TMA Policy Considers Educational, Workforce Benefits of Moonlighting
Tex Med. 2015;111(4):37-43.
By Amy Lynn Sorrel
When student pilots train, they put in a certain number of hours flying solo after demonstrating a level of knowledge and expertise in basic flight maneuvers. For many young physicians, that rite of passage often comes through moonlighting beyond the walls of their residency programs.
"There's no better way to learn than to fly on your own," said Jonathan MacClements, MD, chair of the Texas Medical Association Committee on Physician Distribution and Health Care Access. More important, he adds, many underserved communities in Texas depend on that extra manpower to fill access-to-care gaps.
The committee raised concerns, however, that medical schools and residency programs may become overly restrictive of the practice since the Accreditation Council for Graduate Medical Education (ACGME) recently required moonlighting to count toward a resident's total work-hour cap of 80 hours per week.
In response, TMA's Council on Medical Education adopted a policy put forth by the physician distribution committee that encourages medical schools and residency programs in Texas to reconsider broad limitations or even prohibitions on resident moonlighting. The policy goes before the TMA House of Delegates at its annual meeting in May.
"There seems to be less support among schools because of the immense oversight required by program directors to make sure moonlighting counts toward the max and doesn't interfere with patient safety," said Dr. MacClements, assistant dean for graduate medical education at The University of Texas at Austin Dell Medical School and a former family medicine residency program director and chair at UT Health Northeast in Tyler.
While acknowledging those obligations, the committee doesn't want to see the positive effects of moonlighting overshadowed. "It's our responsibility to look at the adequacy of the physician workforce and access to care, and moonlighting can play a role. For many communities in Texas, their support is moonlighting residents," Dr. MacClements said.
Many educators say it also has direct, positive effects on residents both professionally and personally, from boosting clinical exposure and self-confidence to reducing the ever-increasing medical school debt that impacts their practice decisions. Council on Medical Education Chair Rodney B. Young, MD, vouches for that, having moonlighted in his residency prior to the restrictions. He is a family physician and chair of the Department of Family and Community Medicine at Texas Tech University Health Sciences Center (TTUHSC) in Amarillo.
Drs. Young and MacClements agree that academic performance and patient safety are paramount, as is compliance with ACGME rules. "But there are a lot of tangible benefits to moonlighting, and we would encourage institutions that sponsor residency programs to rethink sweeping policies" that effectively discourage the practice, Dr. Young said.
Striking a Balance
In 2003, ACGME imposed stricter duty-hours requirements, limiting residents' work-week to 80 hours. That included hours spent moonlighting internally, at the same location as their residency program. Residents also may moonlight externally — at a facility that is not part of the residency program — and in 2011, ACGME revised the duty-hours rules to include those hours, too.
ACGME Senior Vice President of Field Activities Ingrid Philibert, PhD, says the rules were not meant to discourage moonlighting altogether. Rather, they guard against resident exhaustion and the potential legal and patient safety risks that could result, and they ensure residents' education comes first.
"Residents are primarily there to learn the science and art of medicine. That is their first job. This is not about banning moonlighting, but educating residents [about it]. Residents should understand moonlighting is not for everybody," she said.
Dr. Philibert acknowledges the many benefits of moonlighting, which include a workforce boost, although she says such policy reasons are "beyond the purview of the ACGME." Besides New York — which as a state bans moonlighting — and the military, she observes few if any residency programs completely prohibiting the practice, even though ACGME rules allow for such a ban. The only restriction ACGME policy explicitly imposes — and program directors agree upon — is barring first-year residents from moonlighting.
But moonlighting is not equally practiced among all specialties, Dr. Philibert notes. Communities may have more of a demand for primary and emergency care or psychiatry, for example, creating more opportunities for family medicine or general surgery residents.
On the other hand, specialties like neurosurgery may require more extensive training first. Still other residents may find moonlighting uncomfortable or burdensome.
And regardless of specialty, with the duty-hours regulations, "there is clearly a shorter number of hours in which to learn the craft and the art of your specialty," she acknowledged.
ACGME rules aim to balance all of those factors, Dr. Philibert says.
TMA leaders emphasize that the Council on Medical Education's proposed policy shares that goal. It states: "TMA believes moonlighting residents, working in compliance with the institutional guidelines of their sponsoring programs, can serve valuable roles in filling gaps in physician staffing in underserved communities and can reap substantial personal and professional benefits. It is acknowledged that moonlighting may not be in the best interest of every resident and may be more appropriate for certain medical specialties and more senior, experienced residents."
The proposal goes on to recognize that "residency program directors serve in the critical role of ensuring compliance with institutional moonlighting requirements and assessing whether residents have the competencies needed to balance residency training and moonlighting. On this basis, TMA encourages medical schools and residency training programs in Texas to reconsider broad institutional or local policies that impose strict limitations or even prohibitions on moonlighting by residents."
TMA's Committee on Physician Distribution and Health Care Access also evaluated emerging research that shows residents may be getting a less well-rounded training experience under the restricted duty hours. A review published in the June 2014 issue of Annals of Surgery surveyed existing studies on the impact of duty hours on surgical training and found "negative impacts on patient outcomes and performance on [board] certification examinations" and incidents of "increased patient handovers, poorer team integration, professional dissatisfaction, concern for maturation of clinical skills, and decreased time in the OR."
ACGME acknowledges the debate surrounding the benefits of the caps, and Dr. Philibert says the organization commissioned two long-term national studies — one in surgery and one in internal medicine — to assess their impact.
"There is this tension of how to get that clinical exposure within the reduced duty hours," Dr. MacClements said. He is optimistic that moonlighting is one way to help meet those needs, as well as those of the community. As long as resident education, resident well-being, and quality of care are assured, "there are many communities in Texas that will directly benefit from competent residents who are able to moonlight outside of their training institutions."
Dr. Young provided that much-needed backup in an emergency department (ED) in rural Crosbyton, 45 miles east of Lubbock, when he moonlighted there in his last two years of family medicine residency. "These were smaller communities that might have had two to four doctors, and there are only so many nights you can be the only doctor in the ED before you get burned out. Having a supply of people to come out made it more sustainable."
The clinical exposure was a proving ground for his skills, but Dr. Young says he had to prove himself even before that. The council's proposed policy recognizes that in order to moonlight in Texas — and most states — doctors in training must obtain a full and unrestricted license to practice medicine independently, just like any other physician wishing to practice.
Residents also must get an individual Drug Enforcement Administration and Texas Department of Public Safety number for prescribing, and those moonlighting outside their institutions must secure their own medical liability insurance.
Robert Cooper, MD, now finds himself in Dr. Young's shoes. The second-year family medicine resident at TTUHSC Amarillo picks up an evening or weekend shift every now and then at an ED, urgent care center, or long-term acute care facility in some of the surrounding towns.
The extra income certainly helps chip away at his six-figure student loans. "But the more invaluable part is the experience and what I've learned to fine-tune me for the real world when I'm on my own. You definitely gain this confidence, and you can't put a price on that," he said.
Without moonlighters, many of the rural hospitals he works for would have to shut down on the weekend or hire more expensive, seasoned physicians, Dr. Cooper adds. "That means decreased access to medicine and increased health care costs — two fundamental things we are trying to fix now in Texas."
Because of the 80-hour limit, he knows certain rotations won't allow extra time for moonlighting. During a lighter rotation that requires less inpatient service, however — even more likely in his third year — he informs the urgent care company of his availability months in advance.
Dr. Cooper did have to get permission from his program director and sign a contract agreeing to log his moonlighting hours, as he does for training. But he doesn't consider the administrative requirements a deterrent. "They encourage us to moonlight here, so long as we aren't doing it at the cost of patient safety and violating the duty hours. It's somewhat of an honor system, but it's a blanket encouragement if you're willing to put in the work and go through the licensing."
TTUHSC Amarillo Family Medicine Residency Program Director Jerry Kirkland, MD, says there is a very low threshold for revoking that privilege if abused. "And it is a privilege. We're not going to send someone out there who's not prepared. But I see a real confidence and seasoning that develops in those residents who get that clinical exposure."
Because residents tend to stay and practice where they train, underserved areas also benefit from exposure to possible recruits moonlighting there, Dr. Kirkland adds. "They might say, 'Hey, this could be a nice place to live, and the quality of life could be good.'"
Some Restrictions Necessary
But educators say broader restrictions are sometimes necessary, and certain parameters should be left to each program's discretion.
Moonlighting not only affects an institution's standing if residents violate the duty-hours rules, but it also impacts programs' federal funding, says Josephine Fowler, MD, a member of TMA's Council on Medical Education. She oversees the residency programs at JPS Health Network in the Fort Worth area as vice president of academic affairs.
"We tell our programs: We are not micromanaging you. We are just helping them recognize when they are going over their duty hours because that's tracked by ACGME," she said. "And moonlighting does not count toward our [federal] reimbursement because residents are working as independent practitioners. Reimbursement to an institution only counts when they are in training mode, so we have to keep track."
JPS has a general institutional policy that encompasses ACGME's requirements and requires moonlighting residents to be in good academic standing and keep up on their charting, for example. JPS also has program-specific guidelines that are more stringent depending on the specialty.
Since the requirements to document both internal and external moonlighting took effect, Dr. Fowler has seen fewer residents moonlight.
"But the biggest factor is, do they have enough time? Most of our program directors just can't see where residents would have enough time to think about moonlighting," she said. "We just want residents to understand what their limits are."
Russell Wagner, MD, directs JPS' orthopedics residency program, which restricts moonlighting to senior residents who typically no longer take heavy call and to specific internal arrangements that coincide with their specialty training: as a faculty member, at the hospital jail clinic, or with a local high school football team.
Until their senior year, the hours most residents work are strenuous enough without moonlighting, "and when they are off, they should be studying or taking time for their family. They have a lot to learn," he said. While general emergency work might be good for family practice residents, "it's not a great learning experience for an orthopedic resident. When I was moonlighting, it was in a psychiatric hospital. I saw patients with minor emergencies and sent them to the hospital. But it was not a learning experience. It was because I was not getting paid enough to support my family."
On the other hand, Dr. Wagner says resident pay nowadays has improved enough for residents to modestly support themselves and their families. He does not discredit the benefits that accompany moonlighting. "But sometimes it's prohibited, and sometimes it needs to be. And it should be up to the programs."
Clear for Takeoff
TMA leaders worry, however, that limiting moonlighting to internal opportunities — where program directors are just a phone call away even if they are not directly supervising — doesn't always provide the same benefits as external moonlighting, where young physicians in training are forced to think on their feet and make quick decisions in their own environment.
Moreover, not all institutions have the resources to support internal moonlighting arrangements on top of their training responsibilities.
In line with ACGME, the council's proposed policy recognizes that not all residents may be comfortable or prepared for moonlighting — for example, in settings outside of their discipline — and program directors should stay involved in the decisionmaking process, Dr. Young says. Within those bounds, however, he hopes programs look for ways to clear the runway for moonlighting opportunities, rather than ground them.
Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
- Absent a waiver, duty hours must be limited to 80 hours per week averaged over a four-week period, inclusive of all in-house activities and all moonlighting.
- Time spent in internal and external moonlighting must be counted toward the 80-hour maximum.
- Moonlighting must not interfere with the ability of the resident to achieve the goals and objectives of the educational program.
- First-year residents may not moonlight.
- Residents/fellows must not be required to moonlight.
- Residents/fellows must have written permission from their program director to moonlight.
- Programs must monitor the effect of moonlighting on a resident's or fellow's performance in the program; adverse effects may lead to withdrawal of permission to moonlight.
- The sponsoring institution or individual ACGME-accredited program may prohibit moonlighting.
Source: Accreditation Council for Graduate Medical Education (ACGME)
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