moonlighting

[fergustsi]

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any tips on how to go about finding a place to moonlight?

id rather not do the whole urgent care route.
Ive contacted some larger groups and they sent me lists of hospitals that will take resident moonlighters. None of the prospects are terribly appealing.

Any other thoughts on finding a place?

I have been told by some faculty they have some sleep for dollars connections at surgical centers, anyone done these, thoughts?

Anyone have any insight on internal moonlighting? is it allowed? is it awkward? ive seen some programs offer it to their residents and others have said by cms rules it is not allowed because youd be "double dipping" as medicaid already pays you to be a resident and now youre billing as a independent physician? thoughts?

 

[EMquest3]

any tips on how to go about finding a place to moonlight?

id rather not do the whole urgent care route.
Ive contacted some larger groups and they sent me lists of hospitals that will take resident moonlighters. None of the prospects are terribly appealing.

Any other thoughts on finding a place?

I have been told by some faculty they have some sleep for dollars connections at surgical centers, anyone done these, thoughts?

Anyone have any insight on internal moonlighting? is it allowed? is it awkward? ive seen some programs offer it to their residents and others have said by cms rules it is not allowed because youd be "double dipping" as medicaid already pays you to be a resident and now youre billing as a independent physician? thoughts?

I thought internal moonlighting was very common. I could have sworn a few places I interviewed said that they only allowed their residents to moonlight internally. Maybe I misunderstood something.

 

[dotcb]

I did urgent care. Pay was OK. It was busy but easy and close. Learned a fair bit about customer service. Others in my program did rural EM. Paid more, more challenging, but a few hours drive. Just look around, cold call, and send out CV's. The point of moonlighting is a bit of extra money and some extra experience as a bonus. You are not looking for your ideal job.

 

[UnderwaterDoc]

We are not allowed to do internal moonlighting, for the same reason stated above, I actually do not know about any programs that allow this although it could just be due to my geographic location (northeast).

It would be awesome to work a few 12s at our fast track for a buck fifty an hour, with our faculty a short hallway away should you need backup. There are plenty of places around that take residents though, you don't have to look hard.

 

[Arcan57]

We are not allowed to do internal moonlighting, for the same reason stated above, I actually do not know about any programs that allow this although it could just be due to my geographic location (northeast).

It would be awesome to work a few 12s at our fast track for a buck fifty an hour, with our faculty a short hallway away should you need backup. There are plenty of places around that take residents though, you don't have to look hard.

I would be shocked if you could make $150/hr moonlighting internally in your fast track. Internal moonlighting involves less risk and less travel then external, and thus usually pays significantly below market rates.

 

[ORL10]

Christ Residents moonlight internally about $700/shift (every night from 9p-6am).

I moonlight outside in a busy community hospital because the pay is better ($150/hr), it is a much farther drive and I work significantly harder.

 

[DreamingTheLive]

We are not allowed to do internal moonlighting, for the same reason stated above, I actually do not know about any programs that allow this although it could just be due to my geographic location (northeast).

It would be awesome to work a few 12s at our fast track for a buck fifty an hour, with our faculty a short hallway away should you need backup. There are plenty of places around that take residents though, you don't have to look hard.

Wow. I felt like at least 2/3 of the programs I saw offered/allowed some type of moonlighting. I wasn't really too interested in the Northeast though...quite the opposite.

 

[eastcoastEM]

Internal moonlighting at the fast track was common in several of the places I interviewed in the southeast. Pay seemed to vary between 60 and 100 an hour. Didn't see any places that let you moonlight in the same department/area that you do your required shifts.

 

[Hercules]

Best resource is to talk to the residents ahead of you. When I was at UAB the outgoing residents have out a word file with the hospitals, volume, approximate rate, and key facts you might want to know (like one of the rural EDs tried to get one of our residents to cover L&D while on shift-- no one ever went there again)

 

[deleted109597]

Wow. I felt like at least 2/3 of the programs I saw offered/allowed some type of moonlighting. I wasn't really too interested in the Northeast though...quite the opposite.

It's probably more common in the areas that have more people working.
Here in the rural South, I don't know of many places that DO have internal moonlighting, but could drive an hour in almost any direction and hit a hospital that does external moonlighting. Even for attendings.

 

[bartleby]

Moonlighting in the ED which is your primary clinical site is indeed problematic according to some programs' interpretation of CMS rules. There is also the issue of some residents getting paid to work along side their compadres who are doing "time served".

Internal moonlighting in ICUs can be a great deal....reasonable pay, malpractice coverage provided by the hospital and work under a supervising attending.

External moonlighting can be helpful in some circumstances in regard to finding out what sort of practice environment would be good for when you graduate or even sort of auditioning with an ED you might choose to work in post graduation.

However, working solo in a single coverage ED as a resident is unsafe and should be avoided. Even when licensed, you are still a resident in training. The mere thought of $100/hr + will make any cash-starved loan-riddled resident swoon, but if you get caught up in a case with a bad outcome and are embroiled in a lawsuit, you will be more than happy to pay the money you earned moonlighting back double or even triple. If you are a moonlighting non board-eligible, non board-certified resident, you will get filleted by the plaintiff's attorney and could be in the unenviable position of looking for a job with a pending case, settlement or even malpractice loss on the book before your career even starts. There are some EDs where you can work as second or even third coverage where you have an attending to bounce things off of or even help you out if you need a hand. There is still risk to this, but it is far preferable to flying completely solo as a resident.

 

[Renaissance Man]

Who is covering a moonlighting resident's butt in the case of malpractice? The residency program?

 

[Mongo32]

Wow. I felt like at least 2/3 of the programs I saw offered/allowed some type of moonlighting. I wasn't really too interested in the Northeast though...quite the opposite.

For the most part, I interviewed Virginia on up on the East Coast. Lots of places I interviewed at allowed moonlighting. Some places allowed it, but because of the tough schedule of being a resident, residents did not commonly moonlight. Other places had residents who would make an extra 2-3k a month moonlighting starting their second year.

 

[dotcb]

I personally don't think you should be doing full scope EM unless you are an R4, and even then - be careful for the reasons mentioned. The problem is - when you're junior - you may not know what you don't know. For this reason, I think it would be unwise to moonlight as an R2, and as an R3 - keep it simple and do something relatively easy that will earn you some cash. You'll have the rest of your career to take care of sick patients and earn big $$$. A lawsuit as a resident where you're the only person on the chart - you don't wanna go there.

 

[DreamingTheLive]

I personally don't think you should be doing full scope EM unless you are an R4, and even then - be careful for the reasons mentioned. The problem is - when you're junior - you may not know what you don't know. For this reason, I think it would be unwise to moonlight as an R2, and as an R3 - keep it simple and do something relatively easy that will earn you some cash. You'll have the rest of your career to take care of sick patients and earn big $$$. A lawsuit as a resident where you're the only person on the chart - you don't wanna go there.

Good perspective.

 

[OccupyTheED]

Who is covering a moonlighting resident's butt in the case of malpractice? The residency program?

If you're moonlighting internally then yeah. Externally? No one. Not unless you have your own coverage

 

[The White Coat Investor]

Why not ask the other residents in your program? Most people moonlight in places that have taken their seniors before.

 

[Hercules]

If you're moonlighting internally then yeah. Externally? No one. Not unless you have your own coverage

Actually your MP is usually going to be covered by the group that hired you to moonlight whether it be a large CMG or the local ED group. Most hospitals will not credential and privilege you without a COI (Certificate of Insurance). As for whether to do solo coverage or not, that's up to each individual and hopefully your program will advise on this (mine did). I've seen residents who were competent and ready for that as late R2s/ early R3s and some that may not have been ready a year after they finish residency.

 

[NERDY]

I am conflicted on the moon lighting issue. Some people say it is a great way to be "less scared" as an attending since you've worked alone before and it looks good on a CV. Plus, the money helps supplement a resident's salary. However, other says it is risky, since you are not a BE/BC doctor and you are still a trainee. Thus, you may miss something important and you don't have another person to supervise your work. Therefore, it seems you could benefit ($, experience) or be harmed (law suit, no moonlighting on CV) whether you moon light or not.

 

[EM_Rebuilder]

I see several mis-informations on here and wanted to clear a thing or two up...

I moonlit in residency, A LOT. I was at a four year program; I started moonlighting the start of my third year.

First of all, DO NOT join up with a 'staffing agency' or 'locums company'. Go directly to the contract holders; look at the 'big people' first as they likely have some in your areas (Teamhealth, EMCare, Hospital MD, ECI, Keystone, etc). There are also some small regional contract holders. Lastly, there are 'private groups' but those tend to have a less likely chance of hiring a 'resident'. Ask your 'big brothers' (aka older residents, recent grads, etc).. they can fill you in.

Supply and Demand folks... Thats where its at. IF you live in an area with an abduance of BE/BC Emergency Physicians, then LIKELY the pay is lower and all hospitals are WELL STAFFED so there will be little to no interest in you as a 'resident'. If you live in areas that are poorly staffed, then I ASSURE you that ANY third year resident on this forum can go perform as good, and likely better, job than many of the people filling those spots. There are GREAT non boarded EM folks working in EDs, but there are some SCARY people filling some of those spots (even some scary BC EM folks). I will take a third year EM resident from a busy program any day.

As far as malpractice, most any of the contract holders above will provide insurance and tail (make sure you do ask about that and verify its in your contract). The fee will be taken from your hourly rate (probably anywhere from 5-20/hour).

Dont sell yourself short; espically if you live in a very underserved area with few physicians to staff your surrounding EDs. Understand that EVERY rate is 'negotiable' and do not be afraid to shoot for the moon if it the shift does not fit your schedule well.

I think moonlighting is great and grows you as a physician. I can argue both ways on 'sleeping for dollars' vs a busier place with double coverage. On the sleepers, likely you see a bunch of snotty noses. I was at one of them one time and 4 people came in, thrown from the back of a truck. It was an MCI essentially for that hospital. On the flip side, a double coverage place, you are probably going to have to see 2+ pts per hour, and stay busy with some sick folks... but you have someone else there to talk to. I have actually worked in about 20 different ECs in my career from a Level 1 trauma center I trained at to the Level 1 trauma center I am now FT at... to places with a 4K/yr volume on a 48 hour shift and everything in between. I personally never liked the 17-25K volume places. Those places are too busy for one physician to run comfortably, and tend to be too slow to have two physicians. Some utilize Midlevels, some just let the doc tough it out. When looking at a place to work, just be cautious of those. When you tend to get around the 30K mark, you probably have double coverage.... These are generalizations, keep that in mind.

ABOVE ALL... Make certain you have your most favorite attendings cell number in your phone and let them know you might call them if you ever have an issue. I bounced several things off my resident peers while moonlighting as well as some attendings I respected greatly. Just be careful, and cautious, think twice about every action, and I assure you that ANY third year EM resident from an accredited program can do just fine out there........

 

[deleted109597]

I agree with Rebuilder.

Moonlighting is good, when you're ready for it. You'll know when you're ready for it, and then, if you're lucky, on your first shift, you'll fly 3 patients to the mothership in extremis. Or maybe you'll get 10 hours of sleep. Either works really.

Don't delude yourself that somehow you'll be "better" if you work somewhere with other people. Yeah, you can bounce ideas off them, but they aren't putting their name on the chart. The database listing and malpractice trial will be the same for single coverage vs double coverage. I would argue you're more likely to be careful and cognizant of risks if you're by yourself than if you act like you have the safety net.

Again, lawsuits in general are based on number of patients seen. If you're seeing 40 pts a shift working a fast track, you're statisically twice as likely to get sued as if you see 20 patients a shift working a single coverage ED.

I certainly wouldn't be doing high school physicals as a moonlighting opportunity.

Lastly, if you don't want to call your favorite attendings cell phone, you should always feel comfortable calling the ED you work at for advice. There should always be one of your attendings willing to talk to you, as long as you aren't moonlighting against the rules. And even if you are, I'll still be happy to help you out, just like if you called from jail. Doesn't mean we wouldn't talk about the problem afterwards, but I wouldn't leave anyone hanging out in the rurals just to be a dick. If you don't feel the same about your attendings, count the days until you graduate is all I can tell you.

 

[EctopicFetus]

I agree. On top of that the belief that not being BC/BE and getting sued is so much worse must not understand what the composition of most rural EDs is like.
Here is my mock deposition from moonlighting

Lawyer: Dr. EF you werent board certified when you moonlit in the boonies.
EF: Correct, I was a resident.
L: Do you think you were ready
EF: ******* Lawyer, you know who else is there? A OB/GYN who moonlights as a vet (not a joke), and a bunch of FPs. While they try hard I spent 2 years getting training in a very busy hospital. I was trained by the best. Sure it would be great if there were BC/BE docs everywhere but thats not the current situation.

 

[DreamingTheLive]

Good discussion. As an M4, I really like, at least the option, of moonlighting during residency. Sure, there are pro's and con's to both sides, but I hope to be "there" at the tail end of 2nd/beginning of 3rd year. I'd also really like for my program's leadership team to feel equally confident in my skills when the time comes so that they're literally pushing me out the door to get my feet wet.

Of course, my opinion could change markedly over the ensuing 2+ years.

 

[Old_Mil]

When you go to a rural facility to moonlight keep a few things in mind...

The acuity of the place you are working will seem lower than a level 1 trauma center because you don't have fleets of ambulances and helicopters concentrating pathology at your front door. But keep in mind that much of this pathology shows up already diagnosed (inbound stemi or head bleed for instance).

However never forget that in society that there is a basic prevalence of disease and that just because you are at someplace quiet don't expect that the amount of badness will drop below that. For instance if PE has a prevalence of 1% (just using this number for ease of calculation), Gotham general with its 100000 visits a year will have 1000 of them roll up to the front door and Community critical access with 10000 visits will have 100.

So such hospitals are easier to work at only because EMS isn't concentrating pathology at your front door. You still can't escape the basic prevalence of badness in life.

Also keep in mind that the nursing staff in particular - is not particularly high speed. If your shift goes to hell in a hand basket this is a problem. It is a very real possibility that you will ask for a bougie during an emergency airway and get a blank stare in response...or the ER may not have one.

Usually such hospitals have adequate equipment but nobody has put the thought into locating it in such a way as to make it relevant to emergency medicine (for instance the bougies may be in central supply or long forgotten in some closet...the glide scope may be sleeping peacefully behind the locked doors of the OR)

Moonlighting is good experience but be fully aware of the capability of your hospital, the equipment you have available, and where that equipment is located. If it is not well placed, it is your responsibility at the start of the shift to make sure that it is. Have a low threshold to transfer.

...and never, ever take a job where the physician turnover exceed that of nursing staff.

Take an airway course

Buy a glides cope ranger and carry it with you.

 

[NERDY]

I agree. On top of that the belief that not being BC/BE and getting sued is so much worse must not understand what the composition of most rural EDs is like.
Here is my mock deposition from moonlighting

Lawyer: Dr. EF you werent board certified when you moonlit in the boonies.
EF: Correct, I was a resident.
L: Do you think you were ready
EF: ******* Lawyer, you know who else is there? A OB/GYN who moonlights as a vet (not a joke), and a bunch of FPs. While they try hard I spent 2 years getting training in a very busy hospital. I was trained by the best. Sure it would be great if there were BC/BE docs everywhere but thats not the current situation.

EF, do you think the lawyer would still side against the resident since he/she was not BC/BE and try to argue that he/she had no business working that ED?

 

[EctopicFetus]

EF, do you think the lawyer would still side against the resident since he/she was not BC/BE and try to argue that he/she had no business working that ED?

The lawyer in my example is the plaintiff. Lots of docs who finish residency are not BC, of course they maintain their BE.

In the end the simple fact is that there are not enough docs to staff those places thats why residents work there. In my job and pretty much any other decent job out there doesnt take moonlighters. There is a reason for that.

One of the toughest situations for me (I moonlit at 2 places, one was a sleepy ED with 15-17 visits per day on avg, and the other had high acuity and did a little over 100 per day).

No US and needing a line, or no US and needing a LE US. I never thought about how to manage these cases since I worked at a big boy facility. Sometimes you have to improvise. To be honest I found the nurses (perhaps quite fortunately) to be rather good.

At the sleepy shop the acuity was insanely low. My last shift was the only time s--t hit the fan. Imagine a sick patient and literally having to call in xray/ct and lab from their homes. Yeah it was that slow.

 

[EctopicFetus]

Remember.. its not the lawyer.. its the jury.

 

[Hercules]

When you go to a rural facility to moonlight keep a few things in mind...

The acuity of the place you are working will seem lower than a level 1 trauma center because you don't have fleets of ambulances and helicopters concentrating pathology at your front door. But keep in mind that much of this pathology shows up already diagnosed (inbound stemi or head bleed for instance).


So such hospitals are easier to work at only because EMS isn't concentrating pathology at your front door. You still can't escape the basic prevalence of badness in life.


Usually such hospitals have adequate equipment but nobody has put the thought into locating it in such a way as to make it relevant to emergency medicine (for instance the bougies may be in central supply or long forgotten in some closet...the glide scope may be sleeping peacefully behind the locked doors of the OR)

Solid points. I moonlit at 7 different rural EDs during residency. I put in central lines and chest tubes in ERs that hadn't seen those procedures in years (don't know what happened to those pneumothoraces when other docs were there...), intubated, pushed lyrics because the nearest cath lab was 2 hrs away, reduced major fracture dislocations. Also worked with some scary consultants and had to threaten one with an EMTALA suit (gen surgeon on call on a weekend said he was uncomfortable managing an SBO and asked me to transfer. Understandably the receiving facility politely said they would accept it but would file the EMTALA suit against the surgeon and the hospital. Ultimately I called admin and they made said surgeon come in and admit it). All in all had a great time and got some great experience while making some nice money. I would recommend moonlighting to any EM resident (once they are ready) looking to work in the community.

 

[DreamingTheLive]

Solid points. I moonlit at 7 different rural EDs during residency. I put in central lines and chest tubes in ERs that hadn't seen those procedures in years (don't know what happened to those pneumothoraces when other docs were there...), intubated, pushed lyrics because the nearest cath lab was 2 hrs away, reduced major fracture dislocations. Also worked with some scary consultants and had to threaten one with an EMTALA suit (gen surgeon on call on a weekend said he was uncomfortable managing an SBO and asked me to transfer. Understandably the receiving facility politely said they would accept it but would file the EMTALA suit against the surgeon and the hospital. Ultimately I called admin and they made said surgeon come in and admit it). All in all had a great time and got some great experience while making some nice money. I would recommend moonlighting to any EM resident (once they are ready) looking to work in the community.

Sounds like a great time.

 

[Hercules]

Sounds like a great time.

I would put that more under the great experience and not the great time category. Dealing with real world problems outside of the ivory tower is an important skill to develop, preferably before you get to your real job.

 

[Old_Mil]

I'll add one more thing: you should never consider taking a job at one of these level 3 single coverage hospitals that accepts ambulances from the in unleveled critical access hospitals around it as a resident and you should have serious reservations about it as an attending. It is remarkable what can rain down on your head.

If you are accepting ambulances, consider at least having a midlevel on a requirement regardless of what they tell you about the volume. Yes, administration will misrepresent the volume. (The job I am getting out of us being readvertised as 1.5 to 2k slower than it is.)

Remember that single coverage = no surge capacity whatsoever

If there is a job that has been open for months and months there probably is a reason. If there is a job that is frequently readvertised there probably is a reason.

If there are demographic challenges associated with a particular location (inner city, meat packing plant, large prison, Indian reservation nearby) just walk on down the road.

The job of a hospital administration is to get a warm body in there at the rate they are paying to protect their profit margins. They care nothing about your quality of life or license.

Consider yourself warned.