Moonlighting For International Medical Students: Exploring Possibilities

Moonlighting is a term used to describe when medical graduates, after their first year of residency, apply for a temporary license to work and earn money at a hospital while completing their residency. In the United States, international medical graduates (IMGs) have not historically been afforded the same opportunity to obtain such a license. However, a new law passed by the Tennessee General Assembly now allows IMGs to moonlight, which could improve physician retention in the state. IMGs in other states face varying restrictions on moonlighting, with some requiring several years of residency before they can obtain a full license to practice independently.

Moonlighting opportunities vary by state

Moonlighting is a common practice among medical residents, who often face the burden of substantial student loan debt. It involves taking on additional work outside of their residency program, often in the form of clinical shifts in settings other than their primary hospital or practice. While moonlighting can provide financial relief, it is important to carefully consider the potential challenges and adhere to state and federal regulations governing the practice of medicine.

The opportunities and regulations for moonlighting vary across different states in the USA. For example, in Tennessee, a new law now allows international medical graduates to moonlight, addressing previous limitations that prevented them from obtaining the necessary licenses. This change aims to improve the retention of physicians in the state and enhance its attractiveness to students starting their residencies.

In contrast, some states or programs may have more restrictive policies. For instance, certain states require IMGs to complete three years of residency before obtaining a license necessary for external moonlighting. On the other hand, some programs may offer "internal" moonlighting opportunities, where residents can pick up additional shifts within their institution, which typically does not require a separate license.

It is crucial for residents to familiarize themselves with the policies and procedures of their state, residency program, and institution before considering moonlighting opportunities. While moonlighting can provide financial benefits and diverse clinical experiences, it is important to carefully manage the additional workload to avoid burnout and ensure high-quality patient care.

IMGs can face difficulties obtaining a license

International medical graduates (IMGs) often face challenges when seeking to obtain a license to practice medicine in their intended country or state. The requirements for medical licensing vary across different countries and even within specific states or provinces. This variation in requirements can make it difficult for IMGs to navigate the licensing process and meet the necessary standards.

In the United States, for example, IMGs were previously unable to obtain a temporary license to work and earn money during their residency in states like Tennessee. A new law passed by the Tennessee General Assembly now allows international medical graduates to "moonlight," providing them with the opportunity to work and earn an income while completing their residency. This change addresses the challenges faced by IMGs, who often had to leave the profession or remain underemployed due to the previous limitations.

In Canada, IMGs also encounter obstacles in obtaining full licensure. To be eligible for licensure in all Canadian provinces and territories, IMGs must meet specific requirements, such as holding a medical degree from an accredited institution listed in the World Directory of Medical Schools. Additionally, IMGs in Canada find it challenging to secure residency programs, with only about ten percent of IMG applicants obtaining a position.

Similarly, in Australia, IMGs must apply to the Australian Medical Council (AMC) and undergo a series of assessments, including an AMC Multiple Choice Question (MCQ) Exam and an AMC clinical exam. This extensive evaluation process can be demanding for IMGs seeking to obtain a license to practice medicine in Australia.

While moonlighting provides IMGs with valuable experience and additional income, the licensing requirements and regulations vary depending on the location and nature of the work. IMGs must carefully navigate these requirements to ensure they comply with the relevant laws and policies of their intended country or state of practice.

Pros and cons of moonlighting

Moonlighting, or taking on a side job as a medical resident, has both advantages and disadvantages that should be carefully considered before making a decision. Here are some pros and cons of moonlighting to help you make an informed choice:

Pros of Moonlighting:

• Extra Income: One of the main benefits of moonlighting is the opportunity to earn extra money. Moonlighting shifts often pay higher than traditional shifts, allowing residents to boost their overall earnings significantly. This additional income can be crucial in addressing financial challenges, such as student loan debt, meagre resident incomes, and increasing bills.
• Experience and Autonomy: Moonlighting provides residents with the chance to gain new experiences by working with different types of patients and doing different kinds of work. It offers more autonomy in managing pay, extra shift schedules, work locations, and even the medical field they want to practice in. This added experience and independence can be advantageous when applying for permanent positions or considering a job change.
• Networking Opportunities: Taking on moonlighting shifts allows residents to meet and network with new people, which can be beneficial for their careers in the long run.
• Addressing Physician Shortages: Moonlighting can help address physician shortages, especially in states like Tennessee, where international medical graduates were previously not allowed to moonlight.

Cons of Moonlighting:

• Added Stress and Workload: Taking on a second job can increase stress levels and workload. Balancing the demands of two positions, including learning new organizational systems, policies, and workflows, can be challenging.
• Liability Risks: Working in medicine already carries inherent risks, and taking on a second clinical job further increases liability issues. Moonlighting positions may require additional medical liability insurance, which is not always covered by existing policies, leading to higher expenses.
• Time Commitment: Moonlighting requires a time commitment that may result in longer hours, fewer days off, and more time away from home. This can impact the free time available for personal pursuits or relaxation.
• Controversy and Program Consent: Moonlighting as a resident can be controversial because they are not yet fully trained physicians. Additionally, residency programs may prefer their residents to work more hours for the program instead of moonlighting. Therefore, it is crucial to ensure that your residency program consents to your moonlighting activities and that you are in good standing with them.

Ultimately, the decision to moonlight depends on your unique personal and professional circumstances. While moonlighting can provide financial relief and valuable experiences, it is essential to carefully weigh the potential benefits against the drawbacks to make an informed choice.

Residency programs' influence on moonlighting

Residency programs can have a significant influence on moonlighting opportunities for medical graduates. Moonlighting, or the practice of taking on extra shifts outside of regular working hours, is a way for residents to earn extra income and gain clinical experience. While it can be a great way to supplement their residency income, it is essential to consider the impact on their education and performance.

Some residency programs may offer internal moonlighting opportunities, where residents can pick up additional shifts within their training institution or affiliated sites. These shifts are often supervised and may include overnight coverage for non-teaching services. Such opportunities allow residents to stay within their ACGME hour limitations and include income in their regular paycheck. However, residents must ensure they get adequate rest and don't exceed the 80-hour weekly work limit.

Other programs may allow external moonlighting, where residents work at unaffiliated institutions. In these cases, residents may need additional licenses and visas, depending on the state and institution. External moonlighting income is typically managed by an ing agency, and self-employed physicians are responsible for their tax payments.

The decision to moonlight depends on the resident's personal and professional circumstances. While it can provide financial relief and valuable experience, it should not detract from their residency program or educational goals. Residency programs should monitor the impact of moonlighting on their residents' performance and well-being and provide support as needed.

Overall, residency programs play a crucial role in shaping moonlighting opportunities for medical graduates. By offering internal moonlighting shifts, providing supervision, and ensuring residents' well-being, residency programs can help residents benefit from moonlighting while maintaining a positive educational experience.

Visa status and moonlighting

International medical students in the United States on an F-1 visa are restricted in the work they can undertake off-campus. During their first year, they are not permitted to work off-campus, including volunteering at a clinic or community organisation. After the first year, they may be allowed to work off-campus with some restrictions, but they will need to obtain authorisation. Working without authorisation will violate the terms of their visa. International students must be careful when seeking out extracurricular activities and ensure they are not engaging in any professional activity.

In the United Kingdom, international students must pay for their healthcare with an additional surcharge on top of their visa application. This surcharge is refunded if their visa application is unsuccessful. International students in the UK are advised to purchase health insurance to cover the cost of their care during their stay.

In Tennessee, a new law was passed in 2024 to allow international medical graduates to moonlight, as long as they are in the state on a legal statute such as a work visa or green card. This law was passed to address the state's physician shortages and make Tennessee more attractive to students looking to start their residencies.

In Canada, the province of Ontario will bar international students from attending medical schools from 2026 onwards. The Ontario government has stated that it is reviewing the visa trainee program that trains international students sponsored by foreign governments to further protect Ontario students.

Frequently asked questions