For resident physicians and fellows struggling with educational loan-repayment obligations, moonlighting can offer a way to supplement what can be a relatively modest salary while gaining valuable experience caring for more patients.
“You don’t make very much as a resident, so it’s an opportunity to increase your income and advance your education—because every moonlighting shift really is an educational opportunity while you're still in training,” said Adam Roussas, MD, MSE, an emergency physician now in Arizona who moonlighted in several locations during his residency training. “You go out and you have the shift, and then you can bring that [experience] back to your home institution.”
The additional work, though, may be more than some residents and fellows can or want to take on during what is already a hectic time. So, how do you know if moonlighting during residency is right for you? In weighing that decision, physicians who’ve been there offered some advice for residents and fellows considering moonlighting, explaining the potential benefits and drawbacks.
Different varieties of moonlighting exist
There are two types of moonlighting shifts that may be available to residents and fellows: internal, in which the work is within the home institution, and external, wherein a physician is contracted to work outside their training program. Not every training program will allow residents and fellows to moonlight externally, though, and some training institutions are not set up to allow internal moonlighting. In external moonlighting, residents must be independently licensed.
“Some places don't let you moonlight because they think it's going to interfere with your academic productivity,” said Dr. Roussas, an AMA member, who added that the topic “definitely came up on my interview trail” for residencies.
Within emergency medicine residency programs, he said, “it seemed like most places are totally fine with it. As far as they're concerned, it's an educational opportunity.”
Accreditation Council for Graduate Medical Education (ACGME) rules prohibit moonlighting by residents in their internship year, but by PGY-2, some training programs may allow the practice with residents in good standing.
“The path to internal moonlighting carries with it a tacit endorsement on the part of the program that it's a legitimate activity,” said John Andrews, MD, the AMA’s vice president for medical education and professional development, while adding that “the program director has some latitude to restrict your access to moonlighting opportunities if there's a perception that your engagement with those activities interferes with your professional development in the residency program.”
Finding opportunities may not be difficult
Once he was in residency, Dr. Roussas heard from colleagues about moonlighting shifts with a health system that often contracted with residents and fellows in his training program. Additionally, he said, sometimes attending physicians who supplemented their income with outside work would tip off residents and fellows about moonlighting opportunities.
“You also could reach out [to hospitals or health systems] as a potential hypothetical, if there’s nothing [in your program guidelines] that says you can't,” said Dr. Roussas, who moonlighted at several rural Midwestern hospitals starting as an emergency medicine PGY-4 after moonlighting internally for two years before.
He said that in his experience, moonlighting roles may be easier to find for residents in specialties like emergency medicine and psychiatry, though radiology residents may get chances to take contrast call or independent overnight read calls. Dr. Andrews said pediatric residents may be able to secure urgent care moonlighting shifts, and opportunities in outpatient care may arise for shifts covering physicians in other specialties who are out of the office. Fellows in all subspecialties have even more options considering they have completed residency.
The additional pay can be helpful
The average salary for a resident physician in the U.S. hovers around $70,000 a year, with more senior residents usually making more. At the same time, residents often are entering the repayment period for their medical student-loan debt, which nationally exceeds an average of $200,000.
AMA policy on moonlighting notes that “increased financial assistance for residents/fellows, such as subsidized childcare, loan deferment, debt forgiveness, and tax credits, may help mitigate the need for moonlighting.
“At the same time,” the policy continues, “resident/fellow physicians in good standing with their programs should be afforded the opportunity for internal and external moonlighting that complies with [Accreditation Council for Graduate Medical Education] policy.”
Though pay for internal moonlighting physicians varies, Dr. Roussas said generally a resident can expect double or triple their training-program rate. The pay may be slightly lower for those in more junior roles. Once a resident is fully licensed, and if their training program allows it, they may begin to moonlight externally and obtain higher rates. Fellows, particularly if board-certified, may be paid even more.
“If you have a relationship somewhere or someone’s willing to hire you as an attending knowing that you're a senior resident but you're not yet boarded or graduated from your residency, then you can go out in a system that is external to your home institution, where you're acting as a full attending,” Dr. Roussas said. “And that comes with all of the liabilities of being a supervisor and, of course, with attending pay.”
Moonlighting may not be for every physician
As far as the challenges of moonlighting go, physicians have different tolerances for how much extra work they can or want to take on. ACGME duty-hour restrictions include the time spent moonlighting both externally and internally, but even within those limitations, residents still may find themselves overwhelmed, especially when factoring in time commuting to far-flung external sites.
Dr. Andrews said that as a pediatrics residency program director, he never prohibited a resident from taking on moonlighting opportunities. However, he said, there were times when he had to have “challenging conversations” with those who were not progressing at the same rate that their colleagues were.
He recalls saying something to the effect of: “Well, gosh, what you really ought to be doing is focusing on your professional development as a pediatrician rather than seeking additional income, because you've got some gaps.”
More often, though “the typical thing would be someone who would have a weekend off from residency coming up and they'd elect to moonlight for the weekend because they wanted to supplement their income,” Dr. Andrews said. “You might wish for them that they actually took the time to rejuvenate, but I didn't begrudge them the opportunity to use the time for that purpose.”
There are also some expenses associated with moonlighting, including the cost of any needed Drug Enforcement Administration registration and medical licensing. And though the institutions where a resident will externally moonlight typically provide medical professional liability insurance, residents should be aware that their training programs do not cover them in those circumstances.
There also can be a feeling of isolation or pressure with external moonlighting when the buck stops with you, Dr. Roussas said.
“Definitely don't go moonlight somewhere you're going to be totally by yourself,” he advised. “Having another attending nearby or someone you can bounce stuff off of is definitely encouraged when you're going to externally moonlight.”
Ultimately, Dr. Roussas found it a rewarding experience, saying that in addition to the pay, some of the most worthwhile benefits from moonlighting were the CV-building experiences and the professional connections he developed. There was also a feeling of confidence, particularly with external moonlighting shifts.
“It was always validating to me to go and do that [moonlighting],” he said. “It was this small taste of what I've been working towards for almost eight years, and I can do it. And I'm getting paid for it.”
