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Moonlighting for residents – some important points to bear in mind
By Elizabeth Kwo, MD MBA – Senior CoverMD Contributing Editor
In this article, Dr. Kwo discusses important issues that a resident needs to be
aware of when it comes to moonlighting.
Moonlighting can help offset educational debt
As a resident, I personally understand the intimidating large educational debt accumulated
after medical school. Moonlighting during residency is seen as a way to reduce this
debt and to provide additional medical training outside the requirements of a residency
program. Residents are legally allowed to provide medical care as licensed physicians
and receive direct financial compensation in return for these services.
With that in mind, several of my colleagues have used moonlighting to not only pay
back medical school debt, but also to support their children and spouses with baby
sitters and private school. A 2004 survey by the Association
of American Medical Colleges (AAMC) found that the median educational debt
after medical school was greater than $100,000, which included over 80% of medical
school graduates. The median income of residents however is $40,000-$45,000.
However, before a resident considers moonlighting, several important policies have
to be taken into account. The
Accredition Council for Graduate Medical Education (ACGME) policy designates
that the 80-hour work week limit must also include the hours moonlighting by a resident.
The weekly duty hour limit was designed to allow residents to enhance their educational
performance and create opportunities for rest. Residents cannot be on call greater
than one in three nights and must have one day off during the week. In addition,
first year residents (PGY-1s) are not allowed to moonlight and neither are residents
on a J-1 visa sponsorship. However residents on an H-1B visa are permitted to moonlight.
In order to be approved for moonlighting, many residencies require the resident
to obtain written consent from the program director and to clearly designate moonlighting
goals and objectives. Residency programs may also withdraw moonlighting privileges
if the activity interferes with the resident's patient responsibilities and performance.
A resident can moonlight in two capacities
A resident can moonlight in two capacities. One is within the residency program
such as in the hospital, emergency room, or clinic of the institution. The other
is outside the residency program. In order to moonlight outside the program, a resident
must not only have a state physician license number, but also a DEA number for state-controlled
substance registration. When the resident chooses to moonlight outside the program,
he or she must find adequate medical liability insurance. Many outside agencies
will provide this malpractice insurance, but the resident should definitely clarify
with the program first before they join. The residency program bears no legal or
professional responsibility for a resident while moonlighting at an outside facility.
Residents should also be sure to avoid violating the rules and regulations of any
federal or state agency, or patient care regulations (e.g. HIPAA).
Ways residents can protect themselves during moonlighting
There are several ways residents can protect themselves during moonlighting:
- Clearly document every service rendered
- Consult specialists in difficult cases
- Work during long free intervals (rather than in between difficult shifts to prevent
- Clearly understand expectations and duties
- Obtain after-the-fact claims malpractice insurance (if working at an outside institution).
Institutions that offer medical malpractice insurance
to moonlighters may only offer claims-made insurance, which only protects malpractice
claims filed at the time the moonlighter is covered by the insurance. If a patient
files a claim for an incident a year later, after the moonlighter has changed insurance
or is no longer practicing at the outside institution, the moonlighter may not be
covered. Therefore, moonlighters may have to purchase “tail-insurance,” which is
coverage to protect against claims not known at the end of the policy period.
This is why many moonlighters find opportunities within their residency program
since they already have the institution’s liability insurance. Their residency malpractice
insurance automatically covers them during their moonlighting shifts.
In my experience, I feel staying in-house for moonlighting is the preferred option
because residents know the computer systems, are more familiar with the staff such
as nurses and case managers, and are legally covered by their residency malpractice
insurance. Leaving an institution allows residents to train independently, but this
can expose them to more liability issues.
Moonlighting Medical Malpractice Insurance
Many of the top-rated medical liability insurance companies also write moonlighting
malpractice insurance. The rates paid vary by state and specialty. However, the
good news is that most carriers consider residents as "new to practice" and so residents
qualify for the new to practice discount - often 50% off the normal rate
for a first year claims made policy. In fact, if a resident chooses to stay with
the same liability insurance carrier after residency many of the carriers will waive
the tail payments from the moonlighting policy (turning it in effect into an occurrence
policy) and still give a new to practice discount the first year out of residency.
This can be viewed as an incentive to stay with the same carrier.
If a resident chooses not to stay with the same carrier then some carriers offer a tail
policy that can be paid over two years in quarterly installments. This varies from carrier to carrier so be sure to ask ahead of time if the option to make tail payments via installments is available.
- When choosing either an occurrence or claims made policy there are a number of important factors to consider. Some states will only allow claims made policies. To ensure
you are getting the best guidance and advice on what is the best policy for your
moonlighting situation request a
free malpractice insurance quote from a licensed and experienced liability
- Claims made insurance policies are generally for one year however the policy can be cancelled at any time. Most carriers
will not charge a cancellation penalty and it's worth asking about a policy cancellation
fee before buying the policy. For some residents trying to balance the hours of
residency and moonlighting may prove to be too much of a workload so it's good to
know that should you decide to cancel your moonlighting policy you won't be penalized.
- Experienced physicians can also purchase moonlighting liability insurance for work
done outside their normal practice e.g. a family practice physician who moonlights weekends in an urgent care center. In this case the doctor is not eligible for
the new to practice discount but can qualify for the part-time discount (non-surgical
only). These physicians can add the moonlighting to their existing policy as a rider
however many choose to purchase a separate part-time policy to keep the liability
exposure of the moonlighting off their main policy.
Moonlighting is a privilege for residents. Therefore, understanding ways to protect
against exhaustion, unnecessarily stressful circumstances, or medical liability
are important to ensure the well-being of the resident. Residents should check with
their program director about their residency specific guidelines regarding moonlighting
because every program is slightly different. Happy moonlighting!
About the Author
Dr. Kwo currently works at Cambridge Health Alliance as an Internal Medicine Resident.
She holds a MD from Harvard Medical School, an MBA from Harvard Business School,
and a BA from Stanford University in Human Biology.
Read Dr. Elizabeth Kwo's full bio
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