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

Dr Verma argues that moonlighting fills a void in medical services produced by system changes. Are residents supposed to moonlight because of physician shortages or for its inherent educational value? Dr Verma states that moonlighting residents can demonstrate their competence “under supervision.” This is untrue: moonlighting residents are almost always unsupervised. How can they refine their clinical skills without feedback?

Dr Verma agrees that moonlighting contravenes resident collective agreements but seems to think that by making it “legal” she can “impose restrictions on the activity.” If she is such a passionate proponent of moonlighting, why does she want to restrict it? Dr Verma assumes that residents can “decide for themselves what is appropriate.” Clearly they cannot, if moonlighting might need to be restricted “if it interferes with educational performance.” The paper that she quotes1 as evidence for the educational value of moonlighting found that most moonlighting residents violated the Accreditation Council for Graduate Medical Education work restriction and that residents with higher student debt were more likely to moonlight. So clearly there is a conflict of interest: residents moonlight for the monetary gain not the educational value.1

In the end we should listen to our residents: 84.8% of emergency medicine residency applicants agreed that unsupervised care by residents carried a higher risk of adverse patient outcomes.2 If asked to assume the patient role, only 22.7% of senior medical residents would allow another resident to treat them for a serious illness or injury.3

Clearly, moonlighting has many disadvantages and one huge addictive attraction: increased income. If allowed, moonlighting will be abused and not only will the education of our residents suffer, but also the care of our patients.

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