Do you need to be upfront about moonlighting?

Do you need to be upfront about moonlighting?

Quality concerns exist, whether doctors moonlight in-house or elsewhere

December 2017

WHEN PHYSICIANS moonlight at different hospitals and health systems on their time off, is it anybody’s business but their own?

Given how many physicians moonlight, it’s no surprise that there’s a wide range of answers to that question. Many make the privacy argument that what people do on their own time is their concern, as long as their on-the-job performance is acceptable.

But others take the position that professionals owe greater loyalty to the employer that pays their benefits and provides their workplace training. At the very least, according to this camp, physicians need approval before they moonlight off-site.

As Jasen W. Gundersen, MD, MBA, president of TeamHealth Hospital Medicine, which manages medical hospitalists in more than 160 hospitals and 100 post-acute facilities nationwide, explains: “If we are the primary employer and cover benefits and malpractice, we have an obligation to make sure our program and the work we are doing is prioritized.”

“We find our retention is best if we can offer our providers flexibility, and the more flexibility the better. I think that allowing them to moonlight satisfies that need.”

~ James Levy, PA-C
Indigo Health Partners

Then there are quality concerns, whether doctors moonlight in-house or elsewhere: How tired will you be working extra shifts on top of a demanding full-time job?

“After a point, burnout creeps in, and that will have a dramatic impact on the whole patient experience,” Dr. Gundersen says. The physician’s full-time employer may be the last to know that a physician’s troublesome performance may be related to overwork.

But then there’s another point of view: Letting “or even encouraging“ physicians to moonlight elsewhere is good for both physicians and their home group. Both may benefit when doctors expand their skills and bring new insights back. Physicians may be inspired by something they see working elsewhere, or they may at least be less distracted by money worries.

“We find our retention is best if we can offer our providers flexibility, and the more flexibility the better. I think that allowing them to moonlight satisfies that need,” says James Levy, PA-C, vice president of human resources at Indigo Health Partners, a private hospitalist group based in Traverse City, Mich.

Setting the rules
In areas where supply more closely matches demand and physicians work for large health systems, groups can set firmer rules and exert more control. Some systems not only want to approve any outside moonlighting, but they discourage external moonlighting that adds no value to a physician’s primary employer.

“In certain markets, we let people know that if you work at this system, you can’t work at that other one.”

~ Jasen W. Gundersen, MD, MBA
TeamHealth Hospital Medicine

Leaders question whether external moonlighting will harm a physician’s ability to be a good partner? Will they get too tired or become distracted due to other distractions.

On the other hand, would moonlighting allow physicians to broaden skills or give back to the community in ways they can’t in their regular jobs?

Even when employers require doctors to get permission for external moonlighting, many never deny permission. But while programs may have permissive policies on moonlighting, most group leaders are quick to emphasize that they feel no obligation to accommodate physicians’ external gigs. They point out that most physicians as professionals understand that.

In a Syracuse, N.Y. hospital, the policy states that reasonable moonlighting requests will not be denied as along as they are approved in advance. (The only other restriction is that new hires are not allowed to do outside moonlighting during their first three months on the job.)

Incentives to moonlight in-house
The physician group is working with administration on a carrot-rather-than-stick-approach, offering doctors incentives to choose internal moonlighting instead.

The plan is designed to make internal moonlighting flexible and easy. Physicians will be able to say how much time they can give the hospital and in return, will receive a certain number of patients. The physicians will be paid hourly and productivity incentives may become a factor as well.

The hospital also plans to incorporate a regular moonlighting shift into the program’s schedule, a 5 p.m.-10 p.m. admitting shift that people can choose to work. That way, physicians who want to earn extra income will always have something available. (That shift is also available to community doctors who want to keep their skills up.)

Doctors can sign up for only two of those shifts per month at first to give everyone a chance.

David Beddow, MD, is the medical director of the hospitalist services for Minnesota’s Allina Health System and a hospitalist at Unity Hospital in Fridley, a Twin Cities suburb.

When to draw the line
There are definitely times when external moonlighting raises red flags. One of those is the real world of competition among health systems. That’s why in some markets, physicians are not allowed to moonlight at competing health systems.

“In certain markets, we let people know that if you work at this system, you can’t work at that other one,” Dr. Gundersen says. “That is usually at the request of the hospital.”

In some cases the line is crossed when moonlighting opportunities may reflect poorly on the primary employer. HealthPartners’ Dr. Siy points out that the moonlighting employer may post the names of its providers and their primary affiliations.

“We didn’t want our name attached” to one clinic, he recalls. And in discussing the situation with the moonlighting physician, “we found out that she wasn’t happy with her experience there either. Together, we decided it would be best for her not to moonlight there.”

This can also happen when people want to moonlight for charity. “Not all charitable organizations are the same,” says Jerome Siy, MD, department head for hospital medicine at Minnesota’s HealthPartners,. “We want to be sure that one of our providers isn’t inadvertently tarnishing the reputation of our own organization.”

In Michigan, Indigo Health Partners requires moonlighting physicians to both inform the group in advance and show proof of malpractice insurance for those outside shifts. According to Mr. Levy, that policy is designed not to discourage people from working externally, but to educate them about the business of medicine.

“We have had people volunteering at free clinics or migrant clinics out of the goodness of their heart, places that were used to office physicians carrying malpractice insurance with them wherever they go,” says Mr. Levy. “It turned out that when our providers were working there, they weren’t covered.” Asking moonlighters to keep the group informed, he added, “is for our protection and theirs.”

TeamHealth’s Dr. Gundersen adds that it’s often a question of fairness and balance.

“We are not trying to give docs a hard time about external moonlighting, but we need to have some discussion,” he says. There is a point with external work, he adds, where doctors increase their risk of clinical compromise and burnout.

Plus, there are consequences of doctors never being available to their core program. “If a colleague gets sick or there is an urgent clinical need and all your physicians already have outside obligations,” says Dr. Gundersen, “that puts pressure on the docs in your program who don’t moonlight elsewhere.”

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.

This article first appeared in Today’s Hospitalist, March 2015


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