12s vs 8s, From Those Who Live It...

Discussion in 'Emergency Medicine' started by Old_Mil, Jan 3, 2009.

  1. Old_Mil

    Old_Mil Senior Member
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    So I'm trying to put together my ROL, and there are two programs I've visited so far that are flip-flopping between the #1 and #2 spots. One works more 8s, the other fewer 12s.

    Could some of you who have made this decision in the past share your thoughts on how and why you made it?

    7a-7p + 7p-7a vs 7a-3p + 3p-11p + 11p-7a
     
  2. docB

    docB Chronically painful
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    12s are hard. When you're on 12s your life is work-sleep-work-sleep for however long a stretch you're on. I much prefer 8s,9s and 10s.

    That said I don't know that I'd weight shift length too heavily when considering residencies. I did 12s during residency (maybe that's where I learned I don't like them) but I'd be a lot more concerned about the shift lenght where you get a job. You can do anything for 3 to 4 years. 20 years is what I'd worry about.
     
  3. Koko

    Koko Koko
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    Did a month of 12s on an away as a 4th year med student. While it was fine for me for that brief stretch, I saw the toll it took on the residents -- one of whom had vacation during my month. When she got back from vaca i asked her what she did and she replied, "sleep." I had multiple advisors warn against joining a pgm that did 12s and I am thankful to be at a pgm that does mostly 8s. It gives you time for life, studying and in my opinion, leads to better quality of life/less burn out.

    I have accepted a job that does 12s, but there is a 2 hour overlap along with 2x to 3x coverage, and you stop seeing new pt's after 9 3/4 hours. It's a 3 on 3 off model and everyone seems very happy regardless of how long they've been on staff.

    Think hard about your learning style and what you need to be happy (that includes your SO if you have one along for the ride). Good luck.
     
  4. jaeida8

    jaeida8 Senior Member
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    I'm at a residency with 8 hour shifts during 2nd and 3rd year, and I will be doing 8s, 9s and 10s at my Texas job. I love 8 hour shifts. I have had plenty of time to read, go out to eat, spend time with my husband, etc.

    I rotated at a Texas program with 12 hour shifts, and the 3rd years said they were tired and had a hard time finding the time or energy to read. I think having the time to study during residency is extremely important, so I decided against 12s for residency.
     
  5. Greenbbs

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    my home program we do 8s, and they're fantastical....you see a decent number of patients, and when you go home, you've got time to do other things.

    we rotate at a hospital where you do 10's and the weekends are 12's, and those 12's are a bitch, especially on that saturday/sunday 7p-7a shift...and at midnight, you're like...damn....7 more hours to go.

    avoid the 12's....they're harsh, especially since you can't always guarantee you get out exactly on time, and then you're really working like 13 hours, then drive and sleep and drive again.
     
  6. WilcoWorld

    WilcoWorld Senior Member
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    I've done 8 hours with no overlap, 10's with overlap, and 12's with no overlap. I strongly prefer the 10's with overlap, because it allows you to stop picking up patients an hour before you sign out, and this allows for a much more tidy sign out. 8's are nice, but with no overlap some people start to let stuff sit near the end of the shift, or they sign out totally undifferentiated patients, and both of those stink. The major upside to 12's is that you work fewer shifts. However, it combines the difficulty of a 12 hour shift with the difficulty of no overlap, which is sorta the worst of both worlds.

    So that's how I feel about shift lengths. However, I agree with docB - There are several factors that are more important in choosing a residency (fit, location, post-graduation job connections, program director) and I would only let shift length become a deciding factor if all else was equal.
     
  7. Jarabacoa

    Jarabacoa non carborundum ilegitemi
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    I currently do 12's. In residency, we did 10's and then switched over halfway to 12's. I prefer 12's due to the massive number of days off I have during the month (I work 12 12's and therefore, get around 18 days off a month.)

    I think from a training standpoint, 8's would be the best as you would have less clock-watching and more focus on seeing patients and less chart build-up to have to stay after for.

    abstract from pubmed:
    Am J Emerg Med. 2008 Sep;26(7):789-91. Links
    Resident productivity: does shift length matter?Jeanmonod R, Jeanmonod D, Ngiam R.
    Department of Emergency Medicine, Albany Medical College, Mail Code 139, Albany, NY 12208, USA. [email protected]

    BACKGROUND: It has been established that residents are able to evaluate more patients per hour as they progress through training. However, it is unknown if shift length influences resident productivity. OBJECTIVES: The aim of this study is to assess whether there is a difference in second-year resident productivity as a function of shift length. METHODS: This is a retrospective chart review of patients evaluated in the emergency department (ED) by second-year residents in a 65,000 volume center; 9- and 12-hour shifts were included. Nine-hour shifts provide a 1-hour overlap, such that three 9-hour shifts provide 24 hours of resident coverage. Shifts on weekly conference day were excluded. A patient was determined as having been evaluated by a resident if the resident initiated care on the patient and dictated the chart. Data were analyzed using 2-tailed t test. RESULTS: A total of 193 nine-hour shifts and 90 twelve-hour shifts met inclusion criteria. Residents working 12-hour shifts evaluated 1.06 patients per hour, and residents working 9-hour shifts evaluated 1.15 patients per hour (95% confidence interval, 0.031-0.151). In an ED with 120 hours of resident coverage per day, this results in 10 additional patients seen by residents working 9-hour shifts. In our department with 9 ED months in the second year of residency, this results in 180 additional patient encounters per resident during that year. CONCLUSIONS: Shorter shift lengths appear to result in more patients evaluated per hour by second-year residents and an increase in patient encounters.

    PMID: 18774044 [PubMed - indexed for MEDLINE]
     
  8. dchristismi

    dchristismi Gin and Tonic
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    I did 12s in residency. Painful sometimes, but doable. And more days off.

    My job is now 8s with some overlap (used to be 9s, but switched recently). It's nice.

    It's something to consider, but really, other factors are more important. And you can do just about anything for 3 years.
     
  9. NeuroSync

    NeuroSync Every day is a good day
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    I did 12s on an away, and I will not rank any programs with that schedule very high. The problem with those programs is that they let the senior residents choose what schedule they should have. When you are looking at 12-14 12s (versus 18-19 as a 1st and sometimes 2nd year), there is a big difference. All I did was work and sleep. In a single month, it took its toll on me in terms of happiness and fitness. I will not do that for 3-4 years. If you don't have outside interests, family, etc., maybe it is better to have more days off. I don't know. All I know is that I need a bit more balance...
     
  10. quideam

    quideam Too tired to complain
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    I guess i'm in the minority (and i'm just a 4th year med student with 2 sub-i's under my belt, so what do I know? :). I definitely prefer 12's, for two reasons. One is the difference in number of shifts per month - I would definitely rather have 18 12's than 22 8's - those extra four days off are days I can use to go skiing, go out to a museum, etc. Honestly, those extra few hours I would wind up having off in the day I would just waste because I would be tired anyway, whereas if I have an entire day, I'll do something with it. My second reason is that I feel that i'm able to have a better quality of experience in a 12 hour shift. Just think about how long it takes the average patient to get dispoe'd - you see them initially, then you need labs/imaging, etc., maybe a procedure or a call to a consultant, etc... This can take hours and hours. So, by doing 12's, I find that i'm able to properly work-up and follow through more patients, say, those that I see in the first 8 or 9 hours of my shift as opposed to those I see for the first 5 - and that's a huge difference.
     
  11. jaeida8

    jaeida8 Senior Member
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    It also depends on your body, sleep habits, etc. I felt extremely tired when I worked 12s during my medical school rotation despite the extra days off, and now that I work 8s I am never tired. The way our ED schedule is set up is 7-3 x 2, 3-11 x 2, 11-7 x 2, 2 days off. I love each of those shifts.

    After I get out of a 7-3, I feel like I still have the entire evening and can do a lot (dinner, errands, etc). After the 2nd 7-3 shift, I can stay up really late because I don't have to be back until 24 hours later. I like 3-11 shifts because I can get up whenever, still have time for lunch, read, errands etc. And I usually do something between the 2nd 3-11 and 1st 11-7 because again I have a full 24 hours off, I sleep in after the 3-11 and can function without a nap before that first overnight. I have driven to the beach during that transition before. I do sleep all day between my 2 overnights, but then once I finish those 2 overnights I have 2 good days off. I have a ton of time to read, but I don't read as much as I should because I end up watching movies, going out, etc...not because I am tired.
     
  12. roja

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    PGY1&2 did 12's. PGY3 did 8's. Thought I would want the 12's but I will enver go back. Yup, more days off. but you pretty much waste huge chunks of your life sleeping and recovering. The quality of your life, both working and not, is MUCH better on 8's.

    also, its hard to give great patient care on hour 11 and 12, for most people
     
  13. DrMom

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    We only do 12s at my program. I agree on the more days off part, but I also agree that during a run of shifts all you can do is work and sleep.

    I moonlight 8s and 16s (double to triple coverage for both of these). The 8s are great! I feel like I've barely gotten going and it is time to go. I can go home and actually *do* normal life things. 16s are insane and I avoid doing them. After 12-14 hrs of work, I feel like I don't think as sharply.

    In an ideal world, I'd go for a mix of 8s and 10s. For residency I like the 12s. Leaves more days for everything else, including moonlighting.
     
  14. quideam

    quideam Too tired to complain
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    Wow, that does sound like a fantastic schedule! I'm sure I would really like that... but, and again i'm certain that i'm going to be in the minority here - I guess (and i'm probably crazy!) I feel that residency just shouldn't be like that. I'm not saying you don't work hard - i'm sure you bust your butt like everyone else - but I guess I want residency to be tough, including time-wise. Before you guys start railing on me for being nuts, I'll throw in that I would probably be a surgeon if EM didn't exist as a specialty :D Honestly, though, when all of the other specialties have long, tough hours, if we're cutting our shifts down to the bare minimum, then how do we stand shoulder-to-shoulder with them? I'm not saying that we need to be bleary-eyed surgeons on our 35th hour at the hospital, but I do feel that 12 hour shifts at least let us work long enough to be able to follow through on many of our patients, and actually work properly hand-in-hand with our consultants. I'm sure i'm also different in this because i'm purposely not looking for a light or family-friendly schedule; I want a "hard core" residency where we work hard. I'm not saying the 8-hour people don't work hard, but... I don't know, it just seems way out there. But that's just me.
     
  15. Pinner Doc

    Pinner Doc drop knees, not bombs
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    I come from a program that does 8, 9, and 10 hour shifts.

    I have a question for those programs doing 12-hour shifts. The RRC/ACGME has work hour standards specific to EM programs that states that the amount of respite time you have between shifts must be equal to the amount of time you spent on your previous shift. Given that you are working 12 hour shifts, and assuming several of these shifts are back-to-back, are you truly being let off work at exactly 12 hours? Maybe this is a loaded question, and I don't intend to flame or have any programs incriminate themselves, but I was curious how your programs deal with this technicality in light of the busy nature of the ED, documentation responsibilities, etc.
     
  16. substanceP

    substanceP Member
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    at my program we do 12's 1st, 2nd, and 4th years, and 8's 3rd year at one hospital, and we do 12's all four years at the second hospital. i still work out 5-6 times/week, still read maybe 5 times/week, still have an active social life. it's doable, you just have to be more focused with your time off. it was the least of my concerns when choosing residency and i'm very happy where i'm at (weather notwithstanding - nyc is butt-***** cold right now).
     
  17. DrMom

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    We can almost always get out in 12 or 12.5 hrs. We sign out patients to the incoming residents. We sometimes stay over if we have a pending procedure or pelvic (we don't sign out either of those) or if we're really close to being done with someone.

    That said, I'm at a DO program so we don't have those same nice EM hours rules.
     
  18. jazz

    jazz Senior Member
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    agree with what others have said in that i wouldn't choose residency based on the length of shifts.

    it's only 3 (or 4) years long. more important is the training you receive and the fit of the program for you.

    that said, if a program has a mix of 8, 10, and 12's -- it's nice in that it will allow you to better decide what kind of job setting to pick as an attending.

    in the end though one thing is true: 12's are long, but you work fewer days/month.
     
  19. Midwest Medic

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    Where I trained we did 9's with one hour overlapping. I didn't care for them that much because it seemed that since you were overlapping by an hour, that meant you had to get all the stuff done in that one hour. Sign out was highly discouraced, to the point of not letting us do it, because we "have an hour or so to get rid of your problems." So we all did major clock watching near the end of the shift so we could get out at the end of 9 instead of the end of 10-11 hours.

    Where I am working now we do 10, and 14 hours. the 10s are nice. It is a good length of a shift, and working 15-18 a month gets you decent hours per month. The 14s are brutal. Granted they are in a smaller ED where you might only see 5-7 people from 11p-7a, but you still have to be there and be awake for all of you shift. Luckily I only work 3 of those a month.
     
  20. EM_Rebuilder

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    We work 12s here in MS. I would say that 95% of the time you are out of there within 10 mins or less after the changeout. The first few weeks of residency when you are still getting used to everything probably has the longest afterstays (tidy up patients, etc).....but I think within a month, everyone gets good at winding down and ready for a s/o when the clocks hit 7 around here. The rare 'longer shift' will be when several traumas/super sick patients come right in and maybe the new guys are dealing with that...or if they roll in right before shift change, you are checking things over before the new guys come on.

    As far as charting, some people are more efficient and better at staying on it through the day and never have charts to finish. A few other people are a bit more slack on it. We can chart from home as well so you have the next 48 hours I think to get a chart done. I stay on my charts and rarely have anything to chart on when I get done. A few isolated incidents are when the 4-5 traumas or really sick med patients roll in the last hour..

    In my first 6 mos of residency.. I have stayed about 1.5 hours after a shift once... another couple of times maybe 20-30 minutes. The rest of the time, I am out on the money or 10 or so after. We try to be there 10-15 early when coming on...more as a courtesy for the off goer.


    I have never lived 8's so I cannot comment on comparing them... I will say that 12s are certainly long, but the added extra days are great. As a side, I just was off 9 days...worked 1...now I am off another 5 before working 3 with one day off then 5 more. EM1s avg 15-18 per month... EM 2/3s avg 12-15 per month. We are moonlight heavy around here, so nobody pushes for 8s as those would cut into moonlight time....


    On the RRC business... I am not sure how things are worded... we certainly would not pick any patient up after 12 hours... and the rare time you are hear much longer than a few minutes...well, maybe that violates something...but we have to think about patient care/education as well and I certainly would not let an occasional few minutes or hour too long on rare occasions cause a hiccup and I would hope the RRC would not be concerned about that. Now, if I program has residents staying hour(s) after near every shift...that is a different story and they need to correct that...
     
  21. NeuroSync

    NeuroSync Every day is a good day
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    I would much rather work more 8s or 9s than work 12s. There is no time for exercise or family working 12s. And the feeling of being burned out is MUCH higher.

    One of the things that is a bit disappointing is that it is usually the senior residents who vote on what type of hours to work, but they get, by far, the most number of days off, so it makes sense that they would make that choice. If they were working 20 12s, I am not sure the outcome would be the same...
     
  22. Dr.McNinja

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    10s. That way I still have time between work and sleep to interact with people. I remember college, when I worked 12s as a tech in the ED, and during the summers, would pull a ton of overtime. So I would work something like 12 days in a row. Basically it was sleep, wake up, work, go home, sleep, wake up, work. I probably was awake an hour outside of work.
     
  23. NeuroSync

    NeuroSync Every day is a good day
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    Exactly. I don't need MUCH time during the day, but I do need some...
     
  24. Drawing Dead

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    My program is 12's everywhere we go, and I love it. I think it depends on the hours we work. Some places we are 7-7 if there is 24 hour resident coverage. We have other sites where we are 9a-9p or 12p-12a if there is only 12 hour resident coverage. My big thing is commuting. 12 hour shifts mean less days at the hospital, so less time commuting. For example, I have a half hour commute to most of my sites, hour round trip.

    16 twelve hour shifts = 192 hours + 16 hours driving = 208 hours.

    24 eight hour shifts = 192 hours + 23 hours driving = 215 hours.

    (Note, this does not include time spent in traffic, or if tolls are to be paid, gas expenses, etc. that comes with commuting).

    On top of that, I have 14-15 days a month off rather than 6 or 7. And If I'm on a 7a-7p, I still leave early enough to do something after work.

    We get emails all the time about job opportunities, and I see many of them offering 8, 9, or 10 hour shifts. I know I have a few years to go, but i'm turned off by that. I would much rather work 12s and have more full days off than have shorter days for the sake of having time to do things after or before work.
     
    #24 Drawing Dead, Jan 15, 2009
    Last edited: Jan 15, 2009
  25. oldtown

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    I'm at a place in NYC that does 12's. The RRC requirements are that you must have an equal amount of time off between shifts as you spent engaged in Patient Care, not total time spent on a shift.

    So, if you spend 12 hours of your shift seeing patients, with 30 minutes of signout (transition) time at the end, you still have 12 hours off from patient care before your next shift.

    Fortunately our signout time is almost always 30 minutes or less. I've heard of some places that do 12's with typical signouts being 1-2 hours. That's brutal.
     
  26. Anonymous M4

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    I'd love to revive this discussion. How possible is it to band together as a class and take a position on what shift length we would like to work? My top programs work 12s at least for the first two years and I'm frankly a little worried about this "sleep work sleep" idea, although some of the proponents of 12s are making me feel a little better. I felt like 12s were a negative aspect of my top programs that I had to overlook to see the general awesome of the rest of the program. Sigh. Any other perspectives?
     
  27. Birdstrike

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    8 hours in a busy ED is like 12 doing anything else. 12's (which often become "13's") are like doing 16's in anything else.

    Bottom line:

    12's are murder, especially 5 or 6 back to back. I don't care how many days you get off after, you're fried days 4-6. In the fastest paced and highest stress specialty of all, why work the longest shifts of anyone? It's the best way to get burnt to a crisp. The only exception is a small volume ED where you get long gaps without having to see patients at night, for example.

    That being said, you're better off getting used to 12's in residency and going to a job after graduation where you work 8's and 10's, as opposed to the opposite.
     
  28. DeadCactus

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    I'm a proponent of shorter shifts, particularly 9's with overlap.

    1) I think (and the above article supports) that productivity is higher on shorter shifts especially when 12 hour shifts start bleeding into 13 or 14 hour shifts.

    2) More days off is nice on paper, but worthless when you're just beat down and only want to sleep. Few people are going to extensively study after any shift but at least after shorter shifts you have time to work out, run errands, do household chores, see your loved ones, and cook a healthy meal. I'm unconvinced that those "extra" days off with 12 hour shifts are anything more than catch-up days and some things (regular exercise, healthy meals, family time) just don't have the same impact when crammed into one day.

    3) I never bought into the argument that you should do 12's just in case you end up working 12's after graduation. Medical education constantly wants to punch you in the nuts to "prepare you" for a future kick in the nuts and I think it's one of the most idiotic dogmas our profession clings to.
     
  29. KeyzerSoze

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    On the off chance that you're subscribed to this thread even though your last SDN post was 2 years ago.... did residency change your point of view on this?
     
  30. DreamingTheLive

    DreamingTheLive (something witty here)
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    For me personally, 12 hour shifts was an absolute, no need to even interview, don't care about your salary, benefits, perks, facilities DEAL-BREAKER for residency.
     
  31. Apollyon

    Apollyon Screw the GST
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    Again, I must disagree in a qualified manner with my esteemed colleague above. I do 2 on, 5 off, 12 hour shifts in a 22K, mostly low acuity critical access hospital with 24 hours of physician and 12 hours of midlevel coverage per day. I also do an occasional isolated night in the mid week.

    I have done 12 hour shifts my entire career, since my EMS days, so that is what I know (except for, when I was in residency, we went to 8s during the week, and 12s only on weekends).

    BirdStrike makes it sound like getting beaten with a rubber hose or a baseball bat would be better, but maybe I'm either cut from better stuff (unlikely) or just more of a dimwit and doesn't realize it (much more likely). If I have to eat the **** sandwich, though, I would rather take big bites. You want to ruin me? Make me work 16 or 20 8 hour shifts a month, or, worse, make me work 4 hours every day of the month. NO, thank you. Fewer, longer shifts, and I am doing just fine.
     
  32. DreamingTheLive

    DreamingTheLive (something witty here)
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    My DREAM JOB! 8 - 12 everyday, wow, where do I sign up?
     
  33. Apollyon

    Apollyon Screw the GST
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    And my esteemed colleague is BirdStrike. Not to take anything off anyone else, but he is to whom I was referring.
     
  34. Birdstrike

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    This is exactly the exception to the rule, I was talking about when I said this...


    "The only exception is a small volume ED where you get long gaps without having to see patients at night, for example."

    A 22k ED is going to be pretty manageable between midnight and 7 am.


    I wouldn't dispute this for a second.
     
  35. Apollyon

    Apollyon Screw the GST
    Physician Lifetime Donor Classifieds Approved 10+ Year Member

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    As I look back, I see that I did not mention it. I do day shifts - drive in Saturday morning, stay over Saturday night, do Sunday day, and drive home Sunday night. I see 14-20 patients in 12 hours. The nights I've worked, I have never gotten a minute's sleep. That 22K is from last year, but, so far this year (actually, from December), we are seeing between 70 and 100 patients per day, with a vast majority ESI 4s and 5s, and the 3s split between "hard" and "soft". If patient volumes continue, we're going up to 27K this year. That is NOT a "slower" department, as that is right on par with 2 pph (for all providers).

    But, I'll be quite honest - I tell people I'm a B+ doctor, which is a candid and truthful self-observation (or "perception", at least).
     
  36. Iride

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    So here is my take on all this, for what its worth. I interviewed across the country at places with both 8's, 10's and 12's and also My sister is an EM doc who works 12's and swears by them that they are the best.

    My take is that as a practicing physician in private practice, 12's are by far the best because you ACTUALLY do get many more days off (she works 12-14 shifts per month full time). However in my experience with residency interviews, the places that worked 12s worked ALMOST just as many shifts (typically 19-20) per month and in general just seemed a whole lot more overworked/exhausted. That being said.... I tended to rank the places with 12s much lower because the residents were just happier at other places, and that says a lot. However, when im an attending, im thinking 12s will be more family friendly for reasons stated above and at this point think that is what I will look to work. Obviously things may change my mind before then, but there ya go, a perspective from both sides.
     
  37. tkim

    tkim 10 cc's cordrazine
    Physician 10+ Year Member

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    Did 12's in residency and got the beat-down. Do 8,9,10's in pp and love it, though we are changing to include 12's which I am not thrilled about but I'm willing to try. The acuity, throughput and other things specific to each shop will determine whether a 12 is doable or a death march. My community shop sees 40k/yr and at times we have triple coverage not including PA's and we still get crushed.
     
  38. Arcan57

    Arcan57 Junior Member
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    We did 8's 10's and 12's in residency. As everyone has mentioned, 12's are significantly harder than any other configuration (except 24's in places with high night volumes). 12's are even harder out of residency when disappearing from family responsibilities for 4 days in a row can be horrifically painful on the back end. Keep in mind though that any configuration that makes even a vague attempt to staff for arrivals by time of day is going to have a high proportion of inconvenient shift times. Most volume comes in on what is traditionally the "swing" shift which means that most of your shifts are going to have 7p in there somewhere.
     

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