Business

Before you moonlight: The ins and outs

More doctors are taking clinical side jobs to make ends meet or determine the next career move. But how do you make sure it doesn't affect your day job?

By Larry Stevens amednews correspondent — Posted Oct. 22, 2007

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Moonlighting isn't just for residents anymore. Many of the same factors -- a desire to supplement income, network for future positions and get a wider range of clinical experiences -- that drive residents to step into separate clinical positions increasingly are pushing practicing physicians into doing the same thing.

The career path of Philadelphia internist Alison Alexander, MD, has included numerous moonlighting gigs. During her residency, Dr. Alexander moonlighted within her residency program a few weekends a month. That, she said, allowed her to improve her training by seeing more patients and to supplement her residency income.

When she completed her residency, Dr. Alexander joined forces with another doctor to form a group. To supplement the practice's revenue, increase its patient base and provide continuity of care for patients, she took moonlighting jobs as medical director of two nursing homes.

"I had to work weekends and evenings, but it provided a number of benefits for our patients and those in the nursing home," Dr. Alexander says. For example, she says a surprisingly large number of patients entering the facilities did not have a doctor. Because they got to know her, Dr. Alexander ended up taking them on as patients. "It was a good way to help build my practice, and it gave the patients continuity of care from the nursing home to outpatient treatment," she says.

Dr. Alexander liked moonlighting so much that she decided to become a full-time moonlighter, leaving her practice to become a locum tenens physician. But most moonlighting physicians are sticking by their current positions as they fill the healthy demand for their skills.

No survey exists showing the number of physicians who are moonlighting. But physician recruiters say they are noticing more of a demand by hospitals and some practices for more moonlighting doctors, who can help fill weekend and evening shifts, and more of a supply of physicians willing to moonlight.

"The market [for moonlighting doctors] is growing primarily because more people are hearing about it, and it is becoming more acceptable to doctors." says Jim Dickens, a recruiter with Linde Healthcare, a locum tenens recruiting firm in St. Louis.

He says physicians haven't told him that declining reimbursements are driving them to moonlight. But in his experience, when doctors hear about moonlighting, they are more likely to turn to it when they need extra money.

Experts, however, say moonlighting isn't as easy as just making a few phone calls and lining up extra work.

Physicians must determine if their own practice or employer would allow them to moonlight, or what approval they must get to take an outside position. Other employment conflicts -- such as whether physicians can cancel the moonlighting work if they are needed by their own patients -- need to be ironed out. Then, the issue of who is responsible for liability insurance during the moonlighting work has to be settled.

Finally, moonlighting physicians have to make sure they aren't burning themselves out -- and affecting care of their own patients in their "day job" -- by working too much.

A shot of income

Family physician Joshua S. Coren, DO, of Hainesport, N.J., is an active moonlighter. He moonlighted during his residency and two years out of residency, he moonlights today. In addition to being medical director of the University Doctors Family Medicine practice and assistant professor at the University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, Dr. Coren puts in 12 hours a week on the Saturday overnight shift providing in-house floor coverage at a Philadelphia-area hospital.

"The experience is invaluable," he says -- not only clinically, but also financially. Dr. Coren wouldn't reveal his own moonlighting income, but he says he has seen a range of offers from $40 to $100 per hour for both inpatient and outpatient work.

With so many doctors facing enormous medical school debts, placement agencies say younger physicians in particular find the extra income from moonlighting appealing. But Dr. Coren says he sees physicians of all ages moonlighting.

Inderpal Randhawa, MD, an internist and pediatrician in the Riverside, Calif., area, says that "as someone who continues to moonlight, I can assure you that this is a growing trend in a broken system of health care."

Dr. Randhawa, whose moonlighting includes working shifts at an urgent care clinic, says getting side work is a must for some doctors, particularly in expensive areas such as Southern California. "Physicians are offered and work for lower salaries with a [more expensive] standard of living," he says. "Hence, many physicians are seeking other job opportunities on weekends or evenings to allow, for example, the ability to afford a home ... without having his/her spouse to work full time."

Dickens says moonlighting pay can work out to more per hour than doctors make at their primary job. The most common moonlighting specialties, he says, are primary care, anesthesiology, emergency medicine and radiology.

Dr. Alexander sees other advantages to moonlighting. For example, she says moonlighting can make it financially feasible for doctors to take on pro bono work.

Or it can help them burnish their credentials. For example, Dr. Alexander says, some doctors are denied access to fellowship programs because of lack of research experience. To solve that problem, some of them work for free in research jobs to improve their resumes. And they pay their way by moonlighting.

Rusty Holman, MD, an internist and president of the Society of Hospital Medicine, says hospital moonlighting -- among the most common type -- can present doctors with both challenging and rewarding medical experiences.

"You see patients when they are very sick, in critical condition. Then you see them make either very rapid decline or very rapid improvement. It's a unique experience compared to what most doctors see in their offices," he says.

Setting yourself up

But there are many considerations before physicians decide to moonlight. One major one is whether they have the time or energy to do it.

Maria A. Schroeder, MD, an Omaha, Neb., anesthesiologist and an instructor with the Dept. of Anesthesiology at the University of Nebraska Medical Center, did internal moonlighting as a resident, taking on extra work within her organization that was outside the scope of her residency. But once she established her own practice three years ago, the clinical moonlighting stopped.

Even as a resident, she took on a lower-paying but less stressful moonlighting position to avoid burnout. "Moonlighting was good when I needed it, but it isn't part of my career plan," she says.

Dr. Coren says a key to avoiding the possibility of burnout is figuring out how you will manage your time. "You have to make sure that nothing is interfering with the next thing. My moonlighting does not interfere with my primary job, and neither one of those two will interfere with my family time." Dr. Coren intentionally looked for a Saturday overnight shift position "because my kids are sleeping, my wife's sleeping."

The other personal consideration, Dr. Coren says, is whether you would prefer the environment in which you're moonlighting, which mostly comes down to whether you have a preference for inpatient or outpatient work. "If you understand it's a second job, you can handle the aspects of the job," he says.

So if you decide moonlighting is for you, you need to determine, assuming you are not in solo practice, if your group or employer will allow it.

Bruce D. Armon, a partner with Saul Ewing in Philadelphia and chair of the firm's Life Sciences Practice Group, says some contracts might restrict any work with a group or hospital deemed a competitor, or might stipulate that any income you earn belongs to the group.

In many cases, you will need to get an outside work agreement form signed by someone at your primary group or employer.

That form also might stipulate who is responsible for liability coverage and how much is necessary. Dr. Coren says liability coverage varies depending on the moonlighting position.

Some organizations who hire moonlighters will cover everything, including tail coverage. Others might require you to buy your own policy. Dr. Coren says you might need to check if your current policy covers you in a moonlighting situation. If not, you will need to buy additional coverage, possibility negating the financial gain you might otherwise receive.

As far as finding moonlighting work, Dr. Coren suggests checking journals that cater to your specialty and perusing state medical society newsletters. An Internet search and word of mouth -- from nurses, pharmaceutical representatives and friends -- also can help.

What moonlighting comes down to, Dr. Coren says, is whether doctors "have another alternative -- what's the next-best thing they can do with their time or money," making sure they utilize their time effectively and gain what they can.

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ADDITIONAL INFORMATION

Steps to moonlighting

Here are some legal and practical caveats on moonlighting provided by attorney Bruce D. Armon, a partner with Saul Ewing in Philadelphia and chair of its Life Sciences Practice Group:

  • Make sure the moonlighting organization provides the flexibility to allow you to take time off from the moonlighting job if the primary position requires your presence.
  • Avoid competitive situations. If the moonlighting job is merely serving on a speaker's panel, there is usually no problem. But your employment contract at your primary job might prevent you from practicing medicine in competing groups. Even if it doesn't, working for competitors can have a negative effect on your relationship with co-workers.
  • Check your primary job's employment contract for disincentives to moonlighting. For instance, some contracts might state, "While employed by employer, any remuneration generated by employee belongs to employer."
  • Residents moonlighting within their own organization are limited to a total of 80 hours of work each week. There is no such limit for doctors who moonlight outside their programs. But check with your program director to ensure that the hospital in which you plan to moonlight does not have a relationship with your primary placement, in which case the 80-hour limit might apply.
  • Some employment contracts include specific language about what constitutes moonlighting -- clinical and nonclinical -- and the approval process necessary before the employee engages in any moonlighting. Make sure you read and follow any such policies exactly.
  • If your moonlighting job covers liability insurance, make sure it also has tail insurance, which covers you after you leave your job.

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