Moonlighting vs. Night Float ?

[wowmd]

Sean,
So are you saying that "In House" moonlighting counts in that 80 hr rule thing, but if you do something outside the hospital, then it's not counted into that 80 hr rule?

and if you dont mind, can you tell me where you did your residency and in what field?

Thanks

[sean]

Hi wow,

Psych...
Here's a copy of ACGME guidelines (may be an old copy but I copied it from the ACGME site) - S :

Frequently-Asked Questions about the Proposed ACGME Common Duty Hour Standards
On July 1, 2003, the ACGME’s new common duty hour standards became effective for all
accredited residency programs. The goal is to set a minimum standard; individual RRCs may set
more restrictive standards, as warranted by patient safety, resident education and resident wellbeing
considerations in their discipline.
In the spring of 2003, the ACGME published the first set of responses to frequently asked
questions (FAQs) about the common duty hour standards. The answers below some updated
responses in areas where the ACGME and the Residency Review Committees (RRCs) have
refined the standards, as well as clarifications related to implementation and monitoring of the
standards. The responses still represent a general answer based on the common standards, and
programs should address specialty-specific question to their RRC team.
Question: What is the definition of “on-call duty”?
Answer: On-call duty is defined as a continuous duty period between the evening hours of the
prior day and the next morning, generally scheduled in conjunction with a day of patient care
duties prior to the on-call period. Call may be taken in-house or from home. Call from home is
appropriate if the service intensity and frequency of being called is low.
On-call duty excludes regular duty shifts worked during night hours, as is done in Emergency
Medicine. It also excludes night float assignment used in many programs to replace on-call shifts
to reduce the continuous waking hours and strenuous nature of some in-house call.
Question: How is the 24-hour limit on in-house call duty applied?
Answer: The activity that drives the 24-hour limit is “continuous duty.” If a resident spends 12
hours in the hospital caring for patients, performing surgery, or attending conferences, followed
by 12 hours on-call, he/she has spent 24 hours of “continuous duty” time, and is limited to up to 6
additional hours for patient care transfer, educational debriefing and didactic activities.
Question: Which standards apply to time in the hospital after being called in from home call?
Answer: For call taken from home (pager call), the time the resident spends in the hospital after
being called in is counted toward the weekly duty hour limit. The only other numeric duty hour
standard that applies is that one day in seven must be free of all patient care responsibilities,
which includes home call. The ACGME also requires that programs monitor the intensity and
workload resulting from home call, through periodic assessment of the frequency of being called
into the hospital and the length and intensity of the in-house activities.
Question: Is it permissible for resident to take call from home for extended periods, such as a
month?
Answer: The requirement that one day in seven must be free of patient care responsibilities
would prohibit residents from being assigned home call for an entire month. Assignment of a
partial month (more than six days but less than 24 days) is possible. Programs considering this
option need to check with their RRC, since the application of this standard varies among RRCs.
Question: How do the ACGME common duty hour standards apply to research activities?
The ACGME duty hour standards pertain to all required hours in the residency program (the
only exceptions are reading and self-learning and time on call from home during which the
resident is not required to be in the hospital). Research of up to 6 months scheduled during one or
more of the accredited years of the program is required in many specialties and may also contain
a clinical element. When research is a formal part of the residency and occurs during the
accredited years of the program, research hours or any combination of research and patient care
activities must comply with the weekly limit on hours and other pertinent duty hour standards.
There are only two situations when the ACGME duty hour standards do not apply to research.
One is when programs offer an additional research year that is not part of the accredited years. In
this case the ACGME standards do not apply to that year. The other case is when residents
conduct research on their own time, which makes these hours identical to other personal pursuits.
One would expect that the combined hours spent on self-directed research and program-required
activities meet the test for a reasonably rested and alert resident when he or she participates in
patient care.
Recently, some programs have view the research rotations as an opportunity to add clinical
activities, such as research residents covering “night float.” This creates an emerging “gray area”
in which research and clinical assignments overlap, which could result in hours that exceed the
weekly limit and could also seriously undermine the goals of the research rotation. RRCs have
traditionally been concerned that required research not be diluted by combining it with significant
patient care assignments. This suggests limits on clinical assignments during research rotations,
both to ensure safe patient care, resident learning and resident well-being, and to promote the
goals of the research rotation.
Question: The ACGME’s definition of duty hours does not explicitly mention participation on
hospital committees, time spent interviewing residency candidates and similar activities? Are
these activities included in the count of duty hours? .
Answer: Yes, hours spent on activities that are required by the accreditation standards, such as
membership on hospital committee, or that are accepted practice in residency programs, such as
residents participating in interviewing residency candidates, must be included in the count of duty
hours? It is not acceptable to expect residents to participate in these activities on their own hours;
nor should residents be prohibited from taking part in them. Programs should note that these
activities do not consume significant hours when averaged over a given period, and their benefits
to the residency program are substantial.
Question: A journal club is held in the evening for two 2 hours, outside the hospital. It is not
held during the regularly scheduled duty hours, and attendance strongly encouraged but not
mandatory. Do these hours count toward the 80-hour weekly total?
Answer: Yes, with attendance “strongly encouraged,” these hours should be included because
duty hours apply to all required hours in the program, and it is difficult to distinguish between
“strongly encouraged” and required. Another way to look at it is that such a journal club, if held
weekly, would add two hours to the residents weekly time, and a program where two added hours
result in a problem with compliance with the duty hour standards likely has a duty hour problem.
Question: Why does the ACGME distinguish between “in-house moonlighting,” which is
counted under the weekly duty hour limit, and external moonlighting, which is not included?
The ACGME has two reasons for counting in-house moonlighting toward the weekly duty hours.
The first is to apply the same standard to all hours residents spend in teaching institutions,
whether they are part of the required educational program or are spent moonlighting in-house.
The second reason is to prevent institutions from inappropriately using in-house moonlighting to
replace clinical service activities residents covered previously as part of the educational program.
The second reason is that the ACGME's purview extends to teaching programs and sponsoring
institutions, but not resident activities outside of their educational program. Many perceive the
ACGME does not have the right to curtail moonlighting or place all moonlighting hours under a
weekly duty hour limit. In contrast, individual programs and institutions may prohibit or limit
resident moonlight, and may do so formally via the resident contract.
Question: What is meant by “sound educational justification” for a request to increase the
weekly limit on duty hours by up to 10 percent?
The ACGME’s position is that increase in duty hours above 80 hours per week can be granted
only when there is a very high likelihood that this will improve the residents’ educational
experience. This requires that all hours in the extended workweek contribute to resident
education. An example is that a surgical program needs to demonstrate that residents do attain
the required case experiences in some categories, unless resident hours are extended beyond the
80-hour weekly limit, and that all reasonable efforts to limit activities that do not contribute to
enhancing their surgical skills have already been made.
Also, programs may ask for an extension that is less than the maximum of 8 additional weekly
hours, and extension in duty hours may be requested for a given level of the program (the chief
resident year) or for individual rotations or experiences.
Question: What is the current ACGME interpretation of the use of the added period of up to six
hours at the end of a 24-hour duty and on-call shift?
Answer: The goal of the added hours at the end of the on-call period is to promote didactic
learning and continuity of care, including ambulatory and surgical continuity. At its June 2003
meeting, the ACGME approved refined RRC-specific language for appropriate activities for the
period of up to six hours after the end of the 24-hour period of continuous duty. They include
RRC specific language detailing acceptable activities, and provide specialty-specific definitions
of what constitutes a “new patient.” A summary document showing the language for each
accredited core specialty can be found on the ACGME’s Website under the duty hour pull-down
menu, under “RRC-specific duty hour language.”
Questions have arisen on how the “no new patients” requirement applies to ambulatory clinic
experiences, especially clinics where both new and return patients are seen. The requirement that
no “new patients” be seen after the 24-hour continuous duty period does not allow post-call
residents to take part in clinical experiences where all patients presumably are “new patients,”
such as the Emergency Department (ED) and a new patient clinic. In specialties with longitudinal
care experiences and those that permit post-call residents to participate in ambulatory clinics,
programs are encouraged to contact their RRC to learn whether residents may provide care for
new patients scheduled among the return patients in these clinics.
Question: How should duty hours be calculated when a resident takes a vacation week?
Vacation days should always be taken out of the numerator and the denominator for calculating
averaged duty hours, or on-call frequency. E.g., if a resident is on vacation for one week, the
hours and the on-call frequency for that rotation should be averaged over the remaining weeks.
Question: We have heard that the duty hour standards can be “relaxed” over the Christmas
holidays or other times when the hospital is “short-staffed.”
The ACGME expects that duty hours in any given four-week period comply with all applicable
standards. This includes months with holidays, during which institutions may have fewer staff
members on duty. During the holiday period, residents not on vacation may be scheduled more
frequently, but the overall scheduling pattern for the month must comply with the common and
RRC specific duty hour standards, and the schedule during the holidays themselves may not
violate common duty hour standards, such as the requirement for adequate rest between duty
periods, or RRC specific standards, such as the Internal Medicine requirement that averaging of
the frequency of in-house call is not permitted.
Question: The ACGME has states that it will rigorously monitor duty hours in accredited
programs, and that the sponsoring institution has the oversight for duty hour. We have that this
requires the sponsoring institution to do electronic, “real-time” monitoring of duty hours in all
accredited programs. Is this true?
The ACGME requires programs and their sponsoring institutions to monitor resident duty hours
to ensure that they comply with the standards, but it does not specify how monitoring and
tracking of duty hours should be handled. The only requirement related to ACGME monitoring is
that all programs complete the six-question duty hour survey on the ACGME’s Web
Accreditation Database (WebADS) and that this information be reviewed and endorsed by the
Designated Institutional Official (DIO).
The ACMGE is aware that a number of approaches exist for monitoring resident hours, from
resident self-reporting to swipe cards and other electronic measures. All of these have some
advantages and some drawbacks, with none clearly being superior in every way and in all
settings. ACGME does not mandate a specific monitoring approach, since the ideal approach
should be tailored to the program and the sponsoring institution, and the approach best suited for
neurological surgery will be different from the one most appropriate for preventive medicine,
dermatology or pediatrics. Programs and institutions may benefit from hearing what has worked
in settings similar to theirs.
Question: Now that the common duty hour standards have gone into effect, will the RRCs
continue to enforce their own more restrictive standards?
Answer: Yes. The common duty hour standards establish a minimum for all specialties where no
standards existed prior to July 2003. Specialties with more restrictive standards will continue to
enforce those. This includes Emergency Medicine, which limits duty hours to 72 per week, and
Internal Medicine, which does not permit averaging of the requirement that call be scheduled no
more frequently than every three days.
Question: Our program only has a few residents and residents prefer to be on call for two days
during one weekend, so they can have another weekend completely free of duties. Does this
practice comply with the duty hour standards?
Answer: It is common in smaller surgical residency programs to have residents on duty one
weekend (Friday and Sunday for instance), so they can be off the next weekend. As long as the
call schedule and total duty hours average out within parameters specified by the relevant
program requirements, this type of every other weekend schedule is acceptable. Note that for inhouse
call, residents must be accorded adequate rest (generally10 hours) between the two
weekend duty periods. There are no exceptions to this rule. Thus, in-house call on two
consecutive nights (e.g., Friday and Saturday) is not permitted, unless the residents are given a
rest period of about 10 hours between the two duty shifts.

[wolfvgang22]

Originally Posted by teratos

BTW, all residents have to have passed step 2. You can't be a resident without that. G

Doh! I have no idea what I was thinking!

Regarding the 80 hour rule, I think it could be a catch-22 to have it or not.
One hospital might work you 100 hours a week without it, and leave you no time and energy to do any moonlighting. But now that the 80 hour rule is in effect, that same hospital works you 80 hours and you can't moonlight.
Another hospital may have only ever worked residents a maximum of 80 hours a week, but whereas you could moonlight before, now you can't.

Thanks so much everyone for clearing up this stuff!

I'm also planning on doing psych right now, sean. Any programs you recommend?

[sean]

Hi Wolf...,

I PM'd u.

[FLK]

Originally Posted by wowmd

Hey guys, I'm new to this particular forum.
But what's the difference between moonlighting and night float?
I think i know what moonlighting is all about, but what is exactly a night float?
In FREIDA, I noticed that many hospital programs offer moonlighting, but they only offer night float STARTING in their 2nd year....

Can someone clear this for me?

well with the new 80 hr garbage, many programs are having residents pull night shifts in order to make up for the lack of on-call doctors doing nights like the old days.

so if there are 5 residents on the medicine service, for example, one of you might work nights all week, so the daytime people will not exceed their hours. since you are working as a resident, you are not paid extra.

this could also be done as a moonlighting job, where you come in and do the night, but are paid 50$ an hour ( or more ) to do the same thing, but from my experience , these opportunities are getting smaller since people are under the 80 hr rule and moonlighting might put you over that.

The good news is that after you become an attending there are no rules as to how many hours you can work.