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Moonlighting residents may risk errors, lawsuits
Unethical, unprofessional, some physicians say
by Stacey Kusterbeck, Contributing Editor
Are residents in training who moonlight in emergency departments (EDs) more likely to experience clinical errors and oversights? The answer is a definite "yes," say experts. "There is absolutely no doubt," says Tom Scaletta, MD, FAAEM, chair of the ED at Edward Hospital in Naperville, IL and current president of the American Academy of Emergency Medicine (AAEM).
He points to a consensus position statement from the Society for Academic Medicine (SAEM), the Council of Emergency Medicine Residency Directors (CORD), and the AAEM. (To access the position statement, go the AAEM Web site, www.aaem.org. Click on "Position Statements,""Critical EM & Practice Issues," "Board Certification," "Landmark AAEM, SAEM, and CORD Consensus Position Reached [added 11/27/00].")
The position statement concludes that ED moonlighting is a form of dependent medical care, and requires the resident to be actively enrolled in an emergency medicine program approved by the Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association, with supervision that is continuous, on-site, and provided by fully licensed physicians who are board-certified and prepared in emergency medicine by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine.
"There are several articles that make it clear that board certification or residency training in emergency medicine enhances the quality of care," says Scaletta.1,2
Moonlighting residents may take the "ignorance is bliss" approach, but this is legally risky and dangerous for patients, says Carey D. Chisholm, MD, director of the emergency medicine residency program and clinical professor of emergency medicine at Indiana University School of Medicine in Indianapolis. "I'm not as worried when they realize they are in over their heads in that environment, but more so with the items they don't realize they are missing," he says.
Chisholm recommends that faculty members ask themselves the question "How often do you have no input whatsoever when a resident, particularly a second year one, is managing a case in the ED?"
There is no "bailout" if a resident is working in a solo practice environment, says Chisholm. "I am personally aware of four lawsuits that were successfully filed against residents working in solo practice," he says. "A number of these lawsuits involved physicians not trained in emergency medicine. Interestingly, that aspect was not capitalized on by the plaintiff's attorney."
Practice is 'unethical'
Unsupervised residents practicing in EDs continues to be a "significant problem" for the specialty of emergency medicine, says Chisholm. "It continues to propagate the impression within the global medical community that anyone can practice emergency medicine," he says.
It is unethical for a resident in training to practice emergency medicine unsupervised, says Scaletta. "It has been two decades since the practice-track, which amounted to learning-on-the-job, has been closed," he says. "Nowadays, it is absolutely against the standard of care for unsupervised care by a resident physician to be occurring in a comprehensive ED."
Chisholm says he feels strongly that the practice is unprofessional, both for the practitioners involved and the specialty of emergency medicine. When you enter a specialty, you make a commitment to master the expertise in that specialty and agree to place your personal well-being behind that of your patients, he says.
"Residents who moonlight in solo practice settings have made a decision to place their financial well being ahead of the patient's. And you denigrate the specialty by saying it's okay to go out and practice it before you're fully trained," says Chisholm. "We don't see that happen with obstetricians or surgeons or dermatologists. They don't go out and practice before they complete their training."
On a positive note, a larger number of residency-trained emergency physicians are being created, so there is less demand for residents to moonlight before they are fully trained. "Having said that, though, there are groups who continue to parasitize residents by making a conscious decision that it's cheaper to hire moonlighting residents than to make a commitment within their own group to take on additional partners," says Chisholm. "So the residents end up working the least desirable shifts at a much lower wage for that group."
However, Bruce David Janiak, MD, FACEP, FAAP, vice chair of the department of emergency medicine at Medical College of Georgia in Augusta, argues there is no ethical problem, as long as the institutions in which they moonlight credential them appropriately. "Requirements regarding board certification and residency completion are institution-specific," he says. "As it turns out, large urban hospitals can attract more ED docs, thus they usually require board certification. Small, rural hospitals do not have this luxury."
A bigger dilemma is that you can be sued for restraint of trade if you do not allow your residents to moonlight, says Chisholm. "Because if the state says they can work there and they have a fully accredited license, why can't they?" he says.
The ACGME has "dodged" this issue, says Chisholm, by addressing only in-house moonlighting and not addressing the issue of residents who work additional hours outside of their own institutions.
"What they have done is taken a rather hypocritical approach," he says. "If they were serious in their desire to promote resident wellness and patient safety, it should just be a blanket rule that while you're in training, you do not work more than 80 hours per week."
Compromise is possible
Allowing moonlighting in urgent care settings and double coverage EDs with a more experienced physician reduces the risks involved, says Scaletta. "Urgent care settings are not EDs. There is much less at risk," he says. "I think a senior ED resident would be fine in this type of setting. As far as acting as an extender for a qualified physician, this may be fine as well, as long as the criteria for appropriate dependent care were met."
With an urgent care setting, you are dealing with a preselected a group of low acuity patients, says Chisholm. "A second-year, fully licensed emergency medicine resident is probably capable of functioning independently in that type of work environment," he says. "I don't consider that emergency medicine."
As for double coverage, that needs to be considered on a case-by-case basis, says Chisholm. Presumably, the resident is being hired to work double coverage because it's a busy ED that cannot be adequately covered alone.
"So it's unlikely they are going to get supervised in that scenario," he says. "What you do have though, is an additional, more experienced clinician who can bail out failed procedures, knows the formulary and care pathways used in that ED, and serves as a resource to guide the resident through difficult patient scenarios or difficult consultants."
Residents are more inclined to accept inappropriate recommendations from consultants, and this is one of the major liability risks involved, says Chisholm. "As a resident working in that facility, you are a guest and you are inexperienced. So you are more likely to accept bad recommendations from your consultants who are full members of the medical staff, than you would after being fully trained and a member of the medical staff," he says.
A physician who is a member of the medical staff working alongside the resident will be able to give input when the resident gets advice he or she doesn't feel comfortable with, says Chisholm. The physician also would be able to assist with patient dispositions such as transfers that may be rarely encountered in the academic center.
Though there are no concrete data to support this, most residents moonlight in low volume institutions; therefore, their exposure to risky situations is likely to be lower, says Janiak. "Also, in many places, a senior emergency medicine resident represents improvement in care quality over the existing staff, especially with regard to procedures," he says.
1. Taylor SF, Gerhardt RT, Simpson MP. An association between emergency medicine residencies and improved trauma patient outcome. J Emerg Med 2005;29:123-127.
2. Holliman CJ, Wuerz RC, Kimak MJ, et al. Attending supervision of nonemergency medicine residents in a university hospital ED. Am J Emerg Med 1995;13:259-261.
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