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Life in Emergistan

Life in Emergistan

The Lost Tradition of Moonlighting (or Why EPs Should Practice in Small Hospitals)

Leap, Edwin MD

doi: 10.1097/
    moonlighting, rural emergency medicine

    Graduating emergency medicine residents are often advised not to work in small, rural hospitals. The argument is they will lose their skills by not practicing in the large centers of America. I have no hard data, but I suspect this belief is in no small part behind the ever-increasing drive to create new residencies so graduates can continue to work in academic centers. They have been taught that those places are where real medicine takes place.

    These brilliant young women and men have another reason not to go to small community hospitals. It's because they have never been allowed to learn autonomy. More to the point, they didn't get to moonlight unsupervised as we did.

    I'm old enough to remember real, honest-to-goodness moonlighting. We had ample moonlighting opportunities when I was a resident. My classmates and I slept after night shifts in the call room of a local cardiology office. We were there to respond to codes that might occur during stress tests. It paid the princely sum of $100.

    We also staffed small racetrack clinics where anything could happen at high speed. We were paid for extra shifts working for our helicopter service. As soon as intern year finished, we ran small community departments at nights and on weekends and holidays, all by our lonesome, as they say. My colleagues and I were always working somewhere that required us to be alone and responsible.

    I remember flying from our hospital to a smaller regional facility for a gunshot wound. As I walked in with the flight crew, I found a friend, one year ahead of me, up to his forearms in the chest of the victim. Sadly, the patient died. But my classmate did a thoracotomy all alone, in rural America, on someone who would have certainly died without him but who had a chance, however slim, as long as he was there. There was no cardiothoracic surgeon. There was no anesthesiologist. He just did it. (Well done, Tom. You're one of my heroes.)

    It may be that we were out of our element. It may be that we did things we weren't always fully prepared to do. But we figured it out, and lives were saved because of that boldness.

    Once, while flying a child with a terrible burn, I performed escharotomies in the community hospital where he first presented. In another moonlighting location, I took care of my one and only case of cyanide poisoning. When I transferred him to the referral center after he received the Lilly kit, the academics at the big house opined that he hadn't taken cyanide after all because he had survived. (Thanks, guys.)

    City of the Unfortunate

    The men and women with whom I trained always inspired me and renewed my imposter syndrome. They were brilliant and bold, clever and innovative, and they rushed headlong into the joy of medicine, the chaos of the emergency department, and the suffering of human beings. The struggles gave them a wonderful joy that permeated their careers for decades.

    This joy and capacity not only developed in our excellent training program but received its razor edge while we were working outside our well-supplied teaching hospital. We learned our skills in places that would give modern residents bad dreams. The residents ahead of me had names for those places, like City of the Unfortunate.

    We learned autonomy and made money to pay off student loans. Lives were saved, limbs were preserved, pain was eased. Families were kept intact. What my friends and I gave to frightened patients in remote places we received back in bedside education and experience. Those adventures led us to love the community hospitals of America.

    It is small wonder that today's residents are eager to stay in teaching hospitals. For one, many of their instructors (and thus mentors) have themselves been lifelong educators in large centers. But probably just as important, for years residents haven't been allowed to experience the glorious terror of being the lone physician on whom everything depends.

    A Peculiar Conclusion

    This is not their fault. They have been kept close to home to avoid working too many hours, a reasonable goal despite the unintended consequences. Their extracurricular work was also limited because it was believed that supervision was safer for patients.

    Yet all across America, small hospitals struggle to find qualified staff. And emergency departments everywhere are staffed, at least in part and in some instances in full, by nurse practitioners or physician assistants. These people have not done an intern year under the tutelage of seasoned physicians. They have not spent years in residency or taken rigorous board exams. They are used the same way physicians are used. And if trends are any indication, they will increasingly be used in that manner. But moonlighting is dangerous? What a peculiar conclusion.

    There are a lot of emergency medicine graduates seeking jobs every year, but many are competing for the same jobs in large referral and teaching centers. There is great joy and great adventure in smaller hospitals off the beaten path.

    They may not have been able to moonlight as we did in the dark ages, but excitement and service await all across America. There are lives to be saved outside the hallowed halls, where, I promise, cross my heart, that our young physicians won't lose their skills.

    Dr. Leappractices emergency medicine in rural South Carolina, and is an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available at, and Working Knights, Cats Don't Hike, and The Practice Test, all available, and of a blog, Follow him on Twitter@edwinleap, and read his past columns at

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    • llabianco10:21:56 PMI wasn't allowed to moonlight (1999-2002), but I gravitated to working many rural locums, nights all alone. Scared to death for about five years, but I felt it made me a better doctor. Also want to thank you for the voice you give emergency medicine docs. I've wanted to say that many times. It is easier now with doing it online. Keep up the good thoughts!
    • wameen9:32:35 AMGreat commentary, Dr. Leap! I'll never forget what I learned while moonlighting around Daytona in my residency in the early 1970s. I moonlit in Greenwood, SC, during my office practice in 1977-78 and all over North Carolina when I moved here, until 2005 (retired except for volunteering since 2014). Speaking of racetracks, one night I had a young woman come in who was fatally hit in the head by a tire that flew off a racecar on a small track in Ormond Beach. The worst thing I ever had to do in my whole career was to tell her parents on the phone in Connecticut that she was dead. I still cry thinking about it.