In December 2008, the Institute of Medicine (IOM) released a report,
Resident Duty Hours: Enhancing Sleep, Supervision, and Safety,
1 calling for changes in resident training programs to reduce fatigue-related medical errors and to protect patients. Shortly after the IOM released its report, the American Osteopathic Association (AOA) weighed in on the report's findings—with a press release
2 on December 2, 2008, and with statements by AOA President Carlo J. DiMarco, DO,
3 on the AOA President's Blog on March 10, 2009. The AOA's press release
2 and Dr DiMarco's remarks
3—both of which expressed opposition to the recommendations in the IOM report
1—are very disappointing. If the AOA does not change its stance on resident work hours, the AOA will lose credibility and relinquish control over the work hour debate.
To illustrate this point, a review of some history is appropriate. In 1950, two British researchers, Richard Doll, MD, and A. Bradford Hill, PhD,
4 reported a link between cigarette smoking and lung cancer in “Smoking and Carcinoma of the Lung: Preliminary Report,” published in the
British Medical Journal. The tobacco industry immediately attacked this research, claiming that there was no scientific evidence to support the claims of Doll and Hill,
4 and that these researchers had merely discovered a coincidental association between smoking and lung cancer.
It was not until 1962 that the conclusions of Doll and Hill
4 received serious consideration. In that year, the US Surgeon General convened a committee of experts in the fields of tobacco use and lung cancer, and in 1964, the committee issued its landmark report,
Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service.
5 In the report,
5 the committee reviewed more than 7000 scientific articles and came to the conclusion that smoking increased the risk of lung cancer by 9 to 10 times, compared with the risk in nonsmokers.
As with the report by Doll and Hill,
4 the tobacco industry tried to discredit the Surgeon General's report
5 by pointing out that it contained no empirical evidence and no proposed biological or chemical method for how smoking caused lung cancer. The tobacco industry was highly successful with its efforts to discredit the Surgeon General's report.
5 The US Congress did not ban radio and television advertising of tobacco until 1970.
6 How many lives would have been saved if the work by Doll and Hill
4 in 1950 had been taken seriously and not discredited by the tobacco industry? Perhaps billions.
The IOM is a prestigious organization made up of eminent experts in many fields of medicine. The IOM has issued a series of landmark studies—most notably the 1999 report,
To Err is Human: Building a Safer Health System,
7 an analysis of the association between medical errors and patient mortality.
Resident Duty Hours1 was produced by a committee of experts in medicine, engineering, education, and occupational safety. After reviewing hundreds of scientific articles, this committee reached the conclusion that the current resident duty hour policies of resident training programs are inadequate, leading to increased medical errors by residents and increased morbidity and mortality of patients. The IOM committee made several recommendations to revise resident work hours and workloads in order to decrease medical mistakes and save patient lives.
In his blog posting of March 10, 2009, AOA President DiMarco
3 stated, “To date, all the information IOM has cited is either anecdotal, not evidence-based or studies that are more than 10 years out-of-date.” However, the following citations are just a few of the studies listed on the first page of the reference section of
Resident Duty Hours1:
These referenced studies are clearly not anecdotal, not 10 years out of date, and not lacking in evidence. Many more such high-quality, evidence-based studies are listed in
Resident Duty Hours1 as references for the information in the report.
The resident work hour debate is starting to sound a lot like Doll and Hill
4 and the Surgeon General
5 vs the tobacco industry. It is clearly not convenient for the AOA or the Accreditation Council on Graduate Medical Education (ACGME) to accept the literature and evidence on the effects of unsupervised sleep-deprived residents—much like it was not convenient for the tobacco industry to accept the literature and reports on the link between smoking and lung cancer. Is the AOA prepared to have the same kind of credibility that the tobacco industry has today?
In the AOA press release
2 from December 2, 2008, the following statement regarding the AOA's position on resident work hours is given:
Thus, in December 2008, the AOA stated its opposition to a single policy that would regulate work hours for all resident training programs. However, in 2003, the AOA apparently supported—and implemented—a single set of requirements to regulate work hours in all resident training programs, as evidenced by the following statement in the same December 2008 press release
2:
These AOA requirements applying to all residency programs must have been successful, because Dr DiMarco
3 stated the following in his March 10, 2009, blog entry:
Considering the seemingly conflicting statements made by the AOA on policies regulating resident work hours, it is confusing to determine exactly where the AOA stands on this issue. Does the AOA support the IOM's single policy on resident work hours applicable to all resident training programs? One would think it might, because the IOM policy appears to be similar to the single set of requirements implemented by the AOA in 2003. Or does the AOA oppose the IOM's single policy applicable to all programs—perhaps because the IOM's suggested regulations were not developed by the AOA?
There is another problem with the AOA's press release
2 from December 2, 2008, as highlighted by the following statement in the release:
In epidemiologic studies, there exists the principle of scientific generalizability, which refers to the applicability of conclusions made in a particular study population to other populations.
8 Generalizing from one population to another depends on a common exposure-disease relationship being present in both populations of interest. If the exposure-disease relationship is present in a study population but not in another population of interest, conclusions from the study population cannot be extended to the other population of interest.
The parameter used in the IOM report
1 to draw conclusions from a sample population and apply those conclusions to a population of interest was work hours—which have common effects among all medical specialties and locations. The effects of long work hours will not change from New York to California. Nor will the effects of long work hours be different in family practice residencies compared with urology residencies. Thus, no additional research is required to show the “unambiguous, robust, and valid” results desired by the AOA.
2
The IOM's
Resident Duty Hours1 report is based on studies that are generalizable throughout all specialties in medicine. Therefore, the report's recommendations can apply to all medical specialties in any geographic location.
The AOA expressed its interest in reducing medical errors in its December 2, 2008, press release,
2 as follows:
If the AOA is serious about reducing medical errors, it should refocus its energies and efforts on the following actions:
By the AOA taking the initiative and demonstrating proactive behavior in calling for federal legislation to regulate resident work hours, the AOA would gain control over this issue. The AOA would also maintain its integrity and credibility with respect to medical education and patient safety.
If the AOA does nothing—or, even worse, tries to discredit the IOM report
1—legislation that may not be favorable to either the AOA or ACGME will likely be created and enacted. By initiating policy regarding the IOM's
Resident Duty Hours report,
1 the AOA will demonstrate that it takes medical errors and patient safety very seriously.
Resident work hour regulations
will undoubtedly become stricter. The tide of healthcare reform, coupled with the illumination of the resident work hour issue by the IOM,
1 will create an upswelling of support for reform in resident training programs—just as the IOM's
To Err is Human report
7 led to unprecedented support for reform to reduce medical errors. If the AOA continues on its current path of discrediting the IOM's
Resident Duty Hours report,
1 the AOA will lose the debate and its own credibility—just like the tobacco industry.
I am an AOA member and an osteopathic physician. I hope that my letter has successfully highlighted some of the flaws in the AOA's arguments
2,3 regarding the IOM report on resident work hours.
1 In my letter, I have also offered an alternative course of action on this matter. I want to be part of an organization that respects well-researched problems and well-reasoned solutions—even when providing that respect may not be convenient. To quote Upton Sinclair,
10 “It is difficult to get a man to understand something when his job depends on not understanding it.” Please do not let the AOA be that “man.” Rather, consider how many patient lives the AOA may save by embracing the IOM report on resident work hours and by fostering reform in resident training programs.
There is a saying in epidemiology that is derived from an 1854 lecture by Louis Pasteur
11: “In the fields of observation, chance favors only the prepared mind.” The IOM has done an enormous amount of work investigating the issue of resident duty hours, showing that the IOM has the “prepared mind.” Let us support this work.