In 2008, the Institute of Medicine recommended a number of changes in medical residency programs to provide better patient care and resident training: Limit shifts without sleep to 16 hours, require five-hour naps for longer shifts, increase the number of days off, improve supervision and cut down on moonlighting.

But the recommendations—which followed on rules by a national body that governs medical training—won’t come cheap, according to a New England Journal of Medicine study published this week: If implemented fully, they will cost $1.6 billion.

The estimate, which tallies the cost of hiring replacement workers, is just slightly lower than the $1.7 billion the IOM projected the changes could cost. And if the government were to pick up the tab, it would be a large toll on the already strained Medicare system, which—contributing $8.4 billion in 2007—is the largest funder of U.S. residency programs.

Despite the hefty price tag, however, "it remains unknown whether implementing the IOM's recommendations would reduce preventable adverse events," note the study authors. In fact, argue authors of an accompanying editorial, more rigid hours could even increase errors in some areas, especially by increasing the number of times a patient is handed off between care providers who might not be as familiar with the case.

But, says Luella Toni Lewis, a geriatric specialist in Jamaica, NY and president of the Committee of Interns and Residents (CIR), which has advocated for work hour restrictions, "I'd much rather get a handover to a well-rested physician than one that's been on duty for 30 hours."

The question of improving medical resident working hours and conditions has been hotly debated since Libby Zion, an 18-year-old patient, died in a New York City teaching hospital in 1984 after being seen only by an intern and resident. New York State responded by mandating cuts in resident working hours to an average of 80 hours a week, a change that the state helped to fund.

A set of very similar changes went national in 2003 when the Accreditation Council for Graduate Medical Education (ACGME), a nonprofit agency that evaluates medical programs, mandated them. The 2008 IOM recommendations came about after a comprehensive study of the 2003 regulations, sponsored by the U.S. Agency for Healthcare Research and Quality.

But the debate may be focusing on the wrong issue by zeroing in on hours, says Bertrand Bell, a professor of medicine at Albert Einstein College of Medicine in New York City who helped craft New York State’s residency work hour rules. "Supervision is more important than the hours," he told ScientificAmerican.com in an email. He explained that although ensuring that the attending physician visits each patient their residents and interns are treating might seem like a burden, it's important—both for the patient and for the student in training.

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