throat becomes an abscess and he ends up in the PICU after emergency surgery? How about when he gets a septic knee from his little cut that you put some lido and a couple stitches in? How about that bump that you didn't notice and didn't get followed up on that was actually a sarcoma?
You think the families will still thank you for playing doctor in their kitchen, or sue you for not meeting accepted standards of care, like keeping records, following up, having documented proper training, etc.

It's still nanny-state that I cannot self-prescribe non-controlled substances for personal use with self-pay. It's like not letting an auto mechanic repair his own car.

 

[criticalelement]

, I want t0 be a physician anesthesiologist. ".

these terms are redundant. That is like saying I want to be a Physician Surgeon. Sounds ridiculous right? Thats because it is.

 

[deleted171991]

these terms are redundant. That is like saying I want to be a Physician Surgeon. Sounds ridiculous right? Thats because Tis.

You're probably right, but this is the new designation the ASA is using to separate us from nurse anesthetists. Which is dumb, because "anesthetist" implies a physician everywhere outside of the US, hence the correct designations should have been "physician anesthetist" or "anesthesiologist".

 

[Morzh]

Do you think your malpractice insurance that covers your anesthetic practice will pay out when the neighbors kid's strep throat becomes an abscess and he ends up in the PICU after emergency surgery? How about when he gets a septic knee from his little cut that you put some lido and a couple stitches in? How about that bump that you didn't notice and didn't get followed up on that was actually a sarcoma?
You think the families will still thank you for playing doctor in their kitchen, or sue you for not meeting accepted standards of care, like keeping records, following up, having documented proper training, etc.

I'm not talking about opening a hack-shop in my kitchen. Ridiculous. I appreciate your extreme examples, and no I don't think my malpractice will cover if such things were to happen, and I fully understood all that before today and don't need the preachy lecture. It's condescending to assume we wouldn't properly follow-up (or give instructions to do so with their PCP once their office opens), document stuff, or otherwise fail to follow standard of care. I'm not reckless.

I guess it's just sad that we live in a world where a medical degree and a board certification (in what doesn't even matter) isn't enough "proper training" to do a few basic bread-and-butter that I'd hoped would transcend any specific specialty.

 

[Morzh]

these terms are redundant. That is like saying I want to be a Physician Surgeon. Sounds ridiculous right? Thats because Tis.

agreed. I guess all the ASA vernacular I read around here has been rubbing off subconsciously.

 

[Morzh]

So hey, I'm EM. You think I could moonlight in anesthesia? I mean, not the big, cardiac cases, but little hospitals doing appys and hernias? That'd be cool, right?

I don't think anyone but BC EPs and their supervised midlevels should be staffing EDs in the 21st century. An urgent care place where you're helping out with fast-track stuff and have someone to defer to if need be is a different scenario. Any licensed physician ought to be qualified there. Or is an actual medical license obsolete and old-fashioned?

 

[B-Bone]

So hey, I'm EM. You think I could moonlight in anesthesia? I mean, not the big, cardiac cases, but little hospitals doing appys and hernias? That'd be cool, right?

A few thoughts about this:
-It's all about supply and demand. Your medical license allows you to do this; there's just nobody willing to pay you to do it. If there were, you could legally do this.
-No disrepect to the specialty of EM. They are the best at this. But it is a general "specialty". It's scope is very broad, and most people are exposed to a large swath of the territory in medical school and internship. Compare that to how much exposure the average PGY-2 (across all specialties) has to anesthesiology. It's virtually zero for everyone outside anesthesia. ER residents may spend a month or so on an anesthesia rotation, but they are generally doing procedures rather than replacing an anesthesia resident doing cases on their own. On the other hand, almost every specialty has to spend some time in the ED working directly alongside EM residents, doing the same job (though probably not as well).
-In many small EDs/UCs (including the ones I referenced above), they will literally go unstaffed without moonlighting residents. There is no long line of BC EM physicians waiting to cover these shifts. There's not even a line of FM or IM docs waiting in the wings. Without moonlighting residents, there is no ED or UC for many many miles in any direction. It's the boonies. This is the "something is better than nothing" argument.
-If you take the "something is better than nothing" argument to the extremes and look at third world countries/mission work, you probably could do anesthesia/surgery/whatever if you want to. Have at it!

 

[deleted547339]

I understand your argument, but you're wrong. There are some surgical subspecialties that moonlight in small ERs around where I do training. They all say how easy it is, but they are grossly mismanaging patients - I routinely see it in patients transferred in. EM is a specialty, yes it is a broad specialty, but a specialty nonetheless.

We see septic neonates, women in labor, multisystem trauma, etc. If you're working in an ER, you are expected to be able to manage these things. Also, low acuity doesn't really mean low acuity, it means low backup and undertrained RNs, RTs, etc. I get that anesthesia is probably competent to work up most clear surgical issues, septic patients, you're procedurally competent, you have more airway experience than we do, etc. But how many febrile infants have you seen? Do you know the intricacies of evaluating chest pain? What about the 80 year old that is weak and dizzy? Are you comfortable with diagnosing the two subsets of Brugada on an EKG or do you know to always look for an epsilon wave in syncope? Can you manage an acute, severe TCA overdose?

I concede that an UC is different because you aren't constrained by EMTALA.

The fact of the matter is that I have a ton of respect for anesthesiologist. That's why I follow this forum, because I learn a ton from you guys. Saying you think you could competently do an EPs job is entirely disrespectful to the field of EM. I'm not trying to be militant, it's just a fact.

A few thoughts about this:
-It's all about supply and demand. Your medical license allows you to do this; there's just nobody willing to pay you to do it. If there were, you could legally do this.
-No disrepect to the specialty of EM. They are the best at this. But it is a general "specialty". It's scope is very broad, and most people are exposed to a large swath of the territory in medical school and internship. Compare that to how much exposure the average PGY-2 (across all specialties) has to anesthesiology. It's virtually zero for everyone outside anesthesia. ER residents may spend a month or so on an anesthesia rotation, but they are generally doing procedures rather than replacing an anesthesia resident doing cases on their own. On the other hand, almost every specialty has to spend some time in the ED working directly alongside EM residents, doing the same job (though probably not as well).
-In many small EDs/UCs (including the ones I referenced above), they will literally go unstaffed without moonlighting residents. There is no long line of BC EM physicians waiting to cover these shifts. There's not even a line of FM or IM docs waiting in the wings. Without moonlighting residents, there is no ED or UC for many many miles in any direction. It's the boonies. This is the "something is better than nothing" argument.
-If you take the "something is better than nothing" argument to the extremes and look at third world countries/mission work, you probably could do anesthesia/surgery/whatever if you want to. Have at it!

 

[B-Bone]

I understand your argument, but you're wrong. There are some surgical subspecialties that moonlight in small ERs around where I do training. They all say how easy it is, but they are grossly mismanaging patients - I routinely see it in patients transferred in. EM is a specialty, yes it is a broad specialty, but a specialty nonetheless.

We see septic neonates, women in labor, multisystem trauma, etc. If you're working in an ER, you are expected to be able to manage these things. Also, low acuity doesn't really mean low acuity, it means low backup and undertrained RNs, RTs, etc. I get that anesthesia is probably competent to work up most clear surgical issues, septic patients, you're procedurally competent, you have more airway experience than we do, etc. But how many febrile infants have you seen? Do you know the intricacies of evaluating chest pain? What about the 80 year old that is weak and dizzy? Are you comfortable with diagnosing the two subsets of Brugada on an EKG or do you know to always look for an epsilon wave in syncope? Can you manage an acute, severe TCA overdose?

I concede that an UC is different because you aren't constrained by EMTALA.

The fact of the matter is that I have a ton of respect for anesthesiologist. That's why I follow this forum, because I learn a ton from you guys. Saying you think you could competently do an EPs job is entirely disrespectful to the field of EM. I'm not trying to be militant, it's just a fact.

Nobody's claiming they're doing it better than EPs. I was merely pointing out that non-EPs moonlighting in an ED is a thing, whereas non-anesthesiologists (or radiologists, or ophthalmologists, or ENTs, or whatever) moonlighting in these specialties is not a thing. Without these non-EPs covering these EDs, these EDs would not exist. You can get as offended as you like about how much of an outrage this is and how many different subsets of Brugada's are getting missed, but the fact remains that somebody needs to cover these hospitals, and ED docs aren't doing it. It's similar to the way solo CRNAs cover small rural hospitals without anesthesiologists. I can get pissed off and rage against the machine that allows this, but I still have to acknowledge that the situation exists.

Of note, I never did this as a resident because I didn't want any part of it (and I didn't need the money). But I could definitely go sign up to cover shifts in these same EDs today. Incidentally, I don't agree that EPs have a monopoly on any of the things you reference. By definition, EPs are generalists with a broad but understandably shallow wheelhouse. For everything an EP sees and does, there is a specialist who knows more and does it better. That's not a knock, just a fact. Again, definitel best people to be working in the ED, but not necesssarily the best at taking care of any individual patient/condition.

 

[Random Anesthesiologist]

Not always. See South Carolina or Virginia. Also see Illinois, Indiana, Minnesota, Mississippi, Missouri, Montana, New York, North Carolina, Oregon, Wyoming and probably others.

Let me just say that I have been refused benign non-controlled substances because the prescription was from a family member.

I know IL very well.

 

[deleted547339]

Nobody's claiming they're doing it better than EPs. I was merely pointing out that non-EPs moonlighting in an ED is a thing, whereas non-anesthesiologists (or radiologists, or ophthalmologists, or ENTs, or whatever) moonlighting in these specialties is not a thing. Without these non-EPs covering these EDs, these EDs would not exist. You can get as offended as you like about how much of an outrage this is and how many different subsets of Brugada's are getting missed, but the fact remains that somebody needs to cover these hospitals, and ED docs aren't doing it. It's similar to the way solo CRNAs cover small rural hospitals without anesthesiologists. I can get pissed off and rage against the machine that allows this, but I still have to acknowledge that the situation exists.

Of note, I never did this as a resident because I didn't want any part of it (and I didn't need the money). But I could definitely go sign up to cover shifts in these same EDs today. Incidentally, I don't agree that EPs have a monopoly on any of the things you reference. By definition, EPs are generalists with a broad but understandably shallow wheelhouse. For everything an EP sees and does, there is a specialist who knows more and does it better. That's not a knock, just a fact. Again, definitel best people to be working in the ED, but not necesssarily the best at taking care of any individual patient/condition.

I disagree. This is not said in arrogance, simply what I've observed. I've had good medicine residents and surgery residents fail to recognize things that are overtly obvious to folks in the ED. We see acute illnesses that only end up in the ED.

 

[afteranesthesia]

It is completely against what my license allows to treat patients outside those I treat as a resident working at my institution. This is spelled out very clearly in my state medical board. Family and friends even for full licensed people is also considered unethical and not appropriate per our state license. Basically anyone you do not have a proper physician/patient relationship with. I will adhere to this and frankly prefer to. I don't want to treat outside my specialty to friends and family. It's not objective and there are liabilities there. What if my zofran masks sepsis and serious illness in their child? And I can't know bc I'm not a pedi and a family member asked for a call in script from me at 2am? No thanks. And since no one in my family will receive anesthesia at home, I think I'm safe there. I plan to adhere to medical board guidelines also bc my license is very precious to me.

 

[scudrunner]

Moonlighting outside of anesthesia is the only possibility with my program. Residents will go to neighboring community hospitals and work as the night floor call doc or as part of the code team and do airways and lines. Pays pretty good too.

 

[scudrunner]

You need to miss just one diagnosis and your career might become history, including your anesthesia residency.

A little melodramatic, IMHO. Primary care docs miss diagnoses every day, that's a fact. MOST of them do not end in lawsuits, and hardly ever end a career.

 

[deleted171991]

A little melodramatic, IMHO. Primary care docs miss diagnoses every day, that's a fact. MOST of them do not end in lawsuits, and hardly ever end a career.

Maybe they miss diagnoses "every day", but their mistakes are definitely not at PGY-2 level.