Resident Moonlighting Research Articles

“What program directors think IV”: Results of the 2017 Annual Survey of the Association of Program Directors in Radiology

The Association of Program Directors in Radiology (APDR) regularly surveys its members to gather information regarding a broad range of topics related to radiology residency. The survey results provide insight into the opinions of residency program leadership across the country. This is an observational cross-sectional study using a web-based survey posed to the APDR membership in the fall of 2017. The final survey consisted of 53 items, 48 multiple choice questions and five write-in comments. An invitation to complete the survey was sent to all 319 active APDR members. Deidentified responses were collected electronically, tallied utilizing Qualtrics software, and aggregated for the purposes of analysis and reporting at the 66th annual meeting of the Association of University Radiologists. The response rate was 36%. Over the past 16 years, more PDs have assistant and APDs to administer growing residency programs, but the time allocation for these APDs has come from the PD's protected time. An overwhelming majority of PDs consider independent call beneficial to residents and most think a call assistant is desirable. The vast majority of PDs support a unified fellowship match and allow resident moonlighting. Most fourth year residents are actively or moderately involved in clinical work and teaching. The majority of PDs have lost or expect to lose DR training positions to the new IR/DR programs. In a competitive match, PDs do not rely on residency interviews in their selection process.

Taking Contrast Coverage Seriously

RADIOLOGY RESIDENT MOONLIGHTING Most residents graduate from medical school with significant debt. As such, moonlighting is a desirable and common aspect of many residency programs. Radiology residency moonlighting opportunities vary in intensity, from the simpler contrast coverage— monitoring for contrast reactions after the administration of contrast agents—to interpreting diagnostic imaging studies, to performing unsupervised invasive procedures [1]. Radiology residents often begin their moonlighting careers with contrast coverage opportunities. In a recent survey of US radiology residency programs, 73% of programs actively encouraged or condoned moonlighting. Of these programs, 73% had contrast coverage opportunities for residents [2]. For contrast coverage, residents are paid to be on site to monitor and treat patients for contrast reactions after the administration of contrast agents. Given the rarity of contrast reactions, most contrast coverage shifts involve little to no stress for moonlighting residents. Unfortunately, this has led to a widespread misconception that a contrast coverage shift involves little to no work. In reality, contrast reactions can be life threatening, and providing contrast coverage is a serious clinical responsibility for which one should be prepared.

Examining the Relationship Between Internal Medicine Resident Moonlighting and IM-ITE Performance

Examining the Relationship Between Internal Medicine Resident Moonlighting and IM-ITE Performance

Resident Moonlighting in Radiology

The indebtedness of medical school graduates has increased dramatically, and this indebtedness, combined with a shortage of radiologists, may result in more moonlighting by radiology residents. Residents may choose to moonlight for an institution not affiliated with the residency program (external moonlighting) or within the same institution as the residency program (internal moonlighting). If residents choose to engage in external moonlighting, they must have a full medical license and separate malpractice insurance and should be aware of their liability. Internal moonlighting is permissible under a resident's limited license and the malpractice coverage provided by the residency but must be within the duty hour requirements of the residency program. Residents with J-1 visas may engage only in internal moonlighting duties that are specifically part of the training program. Internal moonlighting under the control of the residency program offers the most opportunity to supervise residents to make sure that the patient care they are providing is commensurate with their level of experience.

Permission for resident moonlighting among emergency medicine programs

Study objectives: Emergency medicine residency programs differ on their granting of permission for residents to moonlight. We seek to determine whether the following factors might have an influence on the decision to allow resident moonlighting: program format, program age, presence of an emergency medicine fellowship, presence of other emergency medicine programs in the state, and whether the program is based in a rural or heavily populated state. Methods: Using the Graduate Medical Education Companion Directory by the American Medical Association primarily and the Emergency Medicine Residency Program Database by the Emergency Medicine Residents Association secondarily, we determined the number of programs that allowed moonlighting versus programs that did not allow moonlighting for program format (postgraduate year [PGY] 1 to 4, PGY 2 to 4, PGY 1 to 3), program age (0 to 10 years old, 11 to 20 years old, >20 years old), presence of an emergency medicine fellowship versus nonfellowship in the program, solitary emergency medicine program in the state versus nonsolitary programs, and rural state emergency medicine programs (New Mexico, Nebraska, Oregon, Colorado, Arizona, Maine, Arkansas, Ioly populated state emergency medicine programs (New Jersey, Rhode Island, Massachusetts, Connecticut, Missouri, New York, Delaware, Florida, Ohio, Pennsylvania). Afterward, we determined the 95% confidence interval (CI) for the results. Results: One hundred twenty-six of 132 emergency medicine residency programs responded to the database question on whether resident moonlighting is allowed. Five of the 6 nonresponders were new programs that have not accepted their first class yet. In terms of program format, 7 PGY 1-4 (44%, 95% CI 7% to 81%), 5 PGY 2-4 (33%, 95% CI 0% to 77%), and 64 PGY 1-3 (67%, 95% CI 54% to 80%) responded yes, whereas 9 PGY 1-4 (56%, 95% CI 23% to 89%), 10 PGY 2-4 (67%, 95% CI 36% to 98%), and 31 PGY 1-3 (33%, 95% CI 16% to 50%) responded no. In terms of program age, 27 programs 1 to 10 years old (69%, 95% CI 50% to 88%), 17 programs 11 to 20 years old (50%, 95% CI 26% to 74%), and 32 programs 21 years and older (63%, 95% CI 46% to 80%) responded yes versus 12 programs 1 to 10 years old (31%, 95% CI 2% to 60%), 17 programs 11 to 20 years old (50%, 95% CI 26% to 74%), and 21 programs older than 20 years (37%, 95% CI 16% to 53%). In programs with fellowships, 42 indicated yes (58%, 95% CI 43% to 73%), whereas 31 indicated no (42%, 95% CI 24% to 60%). For programs without fellowship, 33 indicated yes (59%, 95% CI 42% to 76%), whereas 41 indicated no (41%, 95% CI 19% to 63%). For state solitary programs, 9 indicated yes (56%, 95% CI 23% to 89%) and 7 indicated no (44%, 95% CI 7% to 81%). When there was a presence of another emergency medicine program in the state, 67 programs indicated yes (61%, 95% CI 49% to 73%), whereas 43 programs indicated no (39%, 95% CI 24% to 54%). For programs in rural states, 8 indicated yes (73%, 95% CI 36% to 100%), whereas 3 indicated no (27%, 95% CI 0% to 83%). For programs in heavily populated states, 33 indicated yes (63%, 95% CI 45% to 79%) and 20 indicated no (38%, 95% CI 16% to 54%). Conclusion: The program format, program age, presence of a fellowship in the program, presence of other programs in the state, and the ruralness of the program seem not to be major factors in whether an emergency medicine residency allows resident moonlighting.

The impact of resident physician coverage on emergency department visits in South Carolina.

This study examines emergency department (ED) visits to assess the potential impact on rural and minority patients if the practice of resident moonlighting was limited. Billing data from all South Carolina ED visits in 1998 were linked to the physician licensure file. Logistic regression analysis was performed to determine patient characteristics predictive of being seen by a resident physician. Resident physicians attended 3.4% of visits for patients residing in rural areas and 1.4% of those from urban areas. The odds of being treated by a resident were higher among persons living in health professional shortage-designated or rural areas, minorities, and persons with government insurance. Patients from vulnerable populations have greater odds of being seen by a resident physician for an ED visit. These populations may be placed at risk for reduced access to health care services if limitations on resident physician moonlighting impair the ability of rural hospitals to staff EDs.

EMRA's Policy on Unsupervised Resident Moonlighting: A Time to Refocus, Indeed

EMRA's Policy on Unsupervised Resident Moonlighting: A Time to Refocus, Indeed

Emergency medicine residency applicant educational debt: relationship with attitude toward training and moonlighting.

Heated debate persists regarding the role of resident moonlighting in emergency medicine (EM). The attitudes of EM residency applicants have not been assessed. The objectives of this study were to assess: 1) the level of educational debt among EM residency applicants, 2) their perception of increased risk potential to patients from unsupervised EM resident practice, and 3) their opposition to laws restricting moonlighting. The authors then report the relationship between the degree of indebtedness and these stated positions. Fifty-four EM residency programs returned 393 responses to a 1996 anonymous survey. Applicants recorded: 1) their indebtedness, 2) whether they believed that EDs should hire only physicians who have completed full training in an EM residency, and 3) whether they believed that unsupervised EM practice prior to completing EM training carries a higher risk of adverse patient outcomes. The authors used a t-test and logistic regression to determine whether there was any significant difference in debt between responders who answered yes and those who answered no to the various questions. A p-value < 0.05 was considered significant. The mean +/- SD debt was $72,290 +/- 48,683 (median $70,000). Most EM applicants (84.8%) agreed that unsupervised medical care by EM residents carries a higher risk of adverse patient outcomes. Paradoxically, only half the applicants opposed a moonlighting ban. Responses did not statistically correlate with educational debt. Emergency medicine residency applicant debt is large. The EM applicants' opposition to laws that would restrict moonlighting was mixed. This was inconsistent with the majority acknowledging an increased risk potential to patients. Nearly all EM applicants would still select EM as a career, even if moonlighting were to be banned.

Moonlighting by Psychiatric Residents

Much of the literature on resident moonlighting has been editorial in nature. Very little information on psychiatric residents' moonlighting practices and attitudes exists. The authors developed an instrument that was mailed to survey the chief residents of all 203 Accreditation Council for Graduate Medical Education-approved psychiatry residencies, with 137 (67.5%) programs responding. According to the responses, the percentage of residents moonlighting increased with each successive year of training, with an average of 31 hours per resident per month. The two major reasons given for moonlighting were payment of living expenses (58%) and repayment of student loans (24%). No supervision was provided to 22% of the moonlighting residents. Only 10% of the programs proscribed moonlighting by their residents. To better assess the positive and negative effects of moonlighting, it is time to truly monitor and guide the moonlighting experience for both residents and their programs.

Emergency medicine resident moonlighting: a survey of program directors. CORD Task Force on Resident Moonlighting.

1) To systematically describe emergency medicine (EM) program directors' perceptions of the benefits and risks of resident moonlighting. 2) To assess moonlighting policies of EM residencies, the degree of compliance with these policies, and the methods of dealing with residents who are out of compliance. A written survey was mailed or hand-delivered to all allopathic and osteopathic EM residency directors in the United States in 1992-93. Incomplete and ambiguous surveys were completed by phone. There was a 96% response rate (113/118). The average EM resident clinical workweek ranged from 38 to 50 hours while the resident was assigned to ED rotations. Most (90%) of the program directors believe moonlighting interferes with residency duties to some degree. Few (10%) programs prohibit moonlighting altogether, although 44% limit moonlighting to an average of 41.5 hours per month. Program directors believe residents moonlight primarily for financial reasons. Most (60%) of the program directors believe moonlighting offers experience not available in the residency, primarily related to autonomous practice. Fifteen programs reported residents who had been sued for malpractice while moonlighting, with one program director named along with the resident. One third of program directors have penalized residents for abuse of moonlighting privileges. EM residency directors are concerned about the effect of moonlighting on resident education. The directors' concerns regarding litigation, excessive work hours, and interference with residency duties are balanced by a general acceptance of the financial need to supplement residency income.

National survey of emergency medicine resident moonlighting. SAEM Inservice Examination Survey Task Force.

To survey emergency medicine (EM) residents regarding moonlighting practices and perceptions for clarifying: 1) resident moonlighting remuneration; 2) any association of perceived educational debt with moonlighting income and hours; and 3) perceptions related to moonlighting (including motivations, impact on resident training, and potential medicolegal difficulties). A confidential, voluntary survey was administered to all allopathic EM residents in the United States. This written survey was provided to residents at their in-service examinations. Completed forms were anonymously returned by residents or local administrative staff to a central site where all identifiers were removed prior to mailing en mass to the investigators. Comparisons between groups were made using chi-square tests and correlations were assessed using the Pearson correlation coefficient. Seventy-six percent (1,826/2,407) of the surveys were returned. There was a weak correlation (r = 0.11) between educational debt and moonlighting hours for residents in the second year and above, but no association of debt with moonlighting income. Most (88%) of the residents reported that their programs permitted moonlighting. Nearly half (49%) reported that they did moonlight in some way. Most (82%) thought moonlighting provided experience not available in the residency. Only 13 (2%) respondents stated they had been sued for malpractice while moonlighting. Most (66%) moonlighting respondents stated that they moonlighted for financial reasons, with educational debt the primary motivating factor. Of the moonlighting residents, 28% were unsure of their type of malpractice insurance coverage, and 9% had no coverage at all. Education about EM practice matters including the risks of moonlighting should begin early in residency, because moonlighting is widespread. Residents are vulnerable to medicolegal action while moonlighting and have insufficient knowledge of their malpractice insurance coverage. Although educational debt is perceived as a strong motivating factor for moonlighting, there is only a weak relationship between educational debt and moonlighting hours.

Psychiatric Resident Moonlighting

Moonlighting by psychiatric residents remains controversial, with debate surrounding the ethical, legal, financial, and educational risks involved in the practice. The authors present a literature review of resident moonlighting, which encompasses the policy positions of various organizations responsible for graduate medical education; surveys of various groups and specialties regarding the prevalence, form, and justification for moonlighting; and models of moonlighting programs in several institutions. The authors conclude with specific proposals for research regarding psychiatric resident moonlighting and, more importantly, emphasize the need for research on the effects of moonlighting on resident performance and education.

Resident Moonlighting: Toward an Equitable Balance

Extracurricular employment ("moonlighting") by resident physicians has been a subject of considerable controversy for many years. A review of the medical literature for the past two decades reveals substantial debate regarding the legitimacy of the practice, the establishment of some organizational policies, and the intrusion of some new legal concerns. I have summarized the findings of previous studies of the subject, including both general reviews and data-based studies. The latter suggest that escalating financial pressures, changing call schedules, and perceived shifts in career opportunities all contribute to continuation of the practice. In addition, some extracurricular jobs seem to offer valuable clinical opportunities. These factors, which have led to several fundamental dilemmas for academic medical programs, have been explicitly defined. There is still a need for a coherent, ethical, economically sensitive, and legally defensible policy on moonlighting. Using the tangible data about moonlighting and the ongoing controversies, I have synthesized some model guidelines that could be used by residency programs to place moonlighting activities on a fair and reasonable footing.

The moonlighting decisions of resident physicians

This paper seeks to identify the determinants of the moonlighting decisions of physicians during their residency training periods. Resident moonlighting has been an area of some controversy for hospital administrators and the medical profession. The results suggest that residents are highly responsive to economic factors and conditions of employment on the residency program when making decisions about a second job.