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Objectives: To compare the performance of paediatric medicine residents following a regular 6 hour and an extended 24 hour call and their own insight into their performance following each duty., Method: The study was conducted at The Children's Hospital, Lahore, from September 2007 to November, 2008. All tasks were performed twice, after 6 hour call and 24 hour long call, evaluating Reaction timer, Concentration test, Number Connection Test, State Trait Anger Anxiety Inventory (STAXI) response for trait anger and modified Wechsler Memory Scale inventory (WMS-R) for cognitive performance. Likert's self assessment tool was used for both set of performances., Result: Thirty two paediatric medicine residents (male 53.1%; female 46.9%) were enrolled in the study with identical duty structure performing 74 hours per week with mean age of 27.53 +/- 0.32 years and mean experience of 3.69 +/- 0.32 years. There was significant deterioration in both verbal recall and logic memory (mean difference in score of 1.81 (95% C.I 1.25-2.37, p < 0.001). Concentration test also showed significantly fewer responses (24 hour mean 239.56, 95% C.I. 228-251.13) vs (6 hour mean 258.94, 95% C.I. 247.42-270.46) in 5 minutes, p < 0.001. Reaction time, vigilance and hand eye coordination was significantly affected after an extended call, p < 0.001. Number of lapses in attention also rose significantly, p < 0.001. STAXI response showed significant increase in anger scores, p = 0.001. Despite the significantly poor performance, the residents could not appreciate the deterioration in their performance with Likert's self assessment score that differed only by 0.63 (95% CI -0.12-1.37), p = 0.1. None of the other factors studied correlated with deterioration in performance of any specific task except the length of duty hours., Conclusion: Continuous long stretch of duty causes significant deterioration in cognitive and behavioural status of residents. More importantly, the residents themselves are unable to appreciate this deterioration. Residents must be made aware of this deterioration as there is a higher risk of medical errors and bad judgments, risking patient safety.