AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. March 2003, Volume 5, Number 3.

Medicine and Society

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Moonlighting for Charity

Although many medical organizations speak out against moonlighting, many residents work extra hours outside of their formal residency, either to earn extra money or as a volunteer in underserved areas.

Audiey Kao, MD, PhD

Want to Earn Up to $100,000 in Extra Cash per Year? Work as a Moonlighting Physician during Your Residency Training To Find Out How, Call 888-MOONLIT

If this fictional ad seems ludicrous, think again. A recent study revealed that 3 emergency medicine residents in their R3 year earned more than $100,000 a piece in one year as a moonlighting physician [1]. Moonlighting, the unsupervised practice of medicine by residents before the completion of residency, has been going on for decades. In the late 70s, more than 40 percent of all residents in a national survey reported that they had moonlighted [2]. While that percentage has decreased slightly, a significant number of residents, especially in certain specialties such as emergency medicine and family practice, engage in the practice of moonlighting [1,3,4]. In keeping with full disclosure, I never moonlighted during residency, but many of my friends and colleagues did.

It's Not Just About the Money

There are many reasons why residents moonlight, and earning money is certainly one of the motivations. Approximately two-thirds of residents report that paying off student loans or other debt is very important when considering whether to moonlight [1]. Many also consider moonlighting as a positive educational experience that helps them with career decisions [5], and allows them to provide relief to physicians in underserved areas [6].

There has been a long debate about whether moonlighting is a right or privilege and whether it improves or degrades the educational and work experience of resident physicians [7-9]. With recent attention on quality of care and patient safety, questions have been raised about the appropriateness of resident physicians providing unsupervised care. Many prominent medical organizations have come out with policies forbidding moonlighting [10-12]; others have voiced support for it.

In 1998, the Federation of State Medical Boards (FSMB) released guidelines stating that "all applicants for licensure should have satisfactorily completed a minimum of 3 years of postgraduate training in an ACGME- or AOA-approved postgraduate training program including completion of PGY-3 level training before full and unrestricted licensure. This guideline would have precluded the possibility of moonlighting as it is currently practiced because hospitals and other health organizations only hire licensed physicians. To date, only Nevada has adopted the requirements set out by the FSMB. In response, the American Medical Association, Association of American Medical Colleges, and the American Osteopathic Association have recommended a "dependent licensure" with which a resident can moonlight under another physician's license with direct on-site supervision by a board-certified physician in the resident's specialty.

The 80-hour Workweek and 1 Day Off in 7

Beginning July 1, the Accreditation Council for Graduate Medical Education expects accredited residency programs to limit the number of hours that residents can work per week to 80 hours [13]. The new rule will also require 10-hour rest periods between daily duty periods and after in-house on-call periods. Currently, medical residents average approximately 120 hours per week. These new requirements may complicate the moonlighting issue. According to ACGME, moonlighting in the institution where one is a resident must count in the allowable 80 hours of work. Residency programs may find it difficult to monitor the time their residents spend moonlighting elsewhere.

As a resident who was trained at a time when duty hours were not a hot topic, I have doubts about the value of mandating a specific quantity of time as appropriate for residency working conditions. Rather, I believe that it is the quality of the experience and not the quantity of time that is critical to training the next generation of physicians. If it is true that money is not the primary motivation for moonlighting, I would submit that resident physicians would benefit from spending a little of their time moonlighting for charity. Free clinics are always looking for physician volunteers and, given the increasing number of uninsured, the demand is surely going to rise. Other public health safety net organizations are in similar straits and would benefit from an infusion of physician volunteerism.

It is time for the medical organizations that are responsible for ensuring the professionalism and professional self-regulation enterprise of medicine to speak up and mandate that all physicians moonlight for charity.



References

  1. Li J, Tabor R, Martinez M. Survey of moonlighting practices and work requirements of emergency medicine residents. Am J Emerg Med. 2000;18:147-151.
  2. Hough DE, Bazzoli GJ. The economic environment of resident physicians. JAMA. 1985;253:1758-1762.
  3. Silberger AB, Thran SL, Marder WD. The changing environment of resident physicians. Health Aff. 1988;7:121-133.
  4. Baldwin DC Jr, Daugherty SR. Moonlighting and indebtedness reported by PGY2 residents; it's not just the about the money! Acad Med. 2002;77:S36-38.
  5. McCue JD, Janiszewski M, Stickley WT. Residents' views of the value of moonlighting. Arch Intern Med. 1990;150:1511-1513.
  6. Yau J. Residents' page. Can Fam Physician. 2000;46:2274-2276.
  7. Beal JM. Moonlighting: good or bad? Am J Surg. 1966;111:475-476.
  8. Moss AJ. Moonlighting house officers. N Engl J Med. 1984;311:1375-1377.
  9. Urbach JR. Resident moonlighting: toward an equitable balance. South Med J. 1994;87:794-800.
  10. Federation of State Medical Boards. Position of the Federation of the State Medical Boards in support of post-graduate training and licensure standards. Available at: http://www.fsmb.org. Accessed February 19, 2003.
  11. Chisolm C, Baumann B. SAEM position statement on the qualifications for unsupervised emergency department care. Acad Emerg Med. 2000;7:929.
  12. Kelm S. CORD position statement on moonlighting. Acad Emerg Med. 2000;7:929.
  13. Accreditation Council for Graduate Medical Education. Resident duty hour documents. Available at: www.acgme.org. Accessed February 19, 2003.

The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.