Toil and trouble?: Should residents be allowed to moonlight?

Moonlighting is incompatible with residents’ work schedules

South of the border, the Accreditation Council for Graduate Medical Education has adopted the 80-hour work week, in which residents cannot exceed 80 hours, including on-call duties, in a single work week; this rule is closely monitored, and institutions that violate it are fined or, worse, lose their accreditation.1 In the past, the Association of American Medical Colleges has noted the irony of closely regulating work hours while ignoring moonlighting.2 In Quebec, the Federation of Medical Residents and the government have negotiated a contract that states the workday can be a maximum of 12 hours, on-call schedules are a maximum of 24 hours, residents must have a full day off following on-call duties, and there is a maximum of 6 in-house calls per 28 days.3 How can residents moonlight and keep within their training guidelines? Hospitals are fined if residents are placed on monthly on-call schedules more than 6 times, yet residents voluntarily work 3 to 4 moonlighting shifts without any penalty. This inconsistency is not acceptable, and if residents want to moonlight then their total number of on-call schedules must be within the mandated guidelines.

Moonlighting is not educational

Many proponents of moonlighting argue that moonlighting provides clinical autonomy, allows residents to refine their procedural skills, and exposes them to clinical material that they might not have seen in tertiary centres. Of course, these people forget that residents who moonlight work with minimal supervision. Who will correct residents’ mistakes? Or will they continually perform the same mistakes? There is a large body of literature on the value of feedback on learning. In acquisition of procedural skills, feedback is indispensable,4,5 and the lack of feedback decreases acquisition of procedural efficiency.6 Family medicine residents’ cognitive or procedural skills will not improve by working in emergency rooms without supervision.

Residents also tend to miss educational programs or events at their primary hospital in order to arrive on time at the moonlighting hospital. If a resident moonlights 3 shifts in a month, he or she loses this time for other educational activities, such as reading or preparing a presentation for rounds. Those in favour of moonlighting must explain how they will prevent this detrimental effect on the resident’s overall educational experience.

Moonlighting does not offer sufficient financial benefits to warrant the extra work

Residents often choose to moonlight because of financial concerns. Evidence shows that residents with higher student debt are more likely to moonlight.7 But at what cost? In one study, the majority of moonlighting residents had violated the work-hour regulations of the Accreditation Council for Graduate Medical Education and in return deprived themselves of seeing and enjoying their families during their off-hours.8 With residents’ salaries gradually increasing, thanks to the effort of unions, the incremental benefit of a few added shifts per month will soon decrease—thereby making the trade-off of family for money less inviting.

Residents who moonlight miss opportunities to attend provincial, national, and international meetings, where they could market themselves and find attractive jobs in places they would want to work. Moonlighting residents must also pay hefty medicolegal fees and expose themselves to the emotional and financial burdens of litigation. Residency is a time to learn in the sheltered environment of a residency program without being exposed to the harsh rigours of independent practice.

Moonlighting produces extreme fatigue, which further inhibits learning

It is inconceivable that residents are able to work on-call, keep up with required readings, perform research, and moonlight without experiencing fatigue. It has been shown that fatigue can decrease memory and attention.9 Papp et al found that moonlighting can lead to fatigue-induced decrease in personal satisfaction; these authors studied 149 residents from various specialties at 5 US academic health centres and found that sleep loss and fatigue had a major effect on residents’ personal lives, noting that meaningful personal pleasures were deferred or postponed.10

The desire to supplement one’s income and pay off accumulated debts will persuade hardworking residents to work even harder. Being young and inexperienced, residents will not understand that these debts will be paid off with time, but the time lost to moonlighting can never be recouped. As their mentors, we need to impart the wisdom we have gained over the years, namely that what matters most in the end is not money but rather family and personal pleasures. We must convince our trainees that residency happens only once, and if they do not take advantage of it, they will find themselves all too quickly graduated and in practice without the same opportunities to learn, be mentored, and enjoy the journey.