Moonlighting and Other Topics


I have been doing a little bit of moonlighting lately and I have to say, it just feels different getting paid six times as much for doing the same work. Sorry, it just does. What’s a chore for twelve dollars an hour is decent work for eighty.
As one of my readers pointed out, moonlighting in Emergency Departments for residents and non-Emergency Medicine board certified physicians is a controversial topic, primarily because of the supposed contradiction of non-qualified physicians working in a field for which the American College of Emergency Physicians believes that stringent qualifications are required. General Surgeons, for example, don’t moonlight as pediatricians so how can, say, a Family Physician or even an incompletely trained Emergency Medicine resident feel comfortable moonlighting in an Emergency Department? If anybody can do it, after all, why require board certification?

The point is not whether anybody can do it. Anybody can actually do it. Just like anybody can do internal medicine, family medicine, and any of the other specialties provided they have the training and the experience. There is nothing magical about Emergency Medicine. You put your head down, open your eyes and ears (uh, with your head down), and muscle through enough cases where you start to get a good handle on the knowledge and procedures that are typically required of an Emergency Physician. The best way to gain this experience however, and for most people the only practical way, is to complete a certain period of residency training where through a combination of formal didactics and supervised clinical training you gain the experience to handle the wide range of real, honest-to-Allah, potentially lethal patient presentations that you will likely encounter.

On the other hand, since there is a lot of overlap between medical specialties and also because Emergency Physicians have now become the closest thing we have to General Practioners (especially as the office-based primary care specialties start punting more and more of their complicated and thus unprofitable patients to the Emergency Department), there is a lot of basic doctoring going on in emergency rooms. Consequently, many physicians with minimal training can gain the illusion of comfort in that kind of environment. Most emergency departments also see a lot of urgent care where the stakes are low and a couple of vicodin or a prescription for amoxicillin covers a multitude of sins.

But that’s not really what Emergency Medicine is about. Those patients are fillers, people who we are happy to see and get the best care we can possibly give but who are dropped like a bad habit when something serious comes in the door. I work at a very busy, high acuity department but if you walked through the halls and didn’t know at what you were looking you’d think it was a just a busy community health clinic. That’s because the really sick people are in the trauma bays or behind curtains. The people in the halls are just hanging out while their work-up proceeds on autopilot, getting angrier and angrier as they mentally compose the scathing letter they are going to write to the hospital’s Patient Relations Department. We get to them when we can because time is money even in medicine. They are seen as quickly as possible given the regrettable fact that every patient does not get their own personal doctor and nurse to hold their hand and chit-chat while the labs cook.

At my program, we generally do in-house moonlighting, filling gaps in the schedule where we work more as physician extenders than regular doctors. In fact, most of our sanctioned moonlighting is in the urgent care side of our department where we pick up physician assistant shifts (and, it is my understanding, make the same hourly rate) working with the same attendings with whom we work during our regular shifts. The point is that even though I can work my way through most common gynecological, pediatric, or medical complaints and would feel comfortable doing it if I were moonlighting solo at an urgent care, at this stage of my training I would feel uncomfortable, almost suicidal, working on my own in an emergency department. Not to mention that it would be unfair to a critically injured or terrifically sick patient to have someone who was less than qualified in charge of his life. Now, sometimes this is unavoidable. If there are no physicians, emergency medicine trained of otherwise, willing or able to staff a sleepy one-horse emergency department in the fly-blown wastelands of Massachusettes they will have to take what they can get and an experienced ATLS-trained resident or Physician Assistant is better than nothing.

And yet, just because it can be done doesn’t mean it should be done or that it is an optimal solution. The optimal solution is to have formally trained Emergency Physicians staffing emergency departments. Allowances need to be made of course because nothing in this bad old world of ours is optimal. Not only is there a shortage of board-certified Emergency Physicians but many non-Emergency Medicine trained physicians practice emergency medicine and have a tremendous amount of talent and experience in it. (The American College of Emergency Physicians did, in fact, have an extensive period where the old hands who pioneered the specialty could become board certified without having done a residency) However, as money drives everything in this aforementioned bad old world of ours and many of the primary care specialties are not paying what they used to, many physicians see a segue to Emergency Medicine as an opportunity for better pay and better hours, both of which are excellent motivations but not things that should be achieved at the expense of patient safety.

Board-certification in any specialty is just a marker, however imperfect, of qualification. By nature it is exclusionary and a little unfair to the minority of otherwise qualified but non-certified individuals who can do the job. But that’s life. As a guy who has had to suck up a lot to both go to medical school and match into Emergency Medicine, while I don’t think it is unreasonable for a residency-trained physician in other specialties to be able to gain board certification in Emergency Medicine after a reasonable period of training, a one year fellowship with minimal hours and scant didactics structured for the fast track to certification isn’t going to cut it.

Emergency Department Crowding

Let’s face it, many of the patients in the Emergency Department at any given time are not really that sick. Many people show up with complaints that seem fairly promising but turn out to be nothing. I can’t tell you the number of chest pains I have seen that have turned out to be dry holes. Even the patients with serious diseases and dozens of frightening comorbidities aren’t usually so sick that they are in imminent danger of death. They’ve been sick for years and their occasional visits are merely opportunities for the rapidly approaching grim reaper to take his government mandated coffee breaks. But people still come and the conventional wisdom is that these patients use the emergency department because they lack health insurance.

Many of these patients, however, do have health insurance and many have their own doctors. So why, I once asked a patient, did he come in and wait three hours to be seen and then six hours in the department when he had excellent health insurance and is a patient of one of the finest physicians in town?

The answer was surprising because it is so obvious. So obvious that I am almost afraid to mention it for fear that you, my wise and long-indulgent readers, will roll your eyes and accuse me of being a simpleton. As my patient related to me, in order to see his doctor he has to make an appointment which is often weeks to months in the future. On the day of his appointment, even if he shows up on time he will usually have to wait an hour or two because the doctor is always running late. Then he will spend a brief ten to fifteen minutes with his doctor who will order a slew of tests and imaging studies, many of which will have to be completed at a different location. He may, for example, have to drive across town for a CT scan and it is usually scheduled for a different day, often weeks in the future.

Then, as my patient explained, he must wait several weeks for his next appointment where his physician will explain the results and finally initiate either definitive treatment or, as is often the case, referral to another specialist who will repeat the time consuming process.

I know this is true on a personal level. I recently had a colonoscopy (everything is fine, by the way and they can still write “no significant past medical history” on my chart) and from my inital visit to my internist to finally getting the results of a post-procedure CT scan from the gastroenterologist took close to six weeks and four separate trips each of which sucked up a big chunk of my infrequent days off.

My patient also confided to me that even getting the results of studies and imaging was not guaranteed. Although we are all quick to relay bad news, apparently follow-up is not that pressing to many physicians if the results are normal. (I still have not actually been infomed of the results of my CT scan and only know it was normal because I walked across the hall and asked the radiologist to look at it for me.)

Consider now a visit to the Emergency Department. First, my patient did not need an appointment. While it is true that he was triaged to a low acuity and had to wait a while, at certain times of the day the waiting times are not that much longer than the typical wait for his delayed primary care physician. Second, the lab tests he needed were drawn on the spot and the results reported within an hour even though he was a low acuity patient. Our goal, you understand, is to discharge or admit as fast as possible. Likewise his imaging studies were obtained, read, and reported quickly. Finally, if anything serious has been discovered he would have been admitted within hours. More importantly to my patient, since everything was all right he knew fairly quickly instead of biting his nails for a couple of months.

As to the cost, even though the same complaint in the Emergency Department costs four times as much as it does at his primary care physician’s office, my patient has insurance and the cost of the work-up is of little concern to him because it costs him roughly the same either way, especially considering that he only has to make one visit versus three or four.

So you see, Emergency Medicine is a victim of it’s own success and, as Emergency Departments begin to look more and more like self-contained hospitals-within-hospitals complete with admitted patients (waiting for rooms, you understand) and even critical care patients being managed for most of the initial five or six hours in which everything important is usually done, the problem of overcrowding is only likely to get worse. Add to this the growing reluctance of office-based practices to handle really complicated patients when it is ridiculously easy to divert them to the Emergency Department and a steadily worsening shortage of primary care physicians, while the situation is no doubt great for my personal job security it is hardly the best way to do business.

Or maybe it is. Maybe what people want is the speed of the Emergency Department, or at least some semblance of it. The problem is that maintaining the infrastructure that lets us move patients quickly is also horrifically expensive.

Come on now. Surely someone has some original slang. I repeat, to be included the word has to be truly original or at least funny enough where it doesn’t matter. Again, I want to give proper credit. I believe I invented “polybabydadic,” “dependocracy,” and “homo polycomorbidus.” The rest are unattributed because I truly do not know form whence they came.

24 thoughts on “Moonlighting and Other Topics

  1. As a family physician and former teacher, I have sometimes bristled at the suggestion that competence is only defined by Board certification. Certification requirements should be uniform throughout the country, so that rural hospitals that can’t attract certified docs are the only ones that end up with family physicians doing OB and ER.

    As a physician executive (see my new blog) I understand that in the absence of personally knowing watching and working with every physician you hire, Board certification is the best way to assure competence. Fact is, competence varies widely.

    I know too many office docs who punt to ER too quickly, but I also know too many ER docs who complain about every other specialty as often as they urinate.

    It may be a good idea to develop a business-line concept with your hospital administrators. Try to tie the ER with the hospitalists and align their interests and compensation incentives. In rural areas where outpatient practices are being purchased by the hospital, they can be included in the group.

  2. I expect that as retail health clinics become more common, you’ll see fewer of these low-acuity patients. Primary care docs are not competing with the ERs for non-urgent matters, when, if they planned properly, they could be their bread-and-butter. It’s depressing, really, especially as you see idiotic arguing from the disconnected ivory towers about how these retail health clinics are a bad thing.

    (I’m not so sure about that.  The retail clinics really only see the ultra-low acuity stuff that we actually don’t see that much of.  What does a retail clinic do if someone comes in with abdominal pain, nausea, and vomiting?  They send them to the Emergency Department.  How about mid-cycle bleeding?  Same thing.  They send them to their OB/Gyn or the ED.  Retail clinics are good for coughs, colds, minor scrapes, sports physicals, paperwork requiring medical opinion and not much else except to serve as outpatient triage for the emergency department.  They are kind of a scam.  The public will probably catch on.-PB)

    Say what you will about midlevels, But ear infections, strep, pink eye, swimmer’s ear, and bronchitis aren’t particularly difficult to diagnose and treat. (Assuming they don’t have a billion other comorbidities.) I’m curious how much of what you see falls into what ?

    And you’re quite right about the really sick patients being behind curtains. I’ve never been left out in the hallway when I’ve been at the ER, despite “private” space being at a very high premium each and every time I’ve needed to go. And I know I was given the evil eye by those who had been waiting for a long time without a space of their own in the hallway.

    Concepts like “triage” don’t seem to mean much anymore in our first-come-first-served world where the Customer Is Always Right.

  3. another good post as usual but there’s a small typo:

    “..even though the same complaint in the Emergency Department costs for times as much as it does…”

  4. Dang it Mark, I’ve seen bloggers quit blogging over exactly this kind of nitpicky stuff. We all know what PB was saying, we all know he’s doing this in his very limited free time and that he doesn’t want to carefully go proofreading through each post after writing it.

    Everyone please just let the small stuff go. Pointing out stuff like this does not help anyone. Just enjoy the posts and take them for what they are, amusing and thoughtful web-based scribblings that will be properly proofread if they ever end up in a book, or somewhere else that proofreaders are routinely employed.

    (And I would like to comment that I am writing without a spelling or grammer checking program, that is, with nothing between me and literary oblivion but a ratty seven-year-old Toshiba laptop and my knowledge of spelling.-PB) 

  5. as always, great post.

    as i have pointed out before we ARE victims of our own success. one of the BAD things about this is that physicians in other specialties (internal med, fp, etc…) are less and less able to care for the truly sick and critically ill because they don’t do it anymore.

    if this were a market based business, we would be rich by now.

  6. I was having the exact same thought about ED overuse and our “efficiency” yesterday. We are the one-stop shop, and it all gets done in hours, not weeks. I’m not sure I could have put it quite as eloquently, though.

  7. GPO: Good for Parts Only
    HAIRY PSALMS: Haven’t Any Idea Regarding Your Patient, Send a Lot More Serum
    LOBNH: Lights on But Nobody Home
    TEETH:Tried Everything Else, Try Homeopathy
    UBI:Unexplained Beer Injury

    Not mine, unfortunately. From:

    Medical Slang in British Hospitals
    Adam T. Fox, Michael Fertleman, Pauline Cahill, Roger D. Palmer
    Ethics & Behavior, 2003, Vol. 13, No. 2, Pages 173-189

    Referenced in the Wall Street Journal Health Blog today (highly recommended btw).

  8. So I was off work and surfing and found this place and thought I would join up. I don’t have much more to say right now except I need to start reading some of the older posts to get up to speed before I can start posting.


  9. Hi! I just found this forum and it looks really cool.

    Now, I gotta run off and read some posts. 🙂

  10. i’m eric. joining a couple boards and looking
    forward to participating. hehe unless i get
    too distracted!


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