During the last two years of my residency, I made over six figures annually, and this was in an era when a resident’s salary was less than $50,000.  How?  Through moonlighting, which I believe is a vital part of any resident’s training (and finances). In all its forms, moonlighting provides additional money, experience, contacts, and confidence as you start your professional career.  This post discusses why I believe all residents should moonlight, how to maximize your efforts, and what pitfalls to avoid.      

Moonlighting Basics

What is it?

     Any clinical activity for which you are paid beyond your resident’s salary can be considered moonlighting, which does not include non-clinical work like medical surveys, administrative tasks, or other non-medical side hustles.  

     Moonlighting can be broken down broadly into two types: internal and external.  Internal moonlighting is performed within your program’s existing hospital system.  For example, working extra shifts for extra pay in your system’s clinics, ER, or inpatient setting is considered internal moonlighting.  Other examples include code call, where you sleep in the hospital and cover any cardiac arrests on the floor, and procedure call, where you cover any overnight procedures.

     External moonlighting occurs outside the confines of your residency program, which may be at another hospital in your city, in another town, or even out of state.  It includes work in private clinics, free-standing ERs, and even locum tenens assignments.  

     A fun form of external moonlighting is performing medical support at sporting or entertainment events.  I worked medical support at the Master’s golf tournament in Augusta, Georgia, during the last two years of my residency.  Although I wasn’t paid for it, I did get in free to see the tournament and received free food and drinks.  It was well worth it.     

How Do I Get a Job?

     Details will vary depending on where you live, but asking your colleagues is a good place to start.  Some of your senior residents are likely already moonlighting and can give you contact information.  Your attendings might also have side jobs they can tell you about.  I would also encourage you to talk to locum tenens companies and CMGs that staff in your state.  Looking outside your immediate area might provide more opportunities and/or better pay.  You can also look out of state if you can get a license.  I know residents who traveled to moonlight from West Texas to Eastern New Mexico.   

My Story

     I didn’t double my salary making $200 an hour in a large ER.  In fact, I never made more than $76 per hour moonlighting on a regular basis, although there were a few occasions where I made substantially more.  Instead, I worked a lot of long hours in rural Georgia ERs for large contract management companies. 

     My emergency medicine residency program had some rules when it came to moonlighting.  We were only allowed to moonlight 3 shifts per month and only if the program director approved.  We also had to make a particular grade on the in-service exam and be in good standing with the program.  

     I took full advantage of the opportunity (and then some), accumulating over 1500 hours by the time I graduated.  Although the rules stated we could only work 3 shifts per month, they didn’t specify how long those shifts could be.  I worked as many 72-hour shifts as I could fit into my schedule.  Additionally, I discovered that if I worked outside the catchment area of the residency program’s main hospital, I would never have to transfer a patient to one of my attendings, and thus, no one would know if I was working.  Allegedly.  

Why Every Resident Should Moonlight

      Not all residents will be able to moonlight, as not all residency programs allow it.  FMGs on a J-1 Visa are ineligible.  Married students with children may not have enough time.  However, most residents should be eligible.  

     You may be able to moonlight internally without a state medical license, using your training license to work under an attending physician.  An external job provides the most benefits but requires a state medical license, which is easier (and faster) to get in some states than others.  You must also be approved by your residency director.  Regardless of location, I recommend everyone participate if they can, as moonlighting provides several benefits.  

Make More Money

     Let’s start with the obvious: residents are seriously underpaid.  It’s a challenge to meet your financial goals on a resident’s salary, which is why so many defer saving and investing until after they graduate.  However, one of the principles of personal finance is that the earlier you start, the more your expected long-term results will be.

     So how much extra money can you make?  Code call paid $30/hour for an 8-hour shift when I was a resident.  We called it “sleeping for dollars” because of the infrequency with which “code blues” were called.  This wasn’t a lot of money, but you could work on days you also worked in the ER, which was a very efficient use of your time.  If you got some sleep it was a great deal.  If you didn’t, you were in for a rough next day.  

     Urgent care clinics usually hire anyone with a medical license and can pay anywhere from $60/hour to $120/hour depending on the location and volume.  These are typically 12-hour shifts from 8-9 am to 8-9 pm.  

     You can make big money moonlighting in the ER.  As mentioned, I never made more than $78/hr. on a regular basis, but times have changed, and you can now make up to $200/hr. or more working in some ERs.  My ER group gladly pays $200 per hour or more for a 24-hour shift in one of the low-volume, rural ERs we staff.  Seriously, if you’re an ER resident with a TX license, shoot me an email!    

     This can all add up to some serious money, which you will hopefully use to jump-start your financial journey.  Use the Financial Vitals Checklist to learn what to do with your next dollar!  

Spend Less Money

     A friend came to my apartment one day and found a stack of checks on my coffee table.  I was moonlighting for a few CMGs at different hospitals, all of whom paid me monthly.  He thought I was rich because I had $10,000 worth of checks sitting there.  My savings rate from moonlighting was approaching 100% at that time, not because I was a financial wizard but because I was too busy to spend any money.  Between residency, moonlighting, and my regular life, I didn’t even have time to take the checks to the bank!  The busier you are during residency, the less time you have to spend, and the more you can save.    

Get Accustomed to Working Hard(er)

     It is challenging to work more than you do as a resident with your clinical and academic responsibilities and a life outside the hospital.  However, you can always work a little extra.  Remember that they only created the 80-hour work restrictions about 20 years ago.  Before this, residents routinely worked more, which is why they made the law!  You can fit another one or two shifts a month into your busy schedule.  Take in-house call and (hopefully) get some sleep.  Moonlight only during off-service months.  Moonlight during your vacation time.  There is always a way.  And the more you work, the more you will find you can.  You will get faster and more efficient at seeing patients and writing notes.  You will build up your tolerance for work, which will serve you well in your first few years as an attending.  

Gain Experience 

     You can’t learn medicine from a book, which is why half of medical school is clinical and residencies last 3-8 years.  Residency programs are essentially elaborate apprenticeships where you get hands-on experience from experienced medical providers.  Like any apprenticeship, the more reps you get, the more varied situations you are in, and the more independence you earn, the better.  Moonlighting gives you all three.

     I have worked with many residents and fellows during my 20 years in the ER, and they all have said the same thing after moonlighting- It’s a whole different ball game when you make the decisions.  As a resident, no matter how permissive your attending might be, you always have a reassuring presence in the background.  When moonlighting, you’re on your own.  You may respond by becoming more conservative, or you may feel free from the shackles of authority, but you must make the final call and live with the consequences.  That is a heavy responsibility you can’t fully understand until you are on your own.  It is a valuable experience for all residents.    

     You also gain practical experience for your resume.  When I interviewed for my first job out of residency, the medical director told me they had never hired a new graduate because their volume and acuity were too high.  I confidently countered that I’d logged 1500 hours of moonlighting, or nearly a year’s worth of full-time work.  

Gain Confidence 

     I was not good at doing lumbar punctures (LPs) during residency.  A resident would get one attempt, maybe two, before the attending took over.  After several misses, my confidence was shot.  But late one night, while moonlighting in a four-bed ER, I had a patient who needed an LP before being transferred.  She had a body habitus that made the procedure difficult, but I was determined to complete it before the transfer.  I probably stuck that poor woman 10 times before I finally saw that clear liquid flow, but something changed with that small victory.  I’ve never had problems with LPs since then.  

     I can remember so many cases from my time moonlighting.  My first solo intubation.  My first chest tube for a spontaneous pneumothorax.  The first time I injected dye into a knee to see if there was an open joint.  The first time I consciously sedated a child to close his facial lac.  I remember how nervous I was in each of these cases and how confident I felt after.    

Become a Better Resident

     I believe I was a better resident because I moonlighted, not just because I got better at procedures.  Because I was moonlighting at smaller ERs, I had plenty of time to read about my patients in real-time.  If I didn’t know something, I looked it up.  I had to.  There was no one to ask.  I quickly discovered the gaps in my knowledge and took action to remedy them.  Working without a safety net made everything more real, which made me focus and improve.  I was able to take my newfound experience, confidence, and knowledge back to my residency program.      

Discover What You Like (and What You Don’t)

     Moonlighting can be a trial run for future jobs.  You may discover you love the pace of working in a rural ER.  Like I did, you may find that working 72-hour shifts eventually makes you feel like a prisoner.  You may even find your future employer.  

     My first job after residency was with a CMG for which I was moonlighting.  I liked the scheduler and didn’t feel like shopping around for jobs.  I asked her where her company paid the most money, interviewed there, and took it.  It sounds like a terrible way to decide, but I still work in that same ER nearly 20 years later.    

Pitfalls to Avoid

     Although I think that all residents should moonlight, it is not all rainbows and butterflies.  There are several pitfalls you need to avoid to ensure you have a positive experience and get the most out of your time and efforts.  

Know Your Limitations 

     There are some rural hospitals that will hire anyone with a license.  If you’re a family medicine resident without ER experience, you probably don’t want to take a gig working single coverage in a small ER without backup.  No amount of money is worth hurting a patient or damaging your career.  

     This doesn’t mean you can’t moonlight in an ER as a non-ER resident.  But you had better be selective and do some prep work: do rotations in your home ER, spend some time with anesthesia performing intubations, and maybe take an educational ER boot camp.  Make sure you have some backup.  Ask an ER resident or attending from your residency if you can call them with any questions that arise when you are on shift.  

      Before accepting any job, assess your current situation honestly to ensure you don’t overextend yourself.  Does your specialty, experience, and skill set align with the position you are considering?  Do you have enough time and physical/mental capacity to handle additional work and stress?  Know your limitations.

Follow the Rules

     Although I didn’t take my own advice (allegedly), I recommend that you follow your residency program’s rules regarding moonlighting.  It isn’t worth getting kicked out of your program and jeopardizing your future income.  The ACGME also has rules you must follow, and moonlighting hours count toward your work-hour limits.  

Don’t Sell Yourself Short

     Don’t choose internal moonlighting if you have other options.  Get out of your comfort zone and push your boundaries.  External moonlighting typically pays better and will help you grow faster as an independent provider.   

     Just as in your future career, don’t sell yourself short because you’re a resident.  You are valuable to anyone who hires you, so know your worth.  Don’t settle for the first job you find.  Keep striving for more pay and new opportunities.  Almost by definition, moonlighting is temporary, and if you are working for a CMG or a Locum’s staffing company, there is no loyalty.  Let your employers know you’re available on holidays and in a pinch but are not a pushover.       

     One early evening a scheduler called to see if I could work an “emergency” 12-hour night shift that started in a few hours because someone else had called in sick.  I had just arrived at the bar with my friends after rugby practice and was hot, tired, and thirsty.  I told her I would work if they paid me triple the standard pay.  She said she couldn’t authorize that, so I informed her that I had just ordered a Guinness draft, and if she hadn’t called me back by the time the head settled, I would drink it and wouldn’t be able to work.  She called me back about a minute later with the approval from her boss.  I gave up a tasty Guinness but made $2,700 that night.    

Understand the Details

     I took one ER gig that was a long drive from where I lived but paid a little more.  Unfortunately, once I got there, I discovered that I was expected to see the ER patients and run codes on the floor, which was typical, but they also wanted me to take nursing calls from the floor and attend to inpatients.  I worked one shift and quit.  I was neither comfortable with nor qualified to see inpatients.  

     You must know all the details of each moonlighting assignment, or you may get in over your head.  What exactly are you expected to do during your shift?  What resources will be available?  What happens if something goes wrong?  Do you have any backup?  You must fully understand the expectations and the risks. 

     Additionally, you need to know some non-clinical details.  Is your malpractice covered with a tail?  If not, don’t take the job.  Are you an employee or an independent contractor?  If you are an IC, you need to make sure you are holding enough back for your taxes.  What happens if your relief doesn’t show up and you have somewhere to be?

  

Conclusion 

     During my residency, when I worked with Dr. Smith, getting a head CT on every patient with a headache was malpractice.  When I worked with Dr. Jones, NOT getting a CT on a patient with a headache was malpractice.  I’m sure everyone who has completed a residency can relate.     

     Moonlighting is about more than money.  It’s your chance to make that decision.  Do you want to practice like Dr. Smith or Dr. Jones or somewhere in the middle?  Who are you going to be as a physician without someone looking over your shoulder?  Moonlighting improves your skills, your experience, and your confidence, all while (finally) paying you some decent money.  It’s time to take your training for a test drive in the real world and return a better resident.  Good luck.