I would encourage folks to read the IOM report itself, as well as the press coverage.  A summary is available online:

http://www.iom.edu/CMS/3809/48553/60449.aspx

I think that they actually do a decent job of acknowledging the problems / risks inherent with the rules, as well as the cost that will be required to implement their recommendations are "rules."  Of course, the rule-defining bodies are distinct from those who hold the purse-strings, which complicates matters greatly.  Also, while they talk in the text about restricting moonlighting, when you look at the proposed changes (the table), all that it says is essentially that the rules that apply to training should also apply to moonlighting...so, not an outright ban.

I agree with Brian that lengthening residency is almost certainly going to be necessary if these recommendations become mandated (which, honestly, I think most if not all will be), and with the irony re: attendings.  In general, the perception here has been that, with workhour rules, work shifted uphill, and attendings were working longer hours...these additional changes will only exacerbate that.  I don't know about you guys, but my tolerance for extended shifts has decreased with age, so it seems somewhat counterintuitive and counterproductive to shift the long hours/work uphill (and it's rather unappealing to contemplate what it means for my life as an attending).

One thing that the report does not address, which I find *quite* concerning, is how you would implement these rules in fellowship programs, where a lot of the call is home-call.  Would this mean that you would need to have 2 fellows on call, so that if it were a bad night and the on-call fellow was working for 16 hours, someone else would essentially be jeopardized into taking over call midway through the night?  The rules seem designed around inhouse call/residency...fellowship is a whole different ball of wax.

I wonder if anyone has ever taken account of how much moonlighting fellows are doing and how it impacts their daily work. Now that I have a family I am doing a minimum of 4-5 shifts/month to stay afloat, and I'm very tired the next day, but I try to do it on weekends or times when I have no/minimal clinical responsibility the next day.

Eiran

I believed the work hours restrictions that went into effect before I started residency would be a benefit to my education, as I thought more work meant less time for reading, life outside medicine, etc. However, I quickly realized that the sheer amount of information I needed to learn in such a short period of time was best learned by seeing patients. I subsequently reversed my opinion about the work hours restriction.

Additionally, there is some data about the lack of efficacy of the work hours restriction on patient mortality rates, so it might be simply an issue of lifestyle rather than patient safety. Either way, it seems to me that further restriction on work hours would lead to a longer residency out of necessity. In my opinion, there is simply too much information to learn if you aren't seeing patients.

This is a very interesting discussion and one that will continue to be debated for some time.  I'm sure that there is some truth to the statistics regarding lack of sleep and extended workhours.  I think eventually we will all go to shift work just like the Emergency physicians and Hospitalists.  However, we also cannot forget the minimum amount of time required to get an "adequate" post graduate medical education.  This is where, there needs to be more discussion.  There are clearly those that believe that we need to continue to extend training of both basic fields such as Internal Medicine as well as subsequent subspeciliaties such as Cardiology, Cardiac CT, MRI or ECHO.  But where does this end?  As Brian said above, medical education ain't getting any cheaper and yet we are proposing increasing the length of training?  Furthermore, with the ongoing healthcare crisis, we are likely heading more and more towards socialized medicines, which ultimately means, less money for everyone (which I don't think is necessiraly wrong).  What we will have is shorters shifts for both house staff and Attendings alike, longer training programs, large amounts of debt, smaller salaries and most importantly a general shortage of physicians.