Moonlighting: Physicians expand income, experience by taking on secondary employment

Family physician Kristen Dillon, MD, spends about 75% of her time seeing patients at Columbia Gorge Family Medicine in Hood River, Oregon. However, she also has lots of other things on her plate-she is the medical director for a nearby nursing home, serves on an Independent Practice Association (IPA) board and is an investigator for a research project.

Dillon says the variety suits her well. She enjoys taking on different tasks and mixing up her work. “A day in the clinic has its own pace and demands. Doing other things is a nice change from back-to-back patient encounters and gives me flexibility,” she says. “It’s a good match for me. The income, of course, doesn’t hurt either.”

She has had a varied professional life ever since she had kids 14 years ago, typically working at the practice about three-quarters of the time. She has been the nursing home medical director for about two years. In addition to caring for patients at the facility, she works with the staff and management on systems and quality improvement initiatives. She estimates she spends about one half-day per week with the nursing home and about 20 hours per month on the IPA and research project together.

Dillon is not alone among physicians in earning from a secondary income today. In Medical Economics’ 2013 annual survey, 36% of family medicine/general practitioners and 35% of internists reported earning income from sources other than their primary practice/employer in 2012. That number was about the same for cardiologists (38%), but was higher for hospitalists (40%). Pediatricians and gastroenterologists were lower, at 25% and 27%, respectively.

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Defying the notion that it is mostly young, debt-ridden residents who moonlight for extra income, the age group most likely to have a secondary income are 50 to 54, followed closely by 45 to 49, 55 to 59, and 60 to 64.

Physicians take on additional roles for many reasons. Younger and mid-career physicians are often looking for ways to pay off medical school debt or increase their income without taking on more work at the practice.

Some physicians are looking for variety in their career and new challenges. Others are looking for ways to give back to the profession by mentoring, teaching, or volunteering.

In general, men were more likely than women to earn money outside their primary jobs, and physicians in rural areas did it more frequently than those in inner city, suburban, or urban locations. Physicians who owned their practice were slightly more likely to do so.

Higher patient volumes were also reported for those physicians with secondary incomes. The highest positive responses were from doctors who see 150 to 174 patients a week and those who see 200 or more.

The sources of these secondary incomes were primarily medical. About 43% of respondents said they earn extra pay through “other medical work,” while 24% said hospital work, 22% said consulting, 7% said clinical trials, 7% said locum tenens assignments, 4% said medical director, 3% said emergency department/urgent care, 3% said clinic work, and 1 to 2% each said hospice medical director, nursing home medical director, teaching, legal/medicolegal-related, speaking, expert witness, or military.

About half the physicians surveyed said the extra income was under $30,000. About a quarter said it was $30,000 to $70,000. Only about 5% said it was over $150,000.

Analyzing the trends

Judy Bee, a management consultant with Practice Performance Group in La Jolla, California and a Medical Economics editorial consultant, says she is not surprised by these findings. She sees many clients earning secondary income working for IPAs. One of her clients does so much of that type of work that he may sell his practice, she says. She also has a client who reviews disability request records. Bee says some physicians do it for the money, some for the diversity of work experiences, while others view it as future part-time work after retiring from practice.

“There used to be a fair amount of money available from drug companies for speaking or conducting clinical trials, but there is not as much anymore,” Bee says. 

She also was not surprised that physicians in rural areas are slightly more likely to earn secondary incomes. Some sparsely-populated areas do not have enough patients to fill a schedule or enough medical professionals to cover all the jobs that need to be done. For example, some might serve as a coroner or a prison medical director.

 Bee surmises that a physician who reports a secondary income of $150,000 or more may own a medical spa or do laser work such as hair or tattoo removal on the side. If they do this work in a separate location, they would be more likely to view it as secondary income, instead of just part of their main pay.

That practice owners are more likely to report secondary incomes is probably due to their greater flexibility in setting their own work hours and not having a contract limiting their work.

She reasons that men are more likely than women to have a second income because women are more apt to have heavier responsibilities at home that don’t leave them the time or energy to moonlight.

Perry A. Pugno, MD, MPH, vice president for medical education at the American Academy of Family Physicians, says that doing extra work may well be driven by the modern economy, but notes that achieving diversity of professional experience is part of the motivation as well. 

Pugno has served as an expert witness in child abuse and rape cases. Few people want to do that type of work and since he had the qualifications, he saw it at least in part as a public service. He estimates that he earned less than $10,000 a year doing so.

Residents

Older physicians may be earning money through secondary incomes, but that doesn’t mean they are the only ones doing it. Residents, many with young children at home, large debt loads, and lower incomes, have always been interested in picking up extra work when possible.

Pugno was a residency program director for more than 20 years, working in programs from California to Connecticut in public, private and university-sponsored settings. He has seen escalating student debt push more residents into picking up secondary positions.

“It makes sense for them to seek additional resources to help offset their debt,” he says, noting that an extra $10,000 a year can increase a resident’s annual earnings by 25%.

Some student loan payments are deferred until after residency, but not all. Also, residents know it is going to take time for their income to grow after their training is complete, and the initial steps of setting up a practice can be expensive, i.e. moving, getting licensed, board certification exam fees, etc. “They may all hit at the same time,” Pugno says.

Some residents may take on extra jobs for the opportunity to gain clinical experience with a different patient population, he adds.

Pugno cautions that residents who are moonlighting must get permission from their program directors, because any violation of their duty hours could impact the accreditation of their program.

In addition, residents must make sure they have proper licensure to moonlight, because the one they have for their residency may only apply to the training location. They also need to be sure they have adequate liability coverage. The residency program probably provides coverage for the work done there, but not work done at an outside facility, he says.

Some residents moonlight at the same location where they are doing their residency.  It is easier to track duty hours this way, Pugno notes. They are on the “honor system” in terms of tracking hours if they moonlight at another location.

Some residents try to sneak around prohibitions on moonlighting, driving a substantial distance to work elsewhere. Sites where they might do this include small, remote emergency departments, urgent care centers or insurance companies that need help processing physical exams.

Pugno admits he did this in his residency years. “I was married, I had three children, had some educational debt, and wasn’t getting paid very much,” he says. However, he cautions residents, and any physician considering working extra hours solely for the money not to overdo it.

“Do just enough to pay your bills, but don’t neglect your family and friends. The importance of having a personal life cannot be overemphasized,” he says.

Volunteering

Some physicians take on added duties for another reason altogether-public service. “I have the sense that the social consciences of various age groups has escalated,” Pugno says. 

He sees medical students, and some faculty, doing more volunteer work and helping in free clinics. “They see how many people have no access to healthcare and want to help,” he says. Some are driven by the desire to gain added clinical experience, he adds. 

Working abroad appeals to some physicians, but he notes that many have to pay their own way, on top of missing time in the office.

“But as worldwide communications get better, we are more and more aware of the needs of populations and exactly where they are,” he says.