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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.

Residents need to consider a number of important policies before starting a moonlighting position

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 burnout)
  • Clearly understand expectations and duties
  • Obtain after-the-fact claims malpractice insurance (if working at an outside institution).
Residents need to consider a number of important policies before starting a moonlighting position

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 consultant.
  • 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.

In conclusion

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

Elizabeth Kwo MD MBA - Senior Contributing Editor

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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