Working overtime

Moonlighting has become an essential perk for hospitalists.

Like many young physicians, Dan Bensimhon, MD, looked for ways to supplement his income when he and his wife—also a physician—were juggling the demands of subspecialty fellowships with supporting a growing family in the early 2000s. Working extra shifts on top of his regular schedule was grueling but necessary to make ends meet.

“During fellowship, my wife and I were raising 2 sets of twins while we each made about $40,000 a year and had over $200,000 each in student loan debt,” said Dr. Bensimhon, now a practicing heart failure cardiologist and president/CEO of Greensboro, N.C.-based Moonlighting Solutions, which specializes in providing night and weekend call coverage for hospitals around the country. “My only option was to start moonlighting.”

Photo by Thinkstock
Photo by Thinkstock

The allure of moonlighting—or taking on paid extra shifts outside of one's regular job—isn't surprising, considering the potential financial rewards. According to a recent article, published in the January Journal of the American College of Cardiology (JACC), a cardiology fellow can earn an extra $60,000 per year by working a single 12-hour moonlighting shift a week.

That extra earning potential is also attractive to full-time hospitalists, especially younger physicians struggling to establish their careers and climb out of debt, said Dr. Bensimhon. Of the physicians employed by Moonlighting Solutions, about half are fellows while the remainder is made up of full-time hospitalists at community hospitals or academic medical centers and or early career private practice doctors.

“The availability of fellows has gone down due to Accreditation Council for Graduate Medical Education [ACGME] work-hour restrictions,” said Dr. Bensimhon. “Meanwhile, physicians are coming out of training with large amounts of debt, and moonlighting helps get them on track and pay off their loans.”

In fact, moonlighting is a key point of discussion during job interviews, say hospital medicine directors. Hospitalists have come to view moonlighting as a basic job benefit, while hospitals count on having an internal pool of moonlighters to handle daily fluctuations in staffing.

“Every physician we've interviewed in the last 2 years has asked about moonlighting,” said James Leyhane, MD, FACP, hospitalist director of St. Joseph's Hospital Health Center in Syracuse, N.Y. “It's considered one of the perks of the job.”

Keeping it in house

Many large hospital systems and academic medical centers do not allow staff hospitalists to moonlight outside their own facilities, a policy that has pros and cons for both physicians and hospitals.

“Some of our younger hospitalists want to work more than the equivalent of a full-time position, and giving them extra shifts is less expensive for the hospital than bringing in locums or hiring another provider,” said Benjamin Hohmuth, MD, chief of hospital medicine at Geisinger Medical Center in Danville, Pa. “Moonlighting can be economically advantageous for both sides.”

However, maintaining adequate full-time coverage while offering opportunities for moonlighting is a balance that's sometimes difficult to strike, he said. For example, Geisinger's main campus was nearly fully staffed at 34 full-time equivalents during the last half of 2014, leaving fewer opportunities for moonlighters.

“If we're fully staffed, our hospitalists are unhappy because there are no internal options to moonlight and they have to drive to one of our other campuses, which range from 15 to 60 or more miles away,” he said. “Ideally, you strike that spot of being a little bit understaffed to allow for those who want extra shifts, but not too low that you wind up compelling people to take on shifts that they really don't want to do.”

Allowing external moonlighting can be positive because it gives hospitalists other options when there are no opportunities internally, said Dr. Leyhane. His hospital, St. Joseph's, allows outside moonlighting by its staff of 18 hospitalists, and he said it doesn't usually affect the hospital's ability to fill open shifts because physicians typically prefer working in familiar surroundings versus traveling elsewhere.

However, there is some concern that allowing physicians to work at other hospitals could have negative repercussions in a tight job market, he said.

“A potential downside for the hospital is having your physicians lured away by competitors,” he said. “Also, you run the risk of having physicians burn out by trying to do too much.”

Large hospitals in busy markets can easily find outside moonlighters, but it's more cost-effective and efficient to draw from within, said Andrew Dunn, MD, FACP, chief of hospital medicine at Mount Sinai Health System in New York City and chair-elect of ACP's Board of Governors.

“We get a lot of requests from other physicians to moonlight, but getting them credentialed here is a really long, elaborate process,” he said. “We almost never hire outside moonlighters unless they are going to commit to a large number of sessions so that it's worthwhile to go through the process.”

Besides avoiding red tape, using staff hospitalists as your moonlighters is the best way to maintain efficiency and quality of care, he added.

“From our perspective, it's much better to use experienced attendings who know our protocols and level of accountability, as opposed to someone who is not experienced here,” he said. “They are more engaged in making sure the service runs well as opposed to an outsider who may be just trying to get through the shift.”

Competitive market

Even with a stable pool of in-house moonlighters, however, busy hospitals sometimes struggle to fill open slots, creating a competitive market.

“There is a huge need in the Atlanta area for moonlighters,” said Alan Wang, MD, FACP, CEO and medical director of Salude, a post-acute care company based in Suwanee, Ga., and former division director of hospital medicine at Emory University School of Medicine in Atlanta. When he was at Emory, for example, 10% to 15% of shifts across 8 facilities were typically open at any given time.

In the busy Northeast corridor, “every hospital within a 1.5-hour radius of us is recruiting,” said Dr. Leyhane. Moonlighters are in constant demand to fill open shifts until permanent hires are made.

The competitive market has been good for Moonlighting Solutions, which has grown at a clip of 30% to 40% a year over the past 7 years, said Dr. Bensimhon. The company maintains a database of over 4,000 qualified moonlighters, over half of whom can provide hospitalist coverage.

“Our main focus now is hospital medicine,” he said. “We're helping staff about 80 programs across the country.”

Part of the appeal of Moonlighting Solutions for hospitals is handing off issues like credentialing and insuring nonstaff physicians without using a standard locum tenens company, which typically charges more in overhead fees, Dr. Bensimhon said. Moonlighting Solutions takes 10% to 15% of the hourly fee that clients pay to use its moonlighters while the rest goes to pay the moonlighter and cover malpractice.

For small hospitals or those in remote areas, it can be difficult to find outside moonlighters when needed, noted Dr. Leyhane. To make positions more attractive, St. Joseph's is considering adding incentives beyond the basic hourly rate, such as rewarding physicians who generate a certain number of relative value units during a shift.

The hospital has also increased the pay for moonlighters on holidays when slots are harder to fill and offers flexible hours.

“We may offer two 6-hour shifts instead of one 12-hour shift,” he said. “It's hard to get longer shifts covered on short notice, whereas if we open it up to 6 or 8 hours we get a lot more volunteers.”

Pros and cons for hospitalists

Compensation is the number one motivator for hospitalists to moonlight. Extra income from moonlighting can range from $10,000 up to about $50,000 annually, depending on number of shifts performed, said Dr. Dunn.

However, money is not the only benefit. For David Friar, MD, ACP Member, president of Traverse City, Mich.-based Indigo Health Partners, which manages several hospitalist programs across Northern Michigan, a recent moonlighting stint laid the groundwork for signing on a new client.

“It was a good way for me to learn their program,” said Dr. Friar. “Moonlighting gives me so much more credibility with hospitals we work with because I know the nurses, the ward, and the throughput issues and can discuss issues with authority.”

“Experiencing how other hospitals handle different issues can enhance quality improvement at your home hospital or health system,”said Dr. Wang. “It's very helpful to look at different systems and processes and then compare and contrast those with your own and possibly use that information to move things forward at your facility.”

Even moonlighting at your own hospital can offer new experiences, said Dr. Friar. For example, a med-ped specialist might pick up a shift in the emergency department. His company also hires local internists who want to maintain their inpatient skills to fill moonlighting slots on nights and weekends.

For fellows, moonlighting can help build confidence before starting full-time staff positions, said Dr. Bensimhon.

“When you're a moonlighter, you may be one of only a few physicians in the hospital and you quickly become very comfortable with your decision making,” he said. “When I got out of fellowship, I felt so much more prepared to join practice than a lot of my colleagues because I knew how to handle critical situations on my own.”

Moonlighting can also be an effective recruiting tool, said Dr. Leyhane. The moonlighter has an opportunity to test-drive a potential new work environment while the hospital is able to evaluate a potential hire without making a long-term commitment.

On the downside, the allure of extra income can be an incentive to take on too many shifts, threatening quality of care and hastening burnout. The authors of the JACC study noted that inadequate sleep is the “most significant negative effect of moonlighting during fellowship” and has been linked to impaired memory, irritability, depression, and anxiety.

Fellows who moonlight have to be careful to comply with ACGME work-hour rules, which specify that they cannot be on call for more than 1 in 3 nights and must be off 1 day during the week. Staff hospitalists may be subject to institutional policies governing how many moonlighting shifts they can take on, as well as the scrutiny of hospitalist directors monitoring for signs of fatigue.

St. Joseph's began requiring moonlighting to be approved by its vice president of medical affairs about a decade ago, after a hospitalist attempted to do a 24-hour shift at another hospital before coming to his regular 12-hour shift, said Dr. Leyhane. He ended up falling asleep midway through the morning.

The incident prompted an official policy, but most reasonable requests for moonlighting are approved informally, said Dr. Leyhane. The thinking is that hospitalists who work regular 7 on/7 off shifts can safely take on 2 or 3 extra 12-hour shifts during their weeks off.

Mount Sinai has no fixed rules about how often someone can moonlight, but Dr. Dunn monitors his staff's schedules closely and is alert to any negative impact on quality of care. The hospital follows a block schedule, in which hospitalists work a certain number of months per year, which allows them to moonlight on the weeks when they are not on duty.

Provided that physicians do not overextend themselves, moonlighting is generally a positive for hospital and hospitalist, those involved say.

“Moonlighting allows physicians to adapt their work life to better fit their needs,” said Dr. Friar. “If a program neither offered enough shifts nor let their providers moonlight, they may find recruiting and retention to be a challenge.”