(8 comments)

Mickey McDonough – While the goal of eliminating 24-hour shifts in medical training is well-intentioned, the evidence does not support this resolution as a universal mandate, and such a policy may inadequately prepare residents for the realities of independent practice where extended on-call duties may apply. Eliminating 24-hour shifts does not consistently improve patient safety and may paradoxically worsen outcomes in certain settings. A 2020 randomized trial in pediatric ICUs found that schedules eliminating extended shifts were associated with significantly increased rates of serious medical errors, particularly at sites with high resident workloads.[1] The iCOMPARE trial, involving 63 internal medicine programs, demonstrated noninferiority of flexible duty-hour policies (permitting extended shifts) compared to standard 16-hour shift limits, with no difference in 30-day mortality.[4] Similarly, the FIRST trial in surgical training showed no increase in death or serious complications under flexible policies.[3] Many attending physician positions, particularly in acute care specialties, require on-call duties and the ability to manage extended work periods. Residency programs that eliminate all exposure to 24-hour shifts may fail to prepare trainees for these realities, potentially increasing errors when graduates transition to independent practice. Strict duty-hour limits have been associated with reduced time in direct patient care (declining from 25% in 1994 to 9-12% more recently), decreased continuity of care, and concerns about inadequate professional maturation. Program directors have reported reduced quality of training under restrictive policies, and systematic reviews suggest that stricter limits may compromise resident education without improving well-being.[2] The elimination of extended shifts during training removes opportunities for residents to develop critical skills in managing fatigue, prioritizing tasks under pressure, and maintaining clinical judgment during prolonged patient care episodes—competencies essential for attending physicians who will face similar demands throughout their careers. **In conclusion, while fatigue-related risks are real, a blanket elimination of 24-hour shifts may compromise training for the realities of medical practice without consistently improving patient safety**. ### References 1. Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts. Landrigan CP, Rahman SA, Sullivan JP, et al. The New England Journal of Medicine. 2020;382(26):2514-2523. doi:10.1056/NEJMoa1900669. 2. Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine. Desai SV, Asch DA, Bellini LM, et al. The New England Journal of Medicine. 2018;378(16):1494-1508. doi:10.1056/NEJMoa1800965. 3. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. Bilimoria KY, Chung JW, Hedges LV, et al. The New England Journal of Medicine. 2016;374(8):713-27. doi:10.1056/NEJMoa1515724. 4. Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules. Silber JH, Bellini LM, Shea JA, et al. The New England Journal of Medicine. 2019;380(10):905-914. doi:10.1056/NEJMoa1810642.

Sandra Stover – I support the overall concern regarding sleep deprivation and the impact of safety for patients and for Residents. I am also aware that there are many places where physicians may work a 24 hour shift, or be on call for multiple days. Knowing one’s capacity to meet those needs could be one of the objectives of a limited number of days in the third year of Residency, when residents are backed by faculty who can assure patient safety and also work with the residents to understand their limitations. Could this be amended to limit the number of 24 hour shifts and also have an expectation of intentional learning objectives?

Anthony Hoff – There are many acute and chronic harms of 24-hour shifts, as this proposal aptly points out. However, the reality of rural medicine in understaffed, low-volume critical access hospitals means that 24-hour shifts can be the only way to ensure patients have access to acute care when they need it. Learning to safely manage the fatigue and stress of a 24-hour shift unfortunately is currently a necessary evil in our current health care system. Accomplishing that learning in the supportive environment of a residency program is safer than getting thrown to the wolves after graduation once there are no more limits on your work hours. In retrospect, I am grateful that I got that supported training in residency, as miserable as it seemed at the time. I absolutely agree that 24-hour shifts should be minimized in general. But completely banning the option could have serious negative downstream consequences for our future rural healthcare workforce.

Nancy Baker – I don’t think it’s reasonable to ban family physicians -in-training from working more than 24 consecutive hours. It certainly should be a goal of all Family Medicine residency programs to provide back-up and/or support for those who have completed their 24-hour work shifts if they have not been able to sleep during their on-call shift. However, there will bel cases where the resident post-call may be needed, or wants to continue providing some aspect of clinical care. For example: it’s not uncommon for a resident’s pregnant patient to present in labor and the resident is either expected, needed, or wants to attend her delivery. I think programs can aspire to providing a minimum of a 4-8 hour period of rest post call, but not outright prohibit working more than a certain number of hours. Finally, as we know, many practicing family physicians will be called upon to provide patient care after-hours, post-call, etc., even when they have worked for 24 or more consecutive hours.

Andrew Slattengren – I am speaking against this resolution. First, there are other organizations outside the University of Minnesota that sponsor Family Medicine Residency Programs without our state and directing the actions of the MAFP toward only one organization is not prudent if the duty hours issues cited are present is other programs and focusing on one organization sets up an adversarial relationship. Second, this is not a UMN issue as multiple programs under the UMN umbrella already have eliminated 24 hour shifts. Further, the ACGME sets duty hours restrictions and not the AAFP. The AAFP already has a policy “Resident Work Hours” that cites “Programs must have formal mechanisms specifically designed for promotion of physician well-being and prevention of impairment. There also should be a structured and facilitated group designed for resident support that meets on a regular schedule.” https://www.aafp.org/about/policies/all/resident-work-hours.html This was last affirmed at the October 2025 COD.

Ainslee Crose – As a family medicine resident at a small program, I am concerned that eliminating 24 hour shifts across the board does not take into account the limitations placed on smaller programs to provide coverage. Currently, our residents do 24 hour shifts in the form of clinic during the day, going home in the evening, and returning to the hospital overnight with a post call day off the next day. This schedule is very popular among residents. If this no longer allowed, we would be forced to transition to a night float program which has historically been extremely unpopular and would not be supported by our residents.

Amy Bonifas – Though I appreciate the spirit of the resolution which aims to improve the mental health of medical residents, the language is both far reaching and at the same time unactionably specific and seeks to address one component of resident training that one might be hard pressed to show is the primary driver of poor resident mental health. 24 call occurs in many varieties with different applications and types of support, and it cannot be placed into one uniform “bucket”. Programs are different sizes and situated in different contexts. Studies have assessed both patient safety and resident wellbeing with respect to 24 hour shifts, though most of the research has focused on the former. A recent and helpful reference: ‘Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts’ NEJM June 2020;382:2514-2523. As a practicing physician and a patient it is important that we are training residents for their future practices and the challenges that await them. This reflection ‘Is the elimination of 24-hour resident call a good idea? NO’ by Jonathan Cools-Lartigue in the Canadian Family Physician 2013 Feb;59(2):133–135 speaks to me: “Various specialties have different training requirements. The goal of residency is to train competent, independent, and safe physicians and surgeons. Some specialties provide emergent care to patients whose problems arise in an unpredictable way without respecting shift duration or daylight hours. Graduating residents must be able to provide life saving emergent care that is in line with the needs of their patients and their training has to take this fact into account.” I fully support case by case accommodations for residents who need them around 24 hour call but cannot support the blanket elimination of this training schedule option for residencies in Minnesota and across the country.

Kate Schreck – As someone who did not complete any 24hr shifts in residency, I support the spirit of this resolution. I do wonder if some slight changes may be appropriate. The ACGME had 16hr shift restrictions for PGY1s in 2011 that were then reversed in 2017 due to lack of data for improved patient care and possible detriment to resident education. Mandating restrictions across specialties doesn’t seem to be within MAFPs purview and I think there may be specialities that would push back against a 24hr shift restriction due to the possible increase in shifts and residency time. Additionally, there are many specialties (FM included) that utilize 24hr shifts in practice and would therefore justify such an approach in residency. If the goal was to modify requirements at the University of Minnesota, one could advocate through SEIU. If the goal was to modify requirements for graduate medical education in MN, I would amend the language to indicate this. There are more residencies in MN than the University of MN. The AAFP already has policy about resident work hours that emphasizes flexibility https://www.aafp.org/about/policies/all/resident-work-hours.html. I would advocate either for collation of information from FM residencies in MN regarding scheduling options to minimize excessive resident work hours that could then be used at the local program level to advocate for change or investigation into the harms of excessive work hours and benefits of reduction across graduate medical education in the state of MN.