Published in the March 2015 issue of Today’s Hospitalist
WHEN FULL-TIME HOSPITALISTS moonlight at different hospitals and health systems on their time off, is it anybody’s business but their own?
Given how many hospitalists 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, hospitalists 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.”
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 hospitalist’s full-time employer may be the last to know that a physician’s troublesome performance may be related to overwork.
In asking for advance notice, “We are not trying to be Big Brother about it,” Dr. Gundersen adds. “But if a clinical problem ever surfaces at the hospital and you find out that you have a doc working outside the bell curve of what people would say is safe, you do want to have some recourse.”
But then there’s another point of view: Letting “or even encouraging “hospitalists 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.
“Some people have lots of energy and lots of need for money,” says James Levy, PA-C, vice president of human resources at Indigo Health Partners, a private hospitalist group based in Traverse City, Mich. “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.”
There’s also the “grass isn’t really greener” phenomenon that groups can benefit from. As Mr. Levy puts it, moonlighters often learn “how good they have it with us.”
Don’t stand in their way
Given the continuing supply-vs.-demand mismatch in hospital medicine, conventional wisdom holds that there isn’t much a group can do if doctors want to moonlight on their days off, as long as their full-time performance remains adequate.
After all, hospitalists are bombarded with so many opportunities that hospitals with blanket prohibitions or broad noncompetes may end up losing staff. And hospitalist leaders who have been around for more than a decade say that hospitalists’ interest in outside moonlighting isn’t going away.
“Within an hour’s drive, you could probably work at 10 different hospitals, and all of them need help,” points out Scott Perlman, MD, interim medical director of the hospitalist program at St. Francis Hospital in Greenville, S.C., and a regional medical director for TeamHealth Hospital Medicine. He expects that most of the 70 hospitalists he oversees in seven programs moonlight some, while a few moonlight a lot and have done so for years.
Dr. Perlman also figures he knows about most of the moonlighting that goes on, but not all. “We haven’t lost physicians to other companies,” he notes. “People moonlight and then come back and tell other people in the group that this is so much better.”
He has had to draw the line and issue a flat-out prohibition only once, when a medical director wanted to moonlight at a competing hospital. “We said, ‘We’d rather you not,’ ” he recalls. ” ‘We are training you to be a leader, so we don’t want you to be going elsewhere when you are working with us.’ ”
But for frontline hospitalists, it’s a different story. “If they want to moonlight to make more money,” Dr. Perlman adds, “you are probably disadvantaged in the long term if you try to stand in their way.”
Picking and choosing
That may be true in some markets. But in areas where supply more closely matches demand and hospitalists 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 hospitalist’s primary employer.
“What does external moonlighting do to your ability to be a good partner in our organization?” That is what Jerome Siy, MD, department head for hospital medicine at Minnesota’s HealthPartners, asks himself when any of the roughly 70 hospitalists at six different sites proposes to moonlight at other hospitals and clinics.
“Are you getting too tired, or being distracted because you have other responsibilities?” Or would moonlighting allow hospitalists to broaden skills or give back to the community in ways they can’t in their regular jobs? External moonlighting that falls into those latter categories are ones that “we approve,” says Dr. Siy, who chairs the Society of Hospital Medicine’s practice management committee.
One HealthPartners hospitalist, for example, was approved to maintain a small moonlighting practice at a community clinic that serves Latino patients with HIV/ AIDS. In another instance, Dr. Siy says, a long-term hospitalist who trained as a nephrology fellow was approved to moonlight in that subspecialty “to keep up her skills.”
In such cases, external moonlighting is a win-win for both the hospitalist and the group, “consistent with our organizational philosophy,” Dr. Siy points out. Otherwise, “We say, ‘We want you to be engaged with our group and company, and absolutely you can do extra work, but do it here.’ As an employer, you are investing a lot in this individual, and to lose that to some other group and have that adversely affect you, that’s a big risk.”
Dr. Siy also notes that his colleagues have begun to change their language around shifts. They no long refer to people being “off” just because they aren’t scheduled for a clinical shift.
“We will say that there are 26 clinical weeks, but there are responsibilities that occur even when you are not reporting for a shift,” he points out. “You may not be working clinically, but you are still a part of this organization.” Such responsibilities may include participating in committees or being available to work extra during a flu outbreak.
Making it work
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 hospitalists ” as professionals “understand that.
Consider a situation that cropped up about eight years ago at St. Francis: Two of the group’s 12 full-time hospitalists had busy moonlighting practices on the side, working 10 shifts or so a month elsewhere on top of the 15 required in their full-time job. St. Francis’s schedule, meanwhile, was request-based, with most people working blocks of four or five days and splitting weekends and holidays equally.
“These docs were basically making a lot of requests” to accommodate their moonlighting, Dr. Perlman explains. “We said, ‘This isn’t working. You can moonlight, that’s fine, but this is your full-time job. You have to commit to us first, and then let the locum company book your moonlighting jobs.’ ”
Not only did open discussion solve the problem, but it prompted the group to improve its scheduling system overall. “They understood, and they have been good about giving us priority,” Dr. Perlman said. These particular hospitalists remain valuable members of the group while continuing to carry heavy moonlighting commitments.
In Syracuse, N.Y., meanwhile, the hospitalist group at St. Joseph’s Hospital Health Center had to adopt a policy on external moonlighting about a dozen years ago after a hospitalist showed up too tired to work. He had pulled a 24-hour moonlighting shift at a different hospital just before his regular 12-hour shift.
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.) James Leyhane, MD, the hospitalist director there, estimates that about two-thirds of his 22 hospitalists moonlight “to some degree,” some more than others.
“Anytime somebody goes elsewhere, you risk them being recruited,” he notes. It can also be frustrating if the group is scrambling to cover an unexpectedly open shift when its own hospitalists are working elsewhere.
“It’s best if you can keep doctors who want to moonlight at your own institution by offering it onsite,” says Dr. Leyhane. He notes that it can be tough to compete if other institutions offer more money.
Incentives to moonlight in-house
Dr. Leyhane says that he is now working with administration on a carrot-rather-than-stick-approach, offering doctors incentives to choose internal moonlighting instead.
He calls the plan “choose your own shift,” designed to make internal moonlighting flexible and easy. “We say we need you to come in for at least six hours and cover 10 or 11 patients, but you can do more if you want,” says Dr. Leyhane. “Physicians will tell us how much time they can give us, and we’ll give them a certain number of patients. Then they are paid hourly, and we are looking to add some productivity incentives too.”
St. Joseph’s 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, hospitalists 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. “Then we open it up for unrestricted sign-up,” he says. “The most that doctors generally sign up for is four of those shifts a month.”
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.
Dr. Beddow believes that allowing doctors who want to earn more to moonlight “helps with job satisfaction and, therefore, retention. If people are doing their job well at their home site and they have an opportunity to make money somewhere else, we allow that as long as they inform the site lead.”
But he too prefers people to moonlight internally.
“We encourage people to be credentialed at all our different sites,” he explains, making it easy for them to find an inside moonlighting shift pretty much any time they want. Hospitalists do need to inform their lead hospitalist about any moonlighting they are doing (typically as part of their annual review), show they have malpractice coverage at their moonlighting site if it’s external, and make sure their “home site is fully staffed first” before taking on work elsewhere.
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, hospitalists 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.”
Other cases that cross lines are when moonlighting opportunities may reflect poorly on the primary employer. HealthPartners’ Dr. Siy recalls one hospitalist who was moonlighting at a pain clinic not associated with HealthPartners. On its Web site, however, the clinic posted the names of its providers and their primary affiliations.
“We didn’t want our name attached” to that clinic, he points out. And in discussing the situation with the hospitalist, “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,” Dr. Siy says. “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 hospitalists 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.