Residents’ Moonlighting Spurred by Debt, May Pose Safety Risks
Abstract
Researchers assess the impact of psychiatry residents’ work schedules on job performance, quality of life, and patient care.
Psychiatry residents allowed to moonlight frequently do so, sometimes without reporting their hours as duty hours and without on-site supervision, according to two studies published in Academic Psychiatry. One study surveyed psychiatry residents, and the second study surveyed both psychiatry residents and residency program directors.
In the first study, researchers from Boston’s Massachusetts General Hospital (MGH) surveyed psychiatry residents from 16 academic center training programs to uncover how common moonlighting is, why residents moonlight, and how it affects their training. The survey was posted online from February 20, 2018, to May 1, 2018. Of 624 general psychiatry residents at the 16 centers, 173 (28%) completed the survey, with nearly equal numbers of women and men responding.
Co-authors Nicole Benson, M.D., a clinical fellow in child and adolescent psychiatry at MGH, and Scott Beach, M.D., an assistant professor at Harvard Medical School and director of the adult psychiatry residency program at MGH/McLean Hospital, found that 94 of 173 residents said they were allowed to moonlight, and 47 reported having done so in the past year.
Most moonlighting residents cited financial reasons as their primary impetus, and 1 in 7 said they sought additional clinical experience, independence, or responsibility.
Nearly all responders said their program had specific guidelines for moonlighting. However, Benson and Beach found that only 68% of moonlighters reported their moonlighting hours, despite an Accreditation Council for Graduate Medical Education (ACGME) requirement that residents report all duty hours.
Of 47 residents who reported moonlighting in the past year, 20 said they had done so outside their home institution. Nine said no supervision was available to them.
Residents who moonlighted spent an average 17 hours each month doing so. Ten percent reported they had moonlighted an overnight shift and then performed regular residency duties the next day. This practice may violate ACGME rules specifying 24-hour maximum continuous shifts or eight-hour minimum time between shifts, the researchers said. Only one resident reported moonlighting that extended work hours beyond the ACGME’s limit of 80 hours a week.
Impact of Shift-Schedule Change on Residents, Patients in Psychiatric Emergency Service
Among residents on rotation in psychiatric emergency services (PES), modest modifications of shift length and timing may improve residents’ performance and well-being, as well as reduce patient wait times, according to researchers from Brooklyn’s Maimonides Medical Center. Their report appeared in the December 2018 Psychiatric Quarterly.
Residents rotating through Maimonides’ PES initially worked 12-hour daytime shifts from 8 a.m. to 8 p.m., Navjot Brainch, M.D., chief resident in psychiatry, told Psychiatric News. These residents reported greatest fatigue in the latter hours of these shifts, which also tend to be the busiest hours of the day—about 40% of their patients arrive between 4 p.m. and 10 p.m.
Typically, three residents worked the 12-hour daytime shift, and two worked the 12-hour nighttime shift from 8 p.m. to 8 a.m.
In July 2016 the Department of Psychiatry introduced an alternative, 10-hour “swing” shift that started at noon and ended at 10 p.m. for 10 PGY-2 residents. Each week, the PGY-2 residents switched between the two daytime shift options, with at least one resident on each shift every weekday. The night shift remained the same.
The department anticipated the 10-hour daytime shifts would lessen resident fatigue, improve time-consuming hand-offs during high-traffic hours, and reduce patient wait times, Theresa Jacob, Ph.D., M.P.H., director of research for Maimonides’ Department of Psychiatry, told Psychiatric News.
To assess the impact of the different shift options, Brainch and her colleagues asked all 38 psychiatry residents to complete the Maslach Burnout Inventory, a validated measure for assessing burnout in professionals. The 10 PGY-2 residents also completed weekly surveys measuring fatigue, sleep, and life outside work.
When working the 10-hour shift, 86% of residents reported getting enough sleep. Of those working the 12-hour shift, 83% reported insufficient sleep. Still, some preferred the 8 a.m. to 8 p.m. shift because its timing meshed better with family responsibilities, including child care. Use of both schedule options continues today.
To measure the impact on patients, the researchers collected data from electronic medical records on patient wait times and length of stay for 1,847 patients seen in the six months before July 2016 and for 1,908 patients seen between September 2016 and February 2017.
The average patient wait time during peak hours fell from 5.3 hours before the change to 3.7 hours after the change and from 5 hours to 3.7 hours across the 24-hour day. Length of stay dropped from about 20 hours to 14 hours during peak time and from an average of 19 hours to 15 hours for the entire day.
Those are significant improvements, Brainch said. Reducing wait times benefits patients with mental illness and substance use disorders for whom prolonged stay in the PES may worsen symptoms, increase agitation that compromises patient and staff safety, and boost elopement risks.
The authors reported no external funding for this study.
“Psychiatric Emergency Services—Can Duty-Hour Changes Help Residents and Patients?” can be accessed here.
The researchers found, to their surprise, that moonlighting had neither a positive nor negative effect on residents’ quality of life, Benson told Psychiatric News.
Benson and Beach urge programs that permit moonlighting to verify that residents report moonlighting hours as duty hours and ensure residents can obtain supervision.
In the second moonlighting study, Lee Robinson, M.D., director of training for the child and adolescent psychiatry fellowship at Cambridge Health Alliance in Cambridge, Mass., and colleagues at the New York State Psychiatric Institute and Columbia University, surveyed 183 ACGME-accredited general psychiatry programs about moonlighting practices; 63 program directors and 238 residents responded.
Most respondents said their programs permitted moonlighting, a practice that increased in frequency with each year of training. Among fourth-year residents who responded, 67% reported moonlighting.
As in the study by Benson and Beach, most residents cited financial reasons as a driving force for moonlighting. Robinson and colleagues found that residents who moonlighted were more likely to have higher levels of debt than those who did not moonlight. In fact, 23% of moonlighting residents reported debt above $300,000. Only 13% of nonmoonlighters had debt that high. More than half of actively moonlighting residents reported earning 25% or more of their overall income from moonlighting.
In many moonlighting jobs, residents work as contract employees and are not covered by a hospital’s malpractice insurance, Robinson told Psychiatric News. Residents need to ask about that before they start moonlighting and get insurance when necessary, he said.
Of the program directors who responded to the survey, 37% said they had no oversight procedures for moonlighting residents, a practice that violates ACGME’s requirement for monitoring resident duty hours, the researchers noted. Their findings also prompted concerns about supervision: 39% of residents reported no supervision at one of their moonlighting sites, and only 9% reported they always had access to on-site supervision.
“Beyond the obvious concerns these figures raise for patient safety, they also indicate that many residents are exposed to a high level of liability risk,” Robinson and colleagues wrote.
The study by Benson and Beach was funded by MGH/McLean Hospital, Harvard Catalyst/The Harvard Clinical and Translational Science Center, and Harvard University and its affiliated academic health care centers. Robinson and colleagues reported no external funding for their study. ■
