Most family medicine residents outside of Quebec must complete in-hospital extended-hour call shifts often exceeding 24 consecutive hours—the equivalent of 3 back-to-back 8-hour workdays—with little to no sleep.1-7
It requires some mental and ethical gymnastics to justify current extended-hour call shift practices. Why do we as physicians support practices that knowingly jeopardize both resident and patient health?8-10 This question has been largely undiscussed in Canadian Family Physician since 2013,11 except for a brief article in 2017 about the Fatigue Risk Management Task Force.12 I hope this commentary can reignite discussion and serve as an indicator that Canadian family medicine residents are still seeking safer working conditions for the benefit of themselves and their patients.
Background
Proponents of extended-hour call shifts may argue that residency training has always operated this way and must continue to do so to ensure adequate competency is attained. This approach dates back to the late 1800s when US physician Dr William Halsted championed a system where his exclusively male residents were expected to be available to work 24 hours a day, 7 days a week, 365 days a year.13 However, it was not until the tragic Libby Zion malpractice case in 1984 that the dangers of excessive resident work hours garnered national attention and ultimately prompted directives to limit working hours.14 Since then, concerns about patient safety, professionalism, resident burnout, and resident mental health15,16 have fuelled debate about any advantages of 24-hour shifts.
Despite mounting evidence linking extended-hour shifts to compromised patient safety and resident health, and provincial case law where 24-hour shifts were determined to violate fundamental rights under the Canadian Charter of Rights and Freedoms,17 24-hour shifts remain standard practice for residents working in hospitals outside of Quebec. The College of Family Physicians of Canada (CFPC) accreditation standards are silent on resident working hour maximums, as resident working conditions are determined by negotiations between the provinces and their respective resident associations. Although CFPC accreditation standard 3.2.2.6 states that fatigue risk management must be part of the curriculum,18 I suspect many family medicine residents are unaware of the option to declare fatigue, and that medical schools often have policies to acknowledge this declaration without personal and professional repercussion.19,20 This disconnect highlights the ongoing need to align residency training practices with the principles of safety, equity, and basic human rights for patients and residents alike.
Risks of extended-hour call shifts
Extensive scientific data demonstrate that shifts exceeding 12 to 16 hours without sleep are unsafe.21 As family physicians, we regularly counsel patients on the importance of sleep and certainly would never endorse sleep deprivation as a lifestyle or health intervention. While this may seem intuitive, researchers have studied the impairing effects of prolonged wakefulness for over half a century.22 For instance, after 17 to 19 hours of wakefulness, cognitive performance is equivalent to having a blood alcohol concentration of 0.05% (50 milligrams of alcohol per 100 millilitres of blood). After 24 hours, it mirrors levels exceeding 0.1% (100 milligrams of alcohol per 100 millilitres of blood).23 For context, operating a motor vehicle with a 0.1% blood alcohol concentration constitutes a criminal offence in all Canadian provinces and territories.
Canadian laws enforce strict work hour limits for professions critical to public safety such as commercial pilots, truck drivers, locomotive crews, and marine personnel. Collective agreements in Canada for nurses and paramedics generally include shift patterns of 16 hours or less.24,25 Somehow, these standards have not been applied to physicians or medical trainees. Human physiology does not vary between professions, and to ignore this evidence in medicine is both inconsistent and unsafe, even at a time when medical staffing shortages exist.
As physicians, we must ask whether the requirement to work 24 consecutive hours or more is compatible with the principles that govern our safe clinical interactions and professional ethics. Fatigue resulting from extended-hour call shifts substantially reduces reaction times, impairs decision making, and increases attentional lapses, all of which ostensibly increase the risk of medical errors.26 For instance, residents working more than 24 consecutive hours committed 36% more serious medical errors and 464% more diagnostic errors compared with those limited to 16-hour shifts.10 Additionally, meta-analytic findings revealed that after 24 to 30 hours of wakefulness, physicians performed at the 7th percentile of a well-rested comparison group, emphasizing the substantial cognitive decline associated with prolonged wakefulness.27 Moreover, reducing shift lengths to 16 hours leads to notable reductions in self-reported harmful and fatal medical errors.28 Given this evidence, how do we justify a scheduling system that forces physicians to work while cognitively impaired and places patients at risk?
The dangers of fatigue do not end at the patient’s bedside.29 Residents driving home after extended-hour shifts were 130% more likely to be involved in a motor vehicle accident and 490% more likely to experience a near-miss incident than those working shorter shifts.30 These scary statistics demonstrate a stark reality that extended-hour shifts put residents and the public at unnecessary risk.
Would we willingly entrust the care of our loved ones to medical residents enduring extended-hour call shifts if given the choice? Canadian survey data show 82% of resident physician respondents believed that working more than 16 consecutive hours compromised their quality of care.31 An overwhelming majority (92%) of 1210 people surveyed from the general population in Quebec believed residents should not work more than 16 consecutive hours, and 72% felt they should be informed if their care provider had already been on duty for 16 hours or longer.32 Similarly, nearly all (97%) of the 4763 American adults in another survey believed that residents should not work for 24 consecutive hours.33 These findings clearly underscore the public’s concern about the perceived impact of fatigue on medical care.
Legal perspective
Nearly 15 years ago, the ruling in Centre universitaire de santé McGill et Association des résidents de McGill (McGill University Health Centre v McGill Residents’ Association) declared 24-hour shifts unlawful because it violated Section 7 of the Canadian Charter of Rights and Freedoms and Sections 1 and 46 of the Quebec Charter of Human Rights and Freedoms.17 The decision reinforced the notion health and safety risks to both residents and patients caused by 24-hour call shifts outweighed any perceived or potential educational benefits. The arbitrator explicitly rejected the justification of maintaining the practice solely because it had occurred without issue in the past, indicating the argument was unconvincing.17 In response to this case law decision, The National Steering Committee on Resident Duty Hours was formed and concluded that “duty periods of twenty four or more consecutive hours without restorative sleep should be avoided.”8 Some may be concerned that reduced shift lengths deprive residents of learning opportunities. However, Quebec family medicine residents, working 16-hour shifts since 2012, have not been flagged by the CFPC as a group that is underprepared for independent practice.
While this decision prompted Canada-wide discussions and research into call shift reforms,34,35 widespread changes have yet to materialize. Physicians are also still written out of the Employment Standards Act in Ontario, where I train, which means we are not legally entitled to daily rest, breaks between shifts, sick leave, or time for eating. Nonetheless, the case law decision in Quebec established a critical precedent by recognizing extended-hour shifts as a violation of both labour and human rights, and it emphasized a need for equitable treatment of family medicine residents from coast to coast.
New standard for tomorrow’s family physicians?
Family medicine faces staggering rates of burnout, waning interest in comprehensive care, and projections of millions of Canadians without access to a family physician.36 To reverse this trend, we need to position our specialty as evidence based, humanistic, and inclusive. Given that women have constituted the majority of family medicine residents for more than 20 years37 and frequently shoulder greater family responsibilities, ensuring humane duty hours is important for both safety and fairness. We should practise what we preach in evidence-based medicine by advocating for evidence-informed solutions to mitigate the risks of extended-hour shifts.38 While potential challenges exist with implementing shorter shifts,39 we must endorse practices that place patient and physician well-being at the forefront and at least acknowledge practices that do not. This approach can help ensure that family medicine is a sustainable, fulfilling, and vital cornerstone of Canada’s health care system.
Although staffing shortages and the economic convenience of resident labour may help sustain the status quo, lengthy duty hours transfer risk onto residents and can undermine patient safety. Despite robust fatigue science showing impairment at intervals shorter than 24 hours,40 resident agreements outside of Quebec still permit duty periods of up to 26 hours (Table 1).1-7 Fatigue is an unavoidable workplace hazard, but it can and should be managed. Residency programs and hospitals should widely implement and advertise formal fatigue risk management plans that intervene at individual, program, and system levels.41 Core elements could include concise teaching on sleep physiology and alertness strategies, technology-enabled handovers, work hour caps, team-based surge rosters, and well-publicized mechanisms for declaring fatigue without stigma or penalty.40,41 Yet many trainees still view fatigue as an inescapable and necessary trial by fire in their training,42 and supervisors often exhibit a “fatigue paradox” whereby they recognize fatigue but downplay its impact on patient care.43 We need to dispel these entrenched attitudes through leadership and education by emphasizing that fatigue is a safety hazard, not a badge of honour.
Maximum duty-hour language in Canadian medical resident agreements
Conclusion
It is time to discuss a new family medicine call shift standard that acknowledges the legal precedent set in Quebec, aligns with work hour limits of other safety-critical professions, and reflects well-established evidence on the impairing effects of prolonged wakefulness. By adopting shift lengths and scheduling practices that better align with human physiology, we can safeguard physician and patient safety. The vision for tomorrow’s family physicians should be built around evidence and a culture of humanism over heroism by upholding the ethical imperative to do no harm, even to residents.
Footnotes
Competing interests
None declared
The opinions expressed in this article are those of the author. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article has been peer reviewed.
Cet article se trouve aussi en français à la page 546.
- Copyright © 2025 the College of Family Physicians of Canada
References
In this issue
Jump to section
Related Articles
Cited By...
- No citing articles found.