Guest Editorial

Moonlighting:

The Resident’s Second Job

Eric England, MD, Robert D. Wissman, MD, Jannette Collins, MD, Med, FCCP, FACR

As another wave of medical students crashes upon the shore of

radiology residency programs during interview season, I am

always amazed at the enthusiasm and inquisitiveness that

each new group of applicants brings. Although these appli-

cants ask a variety of questions during their interviews, a

common theme inevitably emerges regarding the moon-

lighting opportunities available at our program. What should

be a secondary consideration for applicants in their ranking of

programs has evolved into a legitimate feature of the program

that applicants take into consideration before creating their

rank list, almost on par with the educational opportunities

provided by a program. Given that current literature has

well documented the common practice of resident moon-

lighting and the financial incentives associated with it, this

interest should not be surprising (1,2). However, as

academic radiologists, program directors, and department

chairs, are we living up to our obligation of providing an

exemplary residency education by acknowledging and

condoning the breadth of resident moonlighting that

occurs? This is a difficult and somewhat controversial

question given the spectrum of moonlighting opportunities

available to residents, some of which are explored in the

article, ‘‘Internal versus External Moonlighting: Differences

in Roles and Responsibilities’’ (3).

RADIOLOGY RESIDENT MOONLIGHTING: ACOMMON SECOND JOB

This thought-provoking article brings several key facets of

resident moonlighting to life, some of which academic radiol-

ogists may not entirely appreciate. Most notably, the article

reinforces prior literature in documenting that resident

moonlighting is commonplace in that 72% of residents

actively participate in internal and/or external moonlighting

(2,3). Additional research indicates that as many as 87% of

department chairs have allowed internal or external

moonlighting to occur at their programs (1). These figures

Acad Radiol 2014; 21:429–430

From the Department of Radiology, University of Cincinnati Medical Center,234 Goodman St, Mail Location 0761, Cincinnati, OH 45267-0761 (E.E.,R.D.W., J.C.). Received January 29, 2014; accepted January 29, 2014.Address correspondence to: E.E. e-mail: eric.england@uchealth.com

ªAUR, 2014http://dx.doi.org/10.1016/j.acra.2014.01.018

support the conclusion that resident moonlighting is not

only widely practiced but also accepted by the vast majority

of residency programs. Also in this present article, McNeeley

et al. (3) emphasizes a prior study he conducted that found the

majority of residents who moonlight (79%) do so 1–10 h/wk,

and 19.4% of residents moonlight 11–20 h/wk. Thus, we

must acknowledge that resident moonlighting is not only

widespread but also consuming a significant portion of

residents’ time, in some cases on par with a second job.

IMPACT OFMOONLIGHTING ON THE RADIOLOGYRESIDENT

There are limited data in the literature documenting the impact

that moonlighting has on a radiology resident’s education or

well being. However, one can surmise that moonlighting may

be associated with increased physical and emotional stress, espe-

cially for the nearly 1 in 5 residents who spend up to 20 h/wk

away from their families to moonlight.

In addition, sacrificing time that could be spent studying

radiology to moonlight may hinder a resident’s education.

With the recent change to the structure of the radiology-

certifying examinations, residents across the country are

requesting more dedicated study time during their third

year to prepare for the Diagnostic Radiology Core Examina-

tion. Residents cite recently released data from the American

Board of Radiology, which indicate a 13% failure rate on the

examination, to bolster their claim of the need for more dedi-

cated study time. In light of these data, would residents be bet-

ter off moonlighting, or engaging in independent study, daily

lectures, and supervised clinical rotations? Can they do it all?

The present article by McNeeley does an excellent job

highlighting the different aspects of both internal and external

moonlighting as well as suggesting benefits to expanding

internal moonlighting opportunities. Specifically, expanding

internal moonlighting might decrease the amount of external

moonlighting, which is often unsupervised. However,

although admittedly controversial, perhaps we should also

consider curtailing both internal and external moonlighting

opportunities. This may be an unpopular idea among resi-

dents but offers potential benefits. If the majority of residents

spend 52–1040 h/y moonlighting, imagine the knowledge

that could be gained devoting even a small percentage of

that time to studying. Additional benefits of spending time

with family and away from clinical duties would also offer a

much-needed reprieve from the ‘‘daily grind.’’

429

ENGLAND ET AL Academic Radiology, Vol 21, No 4, April 2014

Numerous surveys have documented the onerous level of

debt residents carry as a motivation to participate in moon-

lighting (4). Eliminating moonlighting would cut off this

stream of extra money that could be used to pay off that

debt or to live more comfortably. Certainly, most radiologists

sympathize with the ever-increasing costs of education and

the burdensome level of debt these costs place on residents.

Yet, should training programs be responsible for assisting

residents in repaying that debt by allowing moonlighting,

especially when it may be to the detriment of the resident’s

training? The primary objective of a residency program is to

provide a comprehensive educational experience. Is that

objective being met when moonlighting is permitted? The

Accreditation Council for Graduate Medical Education

(ACGME) requires that, ‘‘Moonlighting must not interfere

with the ability of residents to achieve the goals and objectives

of the educational programs’’ (5).

IMPACT OF MOONLIGHTING ON THE RESIDENCYPROGRAM

There has been little to no research on the effects that moon-

lighting (a resident’s second job) may have on a residency

program (a resident’s primary job). Many residents cite the

need for dedicated study time to adequately prepare for the

Diagnostic Radiology Core Examination and to adequately

compete with other residents who may or may not have this

dedicated time off. Is moonlighting or the residency program

affecting the amount of time available for studying? I have yet

to hear residents advocate limiting or eliminating moon-

lighting to provide more study time. Instead, residents prefer

additional time off or limiting clinical duties. One can

certainly understand the financial incentive to be paid for

both studying during clinical hours and moonlighting.

An additional impact of moonlighting on residency

programs may be the interference of moonlighting with call

and overnight rotations. When and if conflicts occur, depend-

ing on the type of moonlighting coverage, there may be

incentive to try and cover both shifts at the same time that

could negatively affect patient care. Covering studies from

an outside hospital (external moonlighting) while on call or

covering contrast at a remote facility (internal moonlighting)

while on call both have the potential to stretch a resident’s

abilities and negatively impact patient care. Should this

practice be knowingly permitted? Lack of monitoring and

financial incentives may make this practice more common-

place than one might think.

Finally, although multiple studies have documented a low

rate of duty hour violations from resident moonlighting,

McNeeley concludes that ‘‘these violations go largely undoc-

umented’’ (3). I agree that duty hour violations particularly

pertaining to moonlighting go largely undocumented simply

because of the financial incentive not to document these

430

violations. Even if there are just a small percent of residents

who violate duty hours by moonlighting, exceeding duty

hour requirements could have a significant detrimental impact

on residents’ education, negatively affect patient care, and

jeopardize the accreditation status of the residency program.

The ACGME requires that with regard to resident moon-

lighting, ‘‘the program director and institution must ensure a

culture of professionalism that supports patient safety and

personal responsibility’’ (5).

THE CASE FOR RETHINKING OUR APPROACH TORESIDENT MOONLIGHTING

Although some residency programs may have stringent

requirements and testing that must be met before residents

may begin moonlighting, this is the exception rather than

the rule. Many program directors and department chairs

will simply sign a sheet of paper when the resident completes

a certain level of his or her training, allowing that resident to

moonlight and trusting that the resident will work and act in a

responsible way. Is this the most appropriate way to ensure the

highest standard of patient care and resident training? As both

mentors and instructors to residents, it is our primary respon-

sibility to ensure the highest level of patient care and educa-

tional experience for our residents. By allowing resident

moonlighting, are we realizing this high standard?

Radiology resident moonlighting is a contentious issue that

residents are extremely passionate about. Although there is

limited research on this topic, most of the literature to date

emphasizes how to best balance moonlighting with clinical

duties or as discussed in this current issue, how to provide

and expand more supervised moonlighting opportunities

through internal moonlighting. The limited research into

the field of radiology resident moonlighting limits drawing

definite conclusions on the effects that moonlighting has on

both radiology residents and training programs. Clearly,

more investigation in this area is needed. Until then, it may

be prudent to more closely monitor moonlighting and its

effects on residents and the training program.

REFERENCES

1. Baker SR, Romero MJ, Patel A, et al. Internal and external moonlighting by

radiology trainees: a survey of the extent of participation by current

residents and fellows. Acad Radiol 2009; 16:1029–1033.

2. McNeeley MF, Prabhu SJ, Monroe EJ, et al. The nature and scope of moon-

lighting by radiology trainees: a survey of the extent of participation by

current residents and fellows. Acad Radiol 2013; 20:249–254.

3. McNeeley MF, Monroe EJ, Prabhu SJ, et al. Internal versus external moon-

lighting: differences in roles and responsibilities. AcadRadiol 2014;546–553.

4. Mainiero MB, Woodfield CA. Resident moonlighting in radiology. J Am Coll

Radiol 2008; 5:766–769.

5. The Accreditation Council for Graduate Medical Education. Common

program requirements. Available at: http://www.acgme.org/acgmeweb/

Portals/0/PDFs/Common_Program_Requirements_07012011[2].pdf. Ac-

cessed January 18, 2014.