Career Planning, Resident

How Do You Know If You’re Ready To Moonlight?

Every resident: When should I start moonlighting? 

Every Attending: Well, it depends.

Moonlighting is a rite of passage for many residents. It’s the experience that signals a degree of readiness to be on your own.

But the decision to moonlight means knowing the difference between being ready and thinking you’re ready. You may ask your Attending physicians, but there’s always insecurity when you’re receiving direct feedback… If I were unprepared, would they tell me to my face? 

When I made the decision to moonlight as a resident, I wanted clarity from my attendings. I wanted confirmation that I was safe to practice alone before I ventured out. I certainly didn’t want to figure out that I was unprepared while alone at 2 in the morning, in a remote, single coverage facility. 

As a new attending, I realize the answer isn’t as absolute as I wanted it to be. Are all upper-levels ready to moonlight? If so, are they all ready to moonlight anywhere, or just at certain locations? 

Competency is more fluid than I appreciated. It has little to do with your post-graduate year. 

The facility a resident is considering for moonlighting is a key determinant of my answer. At one nearby facility, for example, a moonlighter is essentially the same as any other resident. The moonlighter sees and evaluates patients but doesn’t make any major decisions or dispositions without signing the patient out to staff. 

A resident may be ready to work in this setting by their second year. 

At a different facility — a local critical access hospital, a moonlighter is the sole physician available. This is the other end of the spectrum. 

And in the middle of this wide spectrum is urgent care centers.

A resident may be competent to work in one setting but not the others. So, when residents ask if they’re ready, my answer is: Well, it depends. 

This answer would have been maddening to me as a resident.

In retrospect, there were a few clues that could have helped validate my decision to moonlight, I just didn’t know to look for them at the time.

These are things to consider over the course of weeks to months — one shift will not give you enough information. Also, look for them with different attendings and across different facilities, especially in facilities similar to the place you’re thinking of moonlighting.

Your work-ups don't vary from your attendings’ work-ups.
There may always be some small, stylistic variations — you pick ibuprofen, they pick acetaminophen. However, are they ordering cardiac work-ups on patients you want to send home after a GI cocktail? Did they rule out a PE in a patient you said had bronchitis? 

If major variations occur between your plan and your attendings’  plan, it’s a sign you may not be ready to go alone. 

There are more conservative attendings who work everything up, every time. But, if this is happening to you with multiple attendings across multiple facilities, chances are that it’s not the attending.

Explore your attendings’ plans thoroughly. What would have been the difference between yours and their plans on patient outcome  if they were both carried out?

Follow your patients throughout their inpatient course  — it gives you insight into how you can best serve your patients and will slowly lessen the gap between your plans and your attendings’.

Your dispositions don’t vary from your attendings’ plans.
Do you and your attending want to admit and discharge the same patients?

If you’re erring on the side of admitting too much: You’re more conservative than average — that’s fine, up to a point. You can’t overuse resources or burn equity with consultants. If this is happening, ask yourself before admitting a patient: What specifically do I want to occur as an inpatient that cannot happen as an outpatient? 

If you’re erring on the side of discharging too much: You’re more cavalier than average — that also may be fine, up to a point. Follow those patients you would have discharged to see what develops. Also, ask yourself — if I were working in Moonlighting Hospital X, would I still discharge this patient? There’s a good chance that when you’re on your own, you’ll be less cavalier than when you work under someone else’s license! 

Also, discharging more may be institution-specific. Moonlighting settings often have less resources than your primary training institution. You may be accustomed to discharging people into an outpatient sector where they will be followed up by a system that can support them. That may not be true where you’re moonlighting in a hospital that has less clinic support. You may find that you admit a little more as a moonlighter than you do as a resident. 

Are you receiving more or less oversight than your peers? 
Residencies have different cultures when it comes to resident oversight. However, by the time you’re thinking about moonlighting, you probably have a clear sense of your residency culture and how they interact with residents. 

If you’re in your final year of residency and still are being checked up on, having all of your orders reviewed, being generally treated like an intern, there’s an issue. If you’re being “pimped” on topics that you find patronizing, it’s not a good sign. If clinically liberal attendings are micromanaging you, it’s also not a good sign. 

You aren’t ready. 

On the other hand, if attendings are giving you independence, only seeking you out at the time of disposition, that’s a good sign — it indicates your evaluations are being trusted. If attendings are letting you carry out plans that are stylistically different than their plans, it’s a really good sign! 

You’re waiting on your attendings.
In residency, we had a fast track area that was staffed by an attending physician and a resident. In my third year (I went to a 4-year program), I reached a point where it took as much time to see and dispo patients as it did to have an attending sign the chart. After multiple fast track shifts without significant dispo or patient plan changes when staffed with my attendings, I knew I was ready to moonlight at urgent care centers. When the same pattern emerged in the main emergency department, I decided I was ready for single coverage moonlighting. It was still an intimidating transition, but I knew from my experience in the ED that my plans were solid and I was procedurally competent.

When you get to this point in residency, you start to get the itch for the next step. You have the confidence that you can manage an ED in residency and want to know whether you can do it alone. You’re ready to move, to see the next patient, and you’re just waiting for your attending to sign off on what you’ve done so you can keep things flowing. 

Your motivations aren’t financial.
Moonlighting can be great money — but if that’s your motivation, you’re in it for the wrong reasons. Remember that you do have peoples’ lives in your hands who are trusting you for your expertise. Don’t moonlight prematurely just to make money. 

When you reach a point that your plans are consistent with standard of care, minimal disposition and patient-care discrepancies are noted between the attending physician and yourself, and you feel comfortable undertaking the responsibility for patients’ lives without another physician overlooking your work, then you are ready.

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