What is the purpose of having a moonlighter?

okokok

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First of all - I can feel in my bones this is a stupid question...but I don't understand why a hospital would want to pay a resident moonlighter. The resident still has to staff with the attending, even with a permanent license, so the attending is also getting paid. I rotate at one hospital that sometimes has moonlighters and sometimes doesn't. When they don't, the attending just enters the admission orders from home and sees the new pt in the morning. Why is the hospital willing to pay a resident extra money to avoid this?
 

clozareal

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Not all places require the resident as a moonlighter to staff with an attending. Out of the five places I moonlight, I only have to staff with the attending at one place and that's only if I'm discharging a patient.

It takes the burden off the attendings at the hospital and other residents who would have to take call otherwise, but in this case would get paid for it. It may be that the residents argued for it for their well being and the program director was successful in negotiating this with the services who were willing to pay for moonlighters.
 
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calvnandhobbs68

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First of all - I can feel in my bones this is a stupid question...but I don't understand why a hospital would want to pay a resident moonlighter. The resident still has to staff with the attending, even with a permanent license, so the attending is also getting paid. I rotate at one hospital that sometimes has moonlighters and sometimes doesn't. When they don't, the attending just enters the admission orders from home and sees the new pt in the morning. Why is the hospital willing to pay a resident extra money to avoid this?

Because the attendings don’t want to get woken up every night to put in orders. The attendings usually have a certain amount of call built into their contract or agreement but their call is wayyy easier if they also have a resident on. Resident “staffing” isn’t really staffing depending on where you’re at.

But yes it’s pretty dependent on the hospital or system what ends up being moonlighting and what ends up just being your program forcing you to cover a service. It’s a balance though bc if a program starts making their residents cover too much, they’ll start bitching about it to applicants. It is psych after all, nobody went into it to work medicine hours
 
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oldiebutgoodie1211

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Resident staffing is a one liner just familiarizing the attending with the patient rather than him getting woken up 3 times from the ED, the unit, and some stupid question that will inevitably come up in the process
 
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NickNaylor

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We use resident moonlighters in our ED that staff with an attending, and they get paid what is essentially the equivalent of the midlevels that work in the ED. A couple of things:

- The residents working in the ED are all PGY-3s or 4s, thus they are "advanced" residents and are theoretically more competent than a junior resident. Further, they have all rotated in the ED as part of their required rotations, thus they are familiar with the system.

- Unlike junior residents working in the ED on required rotations, moonlighters get very superfluous "supervision." The attending staffing the case (who is always an attending that is already in the ED for their shift anyway) does the bare minimum necessary to document that they have seen the patient and bill for the visit. When I "supervise" moonlighting residents, I have them fully present the case to me (and will rarely change the plan unless there is something clearly off-base going on), see the patient for a couple of minutes to make sure that they don't have any questions (which is sufficient to complete a mental status exam), and attest the moonlighter note. I do not go see the patient with the resident, I accept the history that they tell me on its face, and I assume that they have done a competent assessment. All and all, it takes me about 10-15 minutes to staff the case vs. 60+ minutes to see the case myself.

- Why do this? Even though I still have to go staff the case and see the patient, it is MUCH more efficient than me having to do two full assessments myself. Since our ED has a perpetually high volume with patients that always need to be seen, any additional work is helpful. This is in contrast to junior residents who are doing their required ED rotations which simply slows the attending down since the interviews take longer, teaching is a part of the experience (= less time actually seeing patients), and the residents just take longer to write notes. The soul-sucking nature of ED work makes it difficult to recruit permanent staff, so there's always a need for additional labor. There's also the added benefit of this functioning, sort of, as recruitment for new faculty: if they enjoy the work, they may be more likely to stay on-board after graduating (and, as above, there is always a need for more faculty). Even though the hospital/department is paying for a moonlighter, it's a whole lot cheaper than paying a locums doc, and for the same price of a midlevel you get, arguably, a more competent clinician.
 

oldiebutgoodie1211

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We use resident moonlighters in our ED that staff with an attending, and they get paid what is essentially the equivalent of the midlevels that work in the ED. A couple of things:

- The residents working in the ED are all PGY-3s or 4s, thus they are "advanced" residents and are theoretically more competent than a junior resident. Further, they have all rotated in the ED as part of their required rotations, thus they are familiar with the system.

- Unlike junior residents working in the ED on required rotations, moonlighters get very superfluous "supervision." The attending staffing the case (who is always an attending that is already in the ED for their shift anyway) does the bare minimum necessary to document that they have seen the patient and bill for the visit. When I "supervise" moonlighting residents, I have them fully present the case to me (and will rarely change the plan unless there is something clearly off-base going on), see the patient for a couple of minutes to make sure that they don't have any questions (which is sufficient to complete a mental status exam), and attest the moonlighter note. I do not go see the patient with the resident, I accept the history that they tell me on its face, and I assume that they have done a competent assessment. All and all, it takes me about 10-15 minutes to staff the case vs. 60+ minutes to see the case myself.

- Why do this? Even though I still have to go staff the case and see the patient, it is MUCH more efficient than me having to do two full assessments myself. Since our ED has a perpetually high volume with patients that always need to be seen, any additional work is helpful. This is in contrast to junior residents who are doing their required ED rotations which simply slows the attending down since the interviews take longer, teaching is a part of the experience (= less time actually seeing patients), and the residents just take longer to write notes. The soul-sucking nature of ED work makes it difficult to recruit permanent staff, so there's always a need for additional labor. There's also the added benefit of this functioning, sort of, as recruitment for new faculty: if they enjoy the work, they may be more likely to stay on-board after graduating (and, as above, there is always a need for more faculty). Even though the hospital/department is paying for a moonlighter, it's a whole lot cheaper than paying a locums doc, and for the same price of a midlevel you get, arguably, a more competent clinician.

on call the pgy1 and 2 here are in house covering the ED and the attending is at home and they staff with a one liner through the phone..is that common?
 

reca

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on call the pgy1 and 2 here are in house covering the ED and the attending is at home and they staff with a one liner through the phone..is that common?

Yeah, think your way is more common. What he describes for PGY-3 and PGY-4 moonlighters is typical for our PGY-1s. PGY-2s staff the ED overnight with attendings available for phone backup. We staff only discharges. There’s never a point where an attending does a full evaluation of the patient we saw, even as an intern. We’re too high volume for an attending to spend 60 minutes with a patient that’s already seen a doctor for an hour!
 

NickNaylor

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on call the pgy1 and 2 here are in house covering the ED and the attending is at home and they staff with a one liner through the phone..is that common?

That's not common in our program as we have a separate psychiatric ED that is quite busy (two separate units with a total bed capacity of ~40 patients which is pretty much always full, in addition to a separate service for the medical ED) and have many staff present 24 hours/day, including faculty who teach and supervise residents doing their required rotations. Residents doing their rotations will typically go see the patient with the attending, discuss the case, and divide up the documentation.

What you describe seems to be pretty typical at most places. Our situation is different since there are faculty already present in-house anyway.
 
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