Moonlighting isn’t a new practice, but lately, it’s become increasingly common. The physicians choosing to do it span a wide variety of specialties and settings. Some begin moonlighting as early as their second year of residency, while others pick up additional shifts even after they’ve officially retired.
Physicians’ reasons for moonlighting vary, but the increasing trend can be traced, at least in part, to a shortage of physicians. In 2016, the Association of American Medical Colleges predicted that the U.S. will face a deficit of 61,700 to 94,700 physicians by the year 2025. No wonder more and more opportunities to moonlight are becoming available. Here’s what you should know as you consider whether or not those opportunities are right for you.
Internal vs. external moonlighting
“There are two types of moonlighting,” explains Richard Williams, M.D., residency program director at the University of Nevada, Reno. Internal moonlighting means picking up extra shifts with your current employer or, if you’re in residency, within your residency program under faculty supervision. External moonlighting means working for a different hospital or employer altogether.
Since many residents are working with a limited license, external moonlighting isn’t an option for them. However, some residency programs, including the University of Nevada, do offer internal moonlighting opportunities. “The faculty supervision and moonlighting within the residency program is why internal moonlighting can be done with a limited license,” says Williams.
Behind the moonlighting controversy
Before you sign up for extra shifts, it’s important to recognize that the practice is sometimes controversial, especially for residents. Some residency programs won’t allow moonlighting, period. Others only allow third-year residents to moonlight. Most require residents interested in moonlighting to receive written approval from a supervisor or program director.
At the University of Nevada, for example, moonlighting by residents is permitted but not necessarily encouraged. “Any discussion of moonlighting in our program is driven by the residents,” says Williams. “It’s not something we bring up. The university’s moonlighting policy is published on our website, so if a resident wants to see what it is, there’s that option.”
Beyond program-specific rules, residents must obey the Accreditation Committee for Graduate Medical Education’s guidelines. The ACGME has capped the number of educational and work hours for residents at 80 hours per week. “The 80 hours applies to all work the resident performs, whether the extra shifts are internal or external,” explains Catherine McCarthy, M.D., professor of family and community medicine at the University of Nevada. Picking up extra shifts runs the risk of putting residents over that limit.
As for hospitals, most consider staffing moonlighting shifts “a necessary evil,” according to Dan Bensimhon, M.D., who moonlighted as a cardiology fellow. Keeping a hospital staffed at all hours is a logistical nightmare. A flu epidemic or mass emergency could strike at any time, but a lull could leave them overstaffed with full-time doctors—at the expense of a hospital’s bottom line.
“Many hospitals will typically staff toward their average census for a given season and fill the gaps with part-time physicians or doctors looking to pick up extra shifts,” explains Bensimhon. “Others will contract with locum tenens groups to fill those slots.”
This may explain the increasing number of physician-founded, physician-owned companies picking up the moonlighting baton. Suneel Dhand, M.D., for example, cofounded DocsDox, an online resource that connects moonlighting physicians and health care facilities, and Bensimhon formed Moonlighting Solutions to help physicians find moonlighting opportunities and help hospitals understand their staffing needs.
Some of these companies cater specifically to non-hospital employers. CrowdRx, founded by Andrew Bazos, M.D., an orthopedic surgeon specializing in sports medicine, provides medical services to concerts, sporting events and other large events. Its chief operating officer, Connor Fitzpatrick, says that while these setting are different from a hospital, the same skill sets are required.
The advantages of moonlighting
For residents especially, the extra money moonlighting provides is alluring. “You’re restricted by what you can make as a resident,” says Daniela Lamas, M.D., a pulmonary and critical care physician. When she began to moonlight, the extra paycheck gave her more money than she was making as a resident—and her first taste of the future.
“I saw it was possible to make good money at something I love doing,” she says. The extra shifts also helped with student debts and the high cost of living during her residency at Columbia University College of Physicians & Surgeons in New York City.
Paying down debt is a powerful motivator for many physicians, but there are other ways to generate income outside of moonlighting shifts. “I never moonlighted as a resident,” says Joel Schofer, M.D., although he now does so in addition to serving as a military emergency care physician. During residency, he earned extra cash by writing articles for professional publications.
Of course, residents aren’t the only ones who enjoy the financial benefits of moonlighting. “Traditionally, there were two main groups who moonlighted: Physicians at the beginning of their careers, including residents and fellows, who moonlighted to supplement their income and pay off debt,” says Dhand. “The second group included physicians at the end of their careers who were looking to wind down their practices but also continue their income stream.” Schofer notes that more and more physicians lately have turned to moonlighting to supplement stagnant income levels.
Justin Smith, M.D., is an electrophysiology fellow at Wake Forest Baptist Health and a hospitalist for Cone Health Medical Group and several locations of Novant Health. He saw moonlighting in residency as a chance to “test the waters in making clinical decisions.”
Similarly, Bensimhon says it helps residents develop decision-making skills. “In residency, you make decision by committee,” he explains. “Moonlighters learn to trust their own judgments and become more confident in their skill sets.”
The opportunity to understand the full medical experience is what drove Ameeth Vedre, M.D., to start moonlighting during his cardiology fellowship. “I learned what it’s like to act as the cardiologist of the day. It gives you a huge advantage over those who don’t moonlight,” he says. “You have the ability to pick up the ropes faster and to build your confidence level.”
“When you’re a resident, you’re under certain constraints you don’t have on a moonlighting shift,” says Lamas. “There’s a greater sense of autonomy when you moonlight.” Even seasoned physicians experience a sense of freedom from moonlighting. “Physicians at all stages of their careers—increasingly frustrated with modern-day clinical practice—are also moonlighting as a way of regaining some autonomy and control over their schedule,” says Dhand.
Exposure to new situations
Moonlighting can also expose you to patients you might not otherwise see as a resident or in your daily practice. That helps build confidence and knowledge. For example, Schofer says military physicians outside of combat zones “are working primarily with a young and healthy population.” In order to see the full scope of patients, these physicians need to practice outside the military. “It’s something I’d encourage,” he says. “It helps put military physicians on par with their colleagues.”
Military physicians aren’t the only ones who need additional exposure. “These days, especially in the area of primary care, a physician will diagnose a problem, then a specialist is brought in to treat it,” says McCarthy. At rural clinics, residents who moonlight are able to both diagnose and treat the problem, so they learn and do more than their non-moonlighting colleagues.
Matt Friedman, M.D., an emergency physician and medical director at CrowdRx, says that pay is a tertiary concern for many of the residents who work the company’s events. They’re primarily interested in the learning experience. “You can make more money working in the ER,” he says. “We even have some medical students who do research for us. They find it’s an eye-opening experience as well.”
Experience working with and managing a team
Moonlighters also learn how to work alongside other medical personnel. Fitzpatrick says, “At our events, residents learn and experience what it’s like to be on the other side of the hospital run. They experience what it’s like to work with first responders onsite. For many, it’s their first opportunity to do so.”
It’s not just learning to work with hospital teams, says McCarthy. She has worked with University of Nevada residents at a Burning Man concert and explains, “Yes, you learn what it’s like to supervise, but you also learn how to work with patients from all over the world.” That’s an opportunity that these residents only were able to experience through moonlighting.
A chance to test drive without commitment
External moonlighting offers yet another advantage: the chance to test drive a job or hospital without making a commitment. “By working a few moonlighting shifts, you can determine if the hospital’s culture, position and personnel are going to be a good fit for you,” Schofer says.
Vedre agrees: “It’s a benefit for you and an employer to judge how the relationship will work. And it gives a moonlighter an opportunity to look at a variety of different systems to find the best fit.” Some physicians even like moonlighting so much that they look into locum tenens arrangements.
Having a trial period can be a major benefit to residents who aren’t sure what setting they want to practice in. “Nearly half of physicians will leave the first job they take after training within two years,” says Bensimhon. “By moonlighting with a hospital or practice during their fellowship, moonlighters get a chance to sample different jobs and hospital settings, and they are more likely to find the right job the first time around.”
It’s also a major benefit to the hospitals. Williams says family medicine residents at the University of Nevada, Reno who take the opportunity to moonlight in rural emergency rooms often decide to locate to rural areas to practice. This is a huge plus for these communities, which are often notoriously short of physicians.
The downsides of moonlighting
An increased risk of burnout
Practicing physicians and residents have demanding schedules as it is. If you’re not careful, adding hours to your workweek is a quick way to wear yourself thin. However, moonlighters say this can be avoided by setting hours that work for you and your lifestyle. “I never experienced burnout,” says Smith. “If I was getting close, I adjusted my hours.”
Moonlighting terms differ, but the arrangement usually involves contracting for a block of time, such as an entire weekend, or spreading the time throughout the week, such as a few hours in the evenings.
No matter how you choose to moonlight, McCarthy says to remember: “Sleep is important.” That’s one of the major reasons residents are capped at 80 hours of work a week, and it’s easy to neglect rest if you’re not careful.
At one point, Lamas was moonlighting at two different hospitals in addition to her full-time research fellowship. “I realized I was becoming exhausted, and I cut down from as many as five shifts a month to two or three. Eventually, I gave up one of the moonlighting jobs,” she says. “The money is great, but you can’t afford to drop the ball on your health or on the work you do in your current position.”
Less time for family life
Many physicians are drawn to moonlighting because it offers the opportunity to provide more for their families. However, there are two sides to that coin. If you’re working more, you have less time to spend with your family, which can wreak havoc on quality time.
This is especially true because of the times of day and year when moonlighters tend to work. Vedre says opportunities to supplement income usually come from working odd hours, including weekends and holidays.
To ensure that extra shifts don’t put a damper on your family life, Vedre recommends keeping an open dialogue with your loved ones. “Discuss your moonlighting opportunities with your family, and decide together what will work best for everyone,” he says.
Increased independence is one of the reasons physicians decide to moonlight in the first place, but this autonomy is a double-edged sword. “Moonlighting can be empowering,” says Lamas, “But it comes with a huge responsibility.
“Anything can happen at night,” says Bensimhon. If you do decide to moonlight, you will still have access to more experienced physicians, but you have to be ready to handle whatever comes up. That can be trickier at some locations than others.
On a hectic night, this can quickly place you outside your comfort zone. “Moonlighting in a high-risk area can also expose you to potential legal risks,” adds Schofer.
If the increased responsibility worries you, you’re not alone. “Not all residents are ready to moonlight,” says Smith. But if you decide to start as a resident, it’s best to ease yourself in. “Start moonlighting internally first,” Smith recommends. “If you moonlight externally, be careful with where and how much you moonlight. You don’t want to be in a position where you’re over your head in terms of the kind of patient care you can deliver.”
Before you moonlight
If you decide to moonlight externally, you’ll be an independent contractor, not an employee. That means there are a few additional factors to consider.
1 Ask about liability insurance
It will be up to you to determine who pays for your liability insurance. “If you are moonlighting externally, you are no longer working as a resident and no longer under any supervision,” Williams says. “That means you need to make sure your malpractice insurance is provided for.”
Bensimhon agrees, adding that it’s best to confirm these details ahead of time: “Ask [prospective employers], ‘What kind of coverage will I have?’ If it’s occurrence-based coverage, that’s fine. Everything is covered. But if it’s a claims-made policy, make sure it comes with a tail.”
Military physicians are covered by the government’s tort claims act as long as they are treating patients as part of their duties. But the same may not be true for military physicians who moonlight at a veteran’s center or event. Schofer says, “They think they’re covered because they are treating veterans, but they’re not.” Just like civilian physicians who moonlight at outside facilities, military physicians should also ask what kind of coverage they will receive.
2 Get the right licensure and certifications
Before you begin moonlighting, it’s important to know what your hospital’s moonlighting policy is and then make sure you’re following it down to the letter. You don’t want to get caught violating a contract or a residency policy.
You also need to be sure you have all of the required licenses and certifications. This can be especially tricky if you’re near state lines.
3 Prepare for salary negotiations
As an external moonlighter, you’re functioning as an independent contractor. That means you are free to negotiate any payment structure that both you and the employer can agree to. PracticeLink.com offers a wide variety of resources on negotiating, and it’s best to read up beforehand.
4 Leave enough time for your job search
If you’re considering moonlighting while in residency or while actively looking for your next position, realize that the extra hours might interfere with your job search. “Moonlighting will cut into your personal time,” Williams warns.
Since residents generally start their job search efforts a year out, moonlighting may eat into the time you have to find an employer. On the flipside, a moonlighting position may lead to a full-time job—especially if you are moonlighting in order to test drive a position or facility.
5 Wait for the right opportunity
There are plenty of moonlighting opportunities out there. That means you can afford to be picky. Make sure the opportunity involves the type of work you want to be doing. “Moonlighters like to feel good about the work they do,” Bensimhon says. “Although the money is important to help make ends meet, making a difference for patients is what really makes the extra work worth it for most of us.”
You should also make sure you know who you’ll be working with and for. “Research the hospital or company you will moonlight for, and make certain it is a bona fide company,” says Fitzpatrick. “Verify who exactly you will work for.”
Is moonlighting right for you?
All of those interviewed here would recommend moonlighting to colleagues. But ultimately, Vedre says, “It’s an individual decision—and one that should be made thoughtfully.”
Smith adds that one lesson he learned as a moonlighter is that medicine is not as clear-cut as it’s often presented in residency. “I discovered nuance,” he says. That’s the kind of lesson that comes usually after years of experience.
Finally, Lamas says that while moonlighting isn’t a good fit for everyone, the benefits outweighed the downsides for her. “Everything is a trade-off,” she says. “But I consider every incremental experience I’ve had as a physician, whether moonlighting or on my regular job, as increasing my education. All of it has made me a better physician.”