Most relevant for radiology, the IOM wants to limit night-shift work, unregulated in the current system, to no more than four nights a week, with a mandatory 48-hour break after three or four nights of consecutive graveyard hauls.

NIGHT-SHIFT WORRIES

And it is these night-shift proposals that worry the authors of the JACR article.

They believe that demanding a two-day break for residents after consecutive night shifts could interrupt their education, and that with IOM recommendations for breaks, radiology residents might miss about 50 percent more educational material than under the current scheduling system.

"Every time you put them on nights [in the proposed system] that's a lot more days they're going to be off, and it also means they'll be away from the conferences," says Martha Maineiro, M.D., lead author of the JACR paper and an associate professor of diagnostic imaging at the Warren Alpert Medical School of Brown University in Providence, R.I. "We don't seem to think that makes any sense."

But Dr. Dinges stresses that night-shift work hits the body hardest, as daytime sleep is more difficult to get, leaving night workers burdened with a grogginess equivalent to jet lag.

"Most industries cap number of nights [someone can work], because you don't adapt to night-shift in a week. You have to live on it all the time to do it. In order to prevent serious build-up, you need recovery sleep," he says.

But Dr. Maineiro says many residents she has spoken with might actually prefer consecutive night shifts, precisely because they find it gets easier with time.

"The residents say the most difficult night shift is the first one or two, and they'd prefer a week of night floats," she says.

THE MONEY ISSUE

But one of the big concerns - and one freely acknowledged by the IOM - is figuring out who will pay for the changes.

In common with most specialties outside of the emergency room, major health centers' radiology departments are staffed with residents at night, Dr. Maineiro says. The cost of replacing them with doctors, or physician assistants, would be great. In the paper, Dr. Mainerio estimates the total costs of making the IOM changes to reach almost $1.7 billion, nearly 9 percent of the whole graduate medical education cost.

SUPERVISION FROM AFAR

IOM's report also called for more direct, on-site supervision of residents by attending physicians. While Dr. Mainiero agrees with the IOM that supervision is critical to prevent mistakes, she believes in radiology it doesn't have to be on-site.

"I think supervision is exceedingly important," she says. But "for radiology we wanted to clarify that supervision with teleradiology should be accepted as equivalent to the standard of having the physician in-house." Radiologists on-call from home or another medical center reading on a computer the slides sent by the resident offers nearly the same level of oversight as having the radiologist check the slides on a computer on-site, she argues.

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