The Debate Over 24-Hour Residency Shifts in 2025

Do Residents Still Need to Work 24-Hour Shifts in 2025?

The Enduring Legacy of the 24-Hour Call
Medical residency has long been synonymous with grueling work hours. The image of a resident trudging through hospital corridors at 3 AM, clutching coffee, and juggling multiple patient crises is both a rite of passage and a cautionary tale. For decades, 24-hour shifts were seen as unavoidable—if not essential—for training doctors to handle real-world unpredictability.

But in 2025, as medicine increasingly emphasizes wellness, patient safety, and efficiency, the question is sharper than ever: do residents still need to work 24-hour shifts, or is it time to retire this century-old practice?

Historical Context: Why 24-Hour Shifts Became Standard
The tradition of long shifts dates back to early 20th-century surgical training under William Halsted at Johns Hopkins. Halsted believed in complete immersion, arguing that round-the-clock exposure built resilience, discipline, and mastery.

Over time, the model persisted because:

• Continuity of care – fewer handovers, more consistent patient management.
  
  
• Educational immersion – more clinical exposure meant more learning.
  
  
• Cultural expectations – medicine prized sacrifice, equating exhaustion with dedication.
  
  
• Hospital economics – residents provide affordable labor, covering service gaps.
  

The Shift Toward Reform
The dangers of sleep deprivation became undeniable in the late 20th and early 21st centuries. Studies showed:

• 24+ hour shifts impair cognitive function as much as blood alcohol levels of 0.1%.
  
  
• Residents working extended hours are at increased risk of motor vehicle accidents after shifts.
  
  
• Medical errors rise significantly when residents are fatigued.
  

This spurred reforms:

• 2003 (USA, ACGME): 80-hour workweek limit, with 30-hour shift maximums.
  
  
• 2011: 16-hour cap for interns (later revised due to concerns over training adequacy).
  
  
• Europe (EWTD): 48-hour workweek limit, enforced across EU nations.
  
  
• Other regions: Vary widely; in many low- and middle-income countries, 24-hour shifts remain the norm.
  

The Current Reality in 2025
Despite reforms, 24-hour shifts persist in many hospitals:

• In the U.S., many programs allow 24-hour calls, particularly for senior residents.
  
  
• In Europe, compliance with the 48-hour directive varies, and some specialties still push boundaries.
  
  
• In Asia, the Middle East, and Africa, 24–36 hour shifts are often routine due to workforce shortages.
  

So, while the global conversation has shifted toward resident wellness, practice remains inconsistent.

Arguments for Retaining 24-Hour Shifts
1. Continuity of Care
Handovers introduce risks. A resident on call for 24 hours can follow a patient through their entire acute illness episode—avoiding miscommunication.

2. Training Value
Medicine is unpredictable. Residents exposed to extended shifts learn how to manage fatigue, prioritize tasks, and make decisions under pressure—skills crucial for independent practice.

3. Hospital Economics
Residency programs provide inexpensive labor. Replacing 24-hour shifts with shorter ones often requires hiring physician assistants, hospitalists, or additional staff—straining budgets.

4. Professional Identity
Some argue that long shifts foster resilience and solidarity, preparing doctors for the realities of demanding careers.

Arguments Against 24-Hour Shifts
1. Patient Safety
Fatigue impairs judgment. Residents working beyond 16–20 hours show slower reaction times, memory lapses, and more diagnostic errors. Patient lives should not depend on exhausted doctors.

2. Resident Health
Long shifts contribute to:

• Burnout and depression.
  
  
• Increased risk of motor vehicle accidents.
  
  
• Higher rates of needle-stick injuries.
  
  
• Cardiovascular and metabolic strain from chronic sleep deprivation.
  

3. Educational Quality
While long shifts increase exposure, they may reduce effective learning. Sleep-deprived residents retain less knowledge, making the marginal gains questionable.

4. Cultural Shift in Medicine
Younger generations are less willing to glorify suffering. As medicine embraces wellness and sustainability, perpetuating harmful traditions undermines progress.

The Global Comparisons

• United States: Flexible duty hours allow up to 24-hour calls, but programs are under scrutiny to balance wellness with training.
  
  
• European Union: 48-hour maximum workweeks. Studies show mixed results: residents complain of reduced case exposure, but fatigue-related errors are lower.
  
  
• Japan: Residents often exceed 80–100 hours per week, raising alarm about mental health crises and suicide risk.
  
  
• Developing countries: Workforce shortages mean 24–36 hour shifts remain a necessity, highlighting systemic inequities.
  

Resident Voices: What Do Trainees Want?
Surveys in 2023–2024 reveal conflicting sentiments:

• Many residents oppose 24-hour shifts, citing wellness and safety.
  
  
• Some residents prefer them, believing they consolidate clinical experience and reduce disruptive night-float schedules.
  
  
• Most residents want flexibility, with the option to work extended shifts for learning but not as a mandatory standard.
  

This diversity of opinion suggests a one-size-fits-all solution may not work.

Technology and the Future of On-Call Work
In 2025, technology offers potential solutions:

• AI-powered decision support reduces cognitive burden on fatigued residents.
  
  
• Telemedicine allows senior consultants to back up residents remotely, providing guidance without physical presence.
  
  
• Smart scheduling software optimizes shifts, balancing exposure with rest.
  
  
• Wearable sleep trackers integrated with residency programs could help monitor fatigue levels in real time.
  

These innovations could allow programs to move away from 24-hour shifts without compromising training.

The Ethical Dimension
At its core, the debate is ethical. Is it acceptable to expose patients to the care of exhausted residents in the name of tradition or training? Do hospitals have a moral obligation to protect residents’ health as well as patients’?

The four principles of medical ethics provide guidance:

• Nonmaleficence – avoid harm to patients by limiting fatigue-driven errors.
  
  
• Beneficence – ensure residents receive high-quality training.
  
  
• Justice – distribute workload fairly among residents and faculty.
  
  
• Autonomy – respect residents’ ability to have input into scheduling.
  

From this lens, 24-hour shifts seem increasingly hard to justify universally.

The Future of Residency Training
The likely path forward is flexibility, not abolition. Instead of rigid mandates, programs may adopt:

1. Optional extended shifts – residents who value immersive training can opt in.
   
   
2. Capped frequency – 24-hour calls limited to once every 1–2 weeks.
   
   
3. Protected recovery time – post-call days off strictly enforced.
   
   
4. Enhanced supervision – ensure fatigued residents have senior backup.
   
   
5. Competency-based training – focus on achieving milestones, not just clocking hours.
   

In this model, training quality, resident wellness, and patient safety can coexist.

Conclusion: Do We Still Need 24-Hour Shifts?
In 2025, the answer is not black-and-white. Some contexts—particularly under-resourced hospitals—may still rely on 24-hour shifts. But in well-staffed, high-income healthcare systems, the justification is eroding.

The better question is not whether residents should work 24-hour shifts, but why, how often, and under what safeguards. The future of residency will likely be one of balance, flexibility, and humanity, where long shifts are the exception rather than the rule.