Medscape article by Leigh Page
Whether you’re on salary or own your practice, you may have times when it feels like you can’t get ahead. Your list of monthly bills probably includes a mortgage and car loans, education debt, money to set aside for retirement, and perhaps kids’ tuitions. None of these costs are likely to go away soon.
That leaves only one option: You will need to earn more.
Where do you start? One approach is to devote a small portion of your free time to a job outside of the practice. Plenty of companies want your medical skills, and it’s often easier to take outside work than to add new services to your practice. By working as an expert witness or an independent medical examiner, for example, you avoid adding space, hiring new staff, and raising your overhead.
Taking on a different job can also revitalize your passion for medicine, adds Michael McLaughlin, MD, founder of Physician Renaissance Network, a consultancy firm based in Pennington, New Jersey, that helps physicians with their careers.Taking an outside job can add $5000 to $10,000 a year in extra income—and even much more in some cases. That’s a nice boost, and not just for young physicians needing to pay off their medical school debt. It can also help employed physicians on fixed salaries, or provide a cushion for independent physicians with fluctuating practice income.
“Doctors looking for extra money may not want to expand their practice and work longer hours doing the same thing,” he says. “They may be feeling burned out or in need of more varied intellectual challenges. Having a new challenge can restore their enthusiasm for their career.”
What Moonlighting Can Mean for You
Some physicians take on quite a few outside jobs. In addition to his internal medicine practice in Highland Park, Illinois, Jordan Grumet, MD, works in a nursing home and a hospice, serves as an expert witness in legal cases, and writes a blog for an online physician community.
“Having other jobs is a great way to balance your work and life,” he says. In a typical week, he spends 20 hours seeing patients in his office, 15-20 hours visiting the nursing home, 5 hours visiting the hospice, and 3-5 hours working on his blog or writing articles. His work as an expert witness varies from week to week and month to month. Dr Grumet says these jobs provide new insights into clinical medicine, making him a better and more efficient physician. When appointments slow down at his practice, he has other work to turn to.
Even though Dr Grumet’s blog-writing brings in only a few thousand dollars a year, he wouldn’t give it up for the world. “Writing, in particular, helps you avoid burnout,” he says. The blog he writes for, Freelance MD, focuses on physicians looking for extra work. “In your practice, you can get to a point where you want to try new things,” he says. “You need to find something new and refreshing.”
To find the jobs he wanted, Dr Grumet developed a wide network of potential employers and constantly reached out to the community. “I see myself as a serial entrepreneur,” he says. “I’m always looking for new opportunities.”
Before you jump at a part-time job opportunity, however, Dr McLaughlin suggests taking some time to consider what sort of work would fit your needs. “People have very different wants,” he says. “Some think that sitting at a desk and reviewing charts is the last thing they’d want to do. Others say, ‘I’ve been seeing 80 patients a day, and I want some peace and quiet.'”
Your own search may yield different choices, of course, but here are some options to consider.
Opportunities for Increased Income
1. Perform Claim Reviews
Reviewing insurance claims is a part-time gig that can be done at home—or anywhere else, for that matter. Your work will be sent to you via the Internet, by an independent review organization (IRO).
IROs are outside companies that health insurers engage to address concerns that they might be improperly denying claims, says Heather Fork, MD, owner of Doctor’s Crossing, a career consulting firm for physicians. The National Association of Independent Review Organizations, which represents these groups, provides a list of IROs on its website.
“All of this work can be done online,” says Barry Korn, MD, national medical director of Concentra Physician Review, an IRO based in Addison, Texas. Dr Korn says that a few hundred physicians work for Concentra as part-time reviewers. These doctors determine the medical necessity of coverage requests that have been flagged by Concentra’s nurse-reviewers. They also perform more extensive reviews that involve looking back at a particular patient’s treatment over an extended period, he says.
Dr Fork says IROs usually pay $85-$200, or more, per hour. At Concentra, for example, Dr Korn says payments range from $100 to $150 per hour or more, on the basis of the physician’s qualifications and specialty. (Certain specialties, such as cardiology, oncology, orthopedics, and psychiatry, tend to be more in demand.)
The IROs, however, expect a lot in return for such compensation. “Physicians who do this work need to be prompt, accurate, and reliable,” Dr Fork says. “These companies often want a 24-hour turnaround,” to meet deadlines they’ve agreed to with the insurance companies. “Many IROs also require some degree of continued clinical practice,” she adds.
You might have to pick up the phone once in a while, too. “If there’s insufficient information in the clinical record, the reviewer calls the patient’s physician to have a peer-to-peer conversation,” Dr Korn says. “The call has basically two purposes: to obtain information and to educate the physician on current evidence-based guidelines.”
To obtain this work, Dr Korn says physicians need to go through a rigorous credentialing process that takes a month or two. If accepted, the physician starts with online training at home. That said, some states, such as Texas, restrict this work to physicians licensed within the state, Dr Korn says.
Pros: You can do this work at home and make decent money.
Cons: You may need to meet very tight deadlines.
2. Work as an Expert Witness
Serving as an expert witness for attorneys is almost always part-time rather than full-time work. That’s because opposing counsel is ready to denounce a full-time expert witness as a “hired gun” who has lost touch with clinical practice. And clinical experience is the real value a good expert brings to legal cases.
Karen Josephson, MD, a solo geriatrician in Long Beach, California, has been moonlighting as a geriatrics expert with law firms for many years. “I really enjoy the work,” she says. “It makes me a better doctor because I have a chance to see what other physicians have done and think about how I could have done it better.”
Also, “the payment will always be better than in my medical practice,” she says. She makes $2000-$5000 per case.
The median hourly fee for file review/preparation for all medical expert witnesses is $350, according to a surveyby SEAK Inc., an expert witness training company in Falmouth, Massachusetts.
SEAK offers seminars and other resources for physicians interested in this line of work. Steve Babitsky, president of SEAK, advises fledgling expert witnesses to start a Web page and establish their expertise. “Develop a niche—a small area of expertise where you can dominate your market,” he says.
Expert witnesses can work directly for law firms or for services that supply expert witnesses, such as American Medical Forensic Specialists or the TASA Group.
Before starting, Babitsky advises negotiating a retention agreement, a cancellation policy, and—if you can get it—a minimum number of hours for deposition testimony and trial testimony.
In most cases, Babitsky says, the work simply involves giving the lawyer your expert opinion. The next most common task is writing a report to be used in a legal case. A small number of those cases may go to court and require you to give a deposition.
To avoid the “hired gun” accusation, you should keep practicing medicine. “If you would like to testify in medical malpractice cases it is best that you maintain at least a part-time practice,” SEAK states on its website.
Before you get the idea that serving as an expert witness might be easy, getting on the witness stand can be a grueling experience. In a recent article, California malpractice attorney Mitch Jackson described his interrogation techniques. He asks experts how often they’ve worked for the same attorney and how much time they still devote to practicing medicine. And when applicable, he points out that an expert’s opinion is “contrary to a well-respected and known treatise,” such as a medical society’s published standards of care.
“Every once in awhile you must put on the gloves, step between the ropes and do your best to land a knockout punch,” he wrote. “Some experts are so full of themselves that they actually make an easy target.”
Pros: This work is geared to part-timers, and payments are quite generous.
Cons: If you go to court, you may face rough treatment by opposing attorneys.
3. Perform Independent Medical Exams
Although this type of part-time work can be rewarding, be forewarned: You’ll be performing a history and physical exam (H&P) that are very different from what you do for your own patients, in that you’ll be trying to establish whether this person merits a payout for worker’s compensation, auto insurance, health insurance, or Social Security. So don’t expect a warm and cozy relationship to develop.
In some cases, patients may be hiding some aspect of their physical condition so that they can qualify for a payout, says David P. Kalin, MD, a family physician and independent medical examiner (IME) in Oldsmar, Florida. If that’s the case, the IME physician will try to uncover it. “You don’t just do a simple H&P,” Dr Kalin says. “You have to be pretty thorough about it.”
“I’ve being doing independent medical exams for quite a long time, and it’s a good business,” he says. His fees range from as little as $100 an hour for a Social Security examination to $500 an hour for private payers. The IME work involves about one quarter of his professional time. He says some cases can take him an hour or two, whereas others take a full day.
The payments can add up to a tidy side income. Scope Medical, a Massachusetts-based company that hires physicians to serve as IMEs, reports that reviewers can earn $5000-$75,000 per year, and the work can be done on Saturdays and early evenings. Scope physicians typically examine six to 10 patients at a time at a Scope facility, following a specified format, the company states.
As is the case with claims reviews in general, Scope says there’s higher demand for certain specialists, such as orthopedic surgeons, neurologists, cardiologists, otolaryngologists, ob/gyns, hand surgeons, and psychiatrists.
“The way you write your report has to be geared to the way a lawyer thinks,” Dr Kalin says. For example, if the doctor reports that the patient’s medical condition was “exacerbated” by a car accident, the patient will probably get very little compensation. But if he reports that it was “aggravated” by the accident, “there is money around that,” Dr Kalin says.
Learning these nuances in terminology, and understanding the goals that IME physicians are supposed to meet, requires training. Dr Kalin advises taking some courses approved by the American Board of Independent Medical Examiners (ABIME), and then getting ABIME certification.
Physicians seeking IME work can contact worker’s comp programs, auto insurers, and other companies and agencies. Many state worker’s comp programs, such as those in Washington and New Mexico, require IME physicians to be approved by the state. SEAK, the expert witness training company, also works with IME physicians and provides a national directory of them on its website.
Pros: Payments can be generous, and you can create your own schedule.
Cons: The people you examine may feel antagonistic toward you.
4. Invent a New Medical Device
Plenty of practicing physicians have made extra income inventing a new medical product. They’re in a perfect position to do so. On the front lines of medicine, they’re constantly confronting unsolved problems and have thought about solutions.
Indeed, there’s evidence that physician-created inventions are generally better than those created by nonphysicians at large biotech companies. According to a 2008 study, almost 20% of medical device inventions involved a physician at least as coinventor, and these physician-linked inventions received more positive citations and had higher ratings than corporate inventions.
Who’s the typical physician-inventor? The same study found that they’re usually orthopedic surgeons, general surgeons, cardiologists, anesthesiologists, internists, ophthalmologists, and diagnostic radiologists.
Physician-inventors don’t have to give up their day jobs to make an impact. Minnesota gastroenterologist Robert Ganz, MD, who has taken out 20 patents in the past 25 years or so, still has a medical practice. He’s also chief of gastroenterology at a 631-bed hospital and an associate professor at the University of Minnesota.
Dr Ganz started inventing in the early 1990s, after he got out of training. He won’t say how much money he’s made from his inventions, but the device company that he cofounded in 2000 to develop one of them—a radiofrequency ablation system for Barrett esophagus—was sold to Covidien for $400 million in 2012.
“It’s a good way to make money,” he conceded, “but it’s very difficult to see it through. Coming up with the idea is the easy part.” The hard part, he says, is taking out provisional and full patents, directing animal and human clinical trials, getting approval from the US Food and Drug Administration (FDA), and marketing the product. The process involves tens of thousands of dollars in investments and lots of worry.
Many inventions don’t pan out. “Some of my projects have failed,” Dr Ganz says, pointing to his work on a clinical trial of using endoscopically delivered blue light to eradicate Helicobacter pylori in parts of the gastric antrum.
Although you always have your practice to fall back on, the work of launching an invention can very easily eat into your practice time, he says. Much of this work involves convincing others to believe in and invest in your product. “People can read your enthusiasm,” he says. “If you’re not absolutely committed to what you’re doing, it will show.”
You can make your life easier by selling the rights to your product as early in the process as possible. But Dr Ganz says there’s a definite downside to that. “When a company pays you for your idea, you’ll never get a lot,” he says. “You might get as little as $25,000.”
Even though he’s done very well with his sideline work, Dr Ganz says each development process has been satisfying, win or lose. “Inventing has been a lot of fun,” he says. “It gives you the ability to help people and to create novel things.”
Pros: You can make a lot of money on inventions and have a positive impact on medical care, while still managing to keep your practice going.
Cons: It takes a lot of time, effort, and money to bring an invention to market, and many ideas fail.
5. See Nursing Home Patients
There’s a reason why physicians caring for nursing home patients usually do it part-time, says Reuben Tovar, MD, a hospitalist who serves as medical director at two nursing homes in Austin, Texas. “If you’re working full-time, going to many different facilities,” he says, “you lose your focus, and the quality of care suffers.”
Dr Tovar says the best way to work in a nursing home is to serve as medical director and see patients there as well, which is what he does. The medical directorship is necessary, he says, because Medicare and Medicaid don’t pay well for patient visits. But nursing homes prefer their medical directors to provide patient care because they’re therefore more engaged with how the facility operates.
A medical director job requires at least 20 hours of work a month, usually in regular meetings with staff and to comply with deadlines for regulations, Dr Tovar says. The medical director typically spends another 10 hours a month seeing patients in the facility.
Salaries for nursing home medical directors run from $54,000 to $103,000 a year, and the median is $78,000, according to PayScale, an Internet-based research firm. In addition, reimbursements for treating individual patients can bring in $75-$150 an hour, if coded correctly, according to a 2010 report published by the Kaiser Family Foundation.
Nursing homes are looking for medical directors who are empathetic and reliable, and who have a lot of older patients in their practice who might consider using the facility someday, Dr Tovar says. Physicians who want to be medical directors should go to classes endorsed by the American Medical Directors Association (AMDA), which represents nursing home medical directors, and obtain AMDA certification, he says. Dr Tovar didn’t take that route, though. He began by visiting a nursing home when one of his patients was admitted, which ultimately led to the administration asking him to be medical director.
Nursing homes are frequently sued for malpractice or elder abuse, but only one fifth of these lawsuits name a physician, according to a 2003 study published by the journal Health Affairs. Dr Tovar says that’s because these cases often involve problems that occur when the physician isn’t in the facility, such as patient falls.
Nonetheless, all the litigation has made it harder for medical directors to get malpractice insurance. A 2009 survey by AMDA found that 11% of nursing home medical directors had problems obtaining coverage. Although that figure was down from 31% in 2003, the problems haven’t gone away. Of the medical directors reporting problems in 2009, 16% said they had to modify their practices, and of those, fully one half had stepped down from their posts.
Certain physicians thrive in a nursing home environment, says Robert Milligan, MD, a family physician in Buffalo, Minnesota, and AMDA member. “They have to love people and be extremely compassionate, and you have to like a good puzzle,” he says. “The average individual we care for in a nursing home has seven medications and 10 diagnoses.”
Nursing home physicians also have to deal with numerous phone calls from staff and demands from family members. “The main talent you need to have is patience,” Dr Tovar says. “The conversations are slower for these patients, and the family needs to be involved.”
Pros: Work in nursing homes is usually part-time, and it can pay well if you combine it with a medical directorship.
Cons: Physicians may be overwhelmed with calls from staff and families’ demands. Facilities face numerous lawsuits for malpractice and elder abuse, but doctors are usually not named in them.
6. Partner With Pharmaceutical or Device Companies
Payments from drug and device manufacturers for advice and speeches continue to be a source of extra income for many physicians, even though this practice has lost some of its luster now that these payments become public knowledge owing to the so-called Sunshine Act.
Since September 30, 2014, the Centers for Medicare & Medicaid Services (CMS) has been reporting payment information on its Open Payments website. The program, based on information that manufacturers are now required to report, was authorized by the Affordable Care Act (ACA). The CMS data are crunched by ProPublica, a journalists’ group, on a site that allows consumers to easily look up payments to a particular doctor.
As recently as 2012, an estimated one fourth of US physicians were being paid by manufacturers for speaking engagements and consultations (as opposed to receiving free meals from drug representatives, which are also reported). But in that year, some drug manufacturers began cutting these payments, and in late 2013, GlaxoSmithKline announced it would stop paying doctors to speak about its drugs altogether.
Device manufacturers may also be cutting back on payments to physicians. Although they haven’t announced anything specific, a survey of device manufacturers showed that 39% planned to cut expenses owing to new taxes on devices under the ACA. And 50% of those companies planned to cut research and development, which is the source of payments to doctors.
But Dr McLaughlin, the career consultant, believes many payments will continue and public exposure of the amounts won’t harm doctors’ reputations. “Patients would not be upset about this,” he says. The CMS sitesupports this view. “Just because there are financial ties doesn’t mean that anyone is doing anything wrong,” the site explains.
There are many different aspects of this work, so if one part doesn’t appeal to you, another one might. “You could speak for them [drug or device manufacturers], or serve as an advisor,” Dr McLaughlin says. “If you don’t want to be a speaker, you can write up a report in your home. Or you could help the company present data to the FDA. Or you could make your practice a site that participates in clinical trials.”
For many of these functions, he says, you’ll need to have good presentation or writing skills. You’ll also need to get training on the drug company’s product line, FDA-approved product labeling, and other regulatory requirements. Manufacturers typically pay $1000 per speech, and you can give the same speech several times.
“Opportunities to work with pharma won’t go away, because this is important work,” Dr McLaughlin says. “Getting the information about a drug out to physician audiences is crucial.”
Pros: Pharmaceutical companies make generous payments to physicians who advise them and give speeches about their products. There’s a wide variety of work to choose from.
Cons: Even though they’re legal, any payments you get will be listed on a public website. Some companies are limiting or stopping certain payments to physicians.
7. Provide Care to Prisoners
Treating inmates in state and federal prisons is emerging as a feasible way for physicians to earn extra income. Prisons have a great need for more doctors, and they have the cash to compensate them for their work.
What’s changed? Prison systems are under growing pressure from the courts to improve their healthcare of inmates, which used to be atrocious. A 1976 US Supreme Court decision (Estelle v Gamble) established a prisoner’s right to healthcare, and in recent years courts have been enforcing aspects of that decision.
From fiscal year 2007-2011, healthcare spending per inmate saw a median growth of 10% in 39 states studiedby the Pew Charitable Trusts and MacArthur Foundation. This is on top of a 50% median growth in healthcare spending from 2001 to 2008, the two groups reported in July 2014. In addition, the ACA has pumped $7.7 billion in Medicaid spending into prison systems, according to a recent report.
Michael Puerini, MD, a family physician in Salem, Oregon, has been working part-time in correctional facilities for about 25 years. The payments are comparable to those of private practice, says Dr Puerini, a past president of the American College of Correctional Physicians.
But is it safe? Although there are many psychopaths behind bars, Dr Puerini says physicians have far fewer risks than with patients in a hospital emergency department. “I have never felt unsafe,” he says, adding that women do the work without fear because guards are always nearby. Still, he advises keeping an emotional distance. “I put up boundaries immediately on every patient relationship,” he says.
Dr Puerini says inmates will try to manipulate physicians’ orders to achieve special status, such as sleeping on a lower bunk or acquiring orthotic shoes. “Outside, you wouldn’t think of this as important,” he says.
Prisoners also require a great deal of medical care, because they usually lacked adequate care before incarceration and have high addiction rates. Prisoners are “the sickest people in the country,” Dr Puerini says, citing high rates of such chronic illnesses as HIV, cancer, emphysema, and hepatitis C. “Physiologically, they’re older than their age.”
As a result, doctors see prisoners frequently. In 2004, almost 70% of prisoners in state prisons, and almost 76% of those in federal prisons, were treated by a healthcare professional, according to the Bureau of Justice Statistics.
Services are often outsourced to private companies. Miami-based Armor Correctional Health Services, which operates in five states, is looking to contract with both primary care physicians and specialists in orthopedic surgery, ophthalmology, cardiology, ob/gyn, infectious diseases, and psychiatry, according to John P. May, MD, the chief medical officer.
Dr May says that casting, radiography, minor surgery, and dialysis are generally performed onsite, and nurses staff the facilities around the clock. Work in county jails, he adds, is more demanding than in prisons. Because newly arrested felons start in a jail, that is where untreated chronic illnesses have to be stabilized and wounds sustained from eluding capture have to be treated. By the time felons are convicted and sent to prison, he says, these issues have often been resolved.
Advantages of correctional medicine include no out-of-pocket payments to collect and malpractice rates that are generally low. There’s another perk, too: “I don’t have to stay late at the end of the day dealing with paperwork,” Dr Puerini says.
This appeals to physicians who want to cut ties with insurers and open direct-pay practices, where the only source of income is monthly payments from patients. Philip Eskew, DO, a family physician who is about to launch such a practice in Wyoming, is moonlighting in a prison while he builds his direct-pay practice. Prison medicine “allows you not to have to deal with third-party nuisances,” he says. Because he has cut ties with Medicare and insurers, however, he can’t moonlight in emergency departments or urgent care facilities.
Pros: Payment is competitive, and physicians have very little paperwork and generally lower malpractice risks. Telemedicine allows some services to be handled off-site.
Cons: Prisoners have multiple health problems, and many of them are mentally ill; however, guards are always nearby, and the work is considered safer than service in an emergency department.
8. Practice Telehealth From Home
Sitting in your own home office, you can provide telehealth consults to distant patients. This work, done by phone or over the Internet, is attractive to physicians who are looking for part-time work, because you can arrange to take the calls in your off hours.
Telehealth doctors, who advise patients whom they will never meet in person, deal with a variety of simple complaints. Because procedures aren’t involved, the work is a good fit for primary care physicians. They can even write short-term prescriptions. If the telehealth physician decides that the complaint can’t be handled over the phone, the patient is directed to a local doctor or emergency department.
Video visits average about $30 per visit. Each encounter takes 8-12 minutes, but the physician also needs to review the patient’s medical history, write a brief summary of the encounter, and provide instructions to the patient.
That rate could be worthwhile if you’re used to seeing a lot of patients quickly, says Philippa Kennealy, MD, a practice consultant in Los Angeles. Some states, such as Texas, maintain that patients must first have a face-to-face encounter with a physician before they can use video visits. But resistance has been eroding. Telehealth consults are legal in at least 21 states, including California, Illinois, New York, Ohio, and Pennsylvania.
Many patients pay out of pocket for telehealth consults. Medicare won’t cover this kind of service, but some major private insurers, such as United Healthcare, Aetna, and Cigna, have begun to cover the charges. At least a dozen states have passed laws requiring private insurers to pay for telehealth.
Caring for a patient whom you can’t see or touch might seem risky, but so far the work has run into little malpractice activity. To reduce risks, physicians starting telehealth consults have to undergo training in telephone best practices and use protocols, such as those devised by David A. Thompson, MD, author of the book Adult Telephone Protocols (American Academy of Pediatrics, 2012).
In addition to Ringadoc, you can check out American Well, Teladoc, and iSelectMD. Another company, NowClinic, hires physicians to provide telehealth consults for United Healthcare members in 22 states. And Soliant Health, an online recruiting organization, has been looking for doctors to make telehealth consults for hospitals. Another good source to find telemedicine companies is the American Telemedicine Association.
Pros: You can work from home and set your own hours. It’s a growing field, and there are many outlets to choose from.
Cons: Payments are somewhat low, and you may be barred from doing this work in your state.
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