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Medical Student Moonlighting in the Psychiatry Emergency Room
To the Editor: Since 1981 the Parkland Health and Hospital System and the University of Texas Southwestern Medical Center (UTSWMC) departments of psychiatry have employed medical students as moonlighters in the psychiatry emergency department (PED). Though we all arrived after 1986, we assumed that other departments of psychiatry offered similar opportunities. However, a literature search and e-mailed inquiries to psychiatry training directors and medical educators revealed that this program may be unique.
This letter describes the history and functioning of a longstanding program for medical students that has served them and the two institutions well. For students it is an opportunity to earn money through clinical work and to gain experience as clinicians. For the hospital, it is an economical way to run a busy service. For the department, it keeps students involved during their senior year.
In 1980, external forces led to the creation of one of the first freestanding PEDs in the country. Legislative mandates required community mental health authorities to offer emergency services. Parkland Health and Hospital System was struggling to provide services to a growing population, and the department of psychiatry, under new leadership, was expanding and developing. The three institutions joined to pool resources, employing a crisis intervention model.
A new medical director committed to emergency psychiatry changed the educational philosophy. Emergency psychiatry was seen as a set of distinct skills warranting focused teaching. Instead of call experiences, residents rotated full time, working set hours. The PED became recognized as an excellent rotation for postgraduate-year 1 (PGY-1) and PGY-2. It became the defining site of the residency, like internal medicine for medical students: sometimes loved, often hated, but recognized as a crucible, and crucial to being a physician. Psychiatric residents who completed their PED rotation felt confident and comfortable approaching all services.
Next, the PED became a primary site for third-year medical students.
Psychiatry emergency department visits varied over the years from 650 visits per month to 1,000 visits. Adequate staffing was always a challenge. At one of many meetings about staffing, someone pointed out that there was now a group of individuals trained in the techniques being used: medical students who had taken their clerkship in the PED. Why not employ them to help as physician extenders?
We conducted a literature review using OVID, PubMed, and PsychLit on student moonlighting, medical student education, and medical student employment. Queries went out on the American Association of Directors of Psychiatric Residency Training and Association for Academic Psychiatry e-mail lists, asking if any other medical schools offered similar opportunities. We interviewed seven faculty members and one staff member: the chair when moonlighting began, former and current medical directors, residency training directors, directors of medical student education, coordinators of the clerkship, and the individual who appoints and assigns the students. Our study received UTSWMC Institutional Review Board exemption.
We randomly selected three medical students who moonlighted the previous year and who were not entering psychiatry, along with a current PGY-3 resident in the UTSWMC psychiatry program. The interview, in the presence of all authors, was semistructured and included the following questions (with follow-up and elaboration): Why did you moonlight? Why this specific opportunity? How did you learn about it? What were the benefits of the experience? Did it have an impact on your choice of specialty? What were your duties? Was there an educational component? Did it impact your experience during residency? Did you ever feel exploited?
We could find no publications describing medical student moonlighting in specialty. We learned of no other medical schools with similar opportunities. Some e-mail respondents wondered about ethical considerations. They worried about role issues: a student was being paid for work similar to that done on rotation. Is the boundary between work and education blurred? Is it unfair for one student to pay tuition to do work for which another student is remunerated?
Initially, only students who spent a full clerkship in the PED qualified to moonlight. Thus, 20—30 fourth-year medical students could moonlight. Claiming a set weekly shift, they became true members of the PED team. Solidly schooled in the procedures, these students could act as the primary clinician, with attending supervision.
Ultimately, increased acuity and volume of patients forced changes in the philosophy, allowing students who had only taken call several times to moonlight, upon recommendation of their primary site attending. In the 2006—2007 academic year, 220 students were eligible to moonlight; 40 enrolled and covered shifts during the year. The vast majority of student moonlighters did not enter psychiatry.
All respondents identified monetary considerations as the primary or sole motivation for working in the PED. One described it as the "king of med student jobs," the only one where you got paid for doing clinical work. Others at our institution are teaching assistants for first-year medical student courses, research assistants, or working in the student center. The pay range for these options was $7— $20/hour. The 2006 PED pay was $18/hour for night shifts and $15/hour for all others. Some students worked one shift the entire year; others worked 10 shifts per month. A monthly signup sheet circulates and shifts are assigned first come, first serve.
Students learn about the moonlighting opportunity by word of mouth from other students. In addition, the administrative assistant for the PED medical director e-mails all rising fourth-year students, alerting them to the opportunity and how to sign up.
Beyond monetary reasons, respondents cited the gratification of being a working clinician and the inevitable refining of clinical skills that comes with experience as the key benefits. Despite this observation, educational benefits were minor. None saw the experience as influencing their choice of specialty. They were perplexed by the ethical questions about exploitation and role confusion raised by colleagues at other institutions.
This program is a small but important part of the department’s overall medical student effort. Its importance lies in the broad knowledge among students of its availability and their appreciation of such opportunities. Our PED would be hard put to function without them. Opportunities for medical students to work as clinicians have disappeared the last few decades. This is unfortunate, because the opportunity to function as a clinician, to be paid for it, and to experience the direct value of one’s developing knowledge, is invaluable. Our department, driven by need, appears to have stumbled upon a way to continue to offer this.
At the time of submission, the authors disclosed no competing interests.