Just to take a little break from some of the dominant discussions in SDN land, I thought I'd share the following with you. While it is from the JAOA and is directed at AOA residencies I certainly think Jeremy's commentary has wider interest/application. I'm also posting the response (both are available freely and I've provided links). I don't necessarily agree with everything Jeremy says (and I think he's left a few important issues out, most notably, that of risk associated with increased patient turnovers amongst house staff) but he's always an eloquent and passionate guy (he was a med school classmate). Thought it might make for some interesting, renewed discussion on another important topic to residents.
http://www.jaoa.org/cgi/content/full/110/3/111
LETTER
AOA Should Support IOM Report on Resident Work Hours
Jeremy H. Conklin, DO, MPH, MBA; Maj, USAF, MC, Medical Director
383rd Training Squadron, Sheppard Air Force Base, Texas
To the Editor:
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 findingswith a press release2 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 release2 and Dr DiMarco's remarks3both of which expressed opposition to the recommendations in the IOM report1are 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 Hill4 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 report5 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 Hill4 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 studiesmost 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 DiMarco3 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:
* Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA. 2005;294:1025-1033.
* Ayas NT, White DP, Al-Delaimy WK, Manson JE, Stampfer MJ, Speizer FE, et al. A prospective study of self-reported sleep duration and incident diabetes in women. Diabetes Care. 2003;26:380-384.
* Barden CB, Specht MC, McCarter MD, Daly JM, and Fahey TJ III. Effects of limited work hours on surgical training. J Am Coll Surg. 2002;195:531-538.
* Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, et al; Harvard Work Hours, Health, and Safety Group. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352:125-134.
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 Hill4 and the Surgeon General5 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 residentsmuch 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 release2 from December 2, 2008, the following statement regarding the AOA's position on resident work hours is given:
The AOA believes that differences in work flow between medical specialties and the geographic location of training programs necessitate a multidimensional policy versus a single policy applicable to all programs.
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 supportedand implementeda 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 release2:
In 2003, the AOA implemented policies governing resident work hours and conditions for all osteopathic graduate medical education programs. These requirements include limitations on resident work hours, scheduling revisions aimed at avoiding sleep deprivation and other steps designed to improve patient safety and the mental well-being of resident physicians.
These AOA requirements applying to all residency programs must have been successful, because Dr DiMarco3 stated the following in his March 10, 2009, blog entry:
AOA work hour standards, as developed by the Council on Osteopathic Postdoctoral Training (COPT), are currently more rigorous than what was originally recommended by the IOM.
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 programsperhaps because the IOM's suggested regulations were not developed by the AOA?
There is another problem with the AOA's press release2 from December 2, 2008, as highlighted by the following statement in the release:
The AOA believes that differences in work flow between medical specialties and the geographic location of training programs necessitate a multidimensional policy versus a single policy applicable to all programs. Any work hour policy should be based on research that is unambiguous, robust, valid and reliable, and must analyze the short term and long term quality tradeoffs.
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 report1 to draw conclusions from a sample population and apply those conclusions to a population of interest was work hourswhich 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:
The AOA remains committed to reducing errors, ensuring quality patient care, and providing comprehensive and continuous education opportunities to osteopathic physicians.
If the AOA is serious about reducing medical errors, it should refocus its energies and efforts on the following actions:
* 1. The AOA should endorse the IOM's recommendations contained in Resident Duty Hours.1 Furthermore, the AOA should assemble an ad hoc Residency Work Hour Committee composed of interns, residents, program directors, and safety experts (who have specific expertise in operator fatigue) to implement policies suggested by the IOM's report.1 This committee should be given a deadline of 90 days to publish its recommendations.
* 2. The AOA should lobby the US Congress to legislate the recommendations made by the proposed AOA ad hoc Residency Work Hour Committee. The AOA would not be successful if it had to solely implement and enforce the committee's recommendations. If the ACGME did not concomitantly implement the same resident work hour regulations as the AOA, many residency program directors might simply terminate their AOA-approved status in favor of ACGME accreditation.
Moreover, both the AOA and ACGME lack the necessary resources to inspect resident training programs to ensure that these programs are in compliance with work hour restrictions. The AOA should lobby for legislation similar to New York State's "Section 405" resident work hour restrictions (ie, random inspections by a government agency, anonymous reporting of violations, fines for noncompliance).9 With such restrictions in place, resident training programs would not lose accreditation status as a result of work hour violations. In addition, the possibility of financial penalties would make programs more likely to remain compliant with work hour restrictions.
* 3. The AOA should lobby the US Congress for increased funding for graduate medical education to help pay for the new resident work hour restrictions. This increased funding would likely be offset by decreased medical errors, resulting in decreased patient complications and decreased healthcare costs.
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 nothingor, even worse, tries to discredit the IOM report1legislation 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 programsjust as the IOM's To Err is Human report7 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 credibilityjust 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 arguments2,3 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 solutionseven 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 Pasteur11: "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.
References
1. Institute of Medicine. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: The National Academies Press; December 2008.
2. AOA applauds efforts of IOM to improve patient safety; questions one-size-fits-all approach [press release]. Washington, DC: American Osteopathic Association; December 2, 2008. http://www.osteopathic.org/index.cfm?PageID=mc_iomRelease. Accessed July 21, 2009.
3. DiMarco CJ. Question re: resident work hours. AOA President's Blog. March 10, 2009. http://blogs.do-online.org/aoapresident.php?blogid=3&archive=2009-03. Accessed July 21, 2009.
4. Doll R, Hill AB. Smoking and carcinoma of the lung: preliminary report. Br Med J. 1950;2:739-748. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2038856&blob-type=pdf. Accessed August 4, 2009.
5. US Dept of Health, Education and Welfare. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC: US Public Health Service, Office of the Surgeon General; 1964. PHS publication 1103. http://profiles.nlm.nih.gov/NN/B/B/M/Q/_/nnbbmq.pdf. Accessed August 4, 2009.
6. History of tobacco regulationthe ban on advertising. Schaffer Library of Drug Policy Web site. http://www.druglibrary.org/Schaffer/Library/studies/nc/nc2b_10.htm. Accessed August 4, 2009.
7. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: The National Academies Press;November 1999.
8. Hennekens CH, Buring JE. Epidemiology in Medicine. Boston, MA: Lippincott Williams & Wilkins;1987 .
9. New York State Dept of Health §405.4. http://www.health.state.ny.us/nysdoh/phforum/nycrr10.htm. Accessed August 4, 2009.
10. Sinclair U. I, Candidate for Governor: And How I Got Licked [reprint of 1935 edition]. Berkeley: University of California Press; 1994.
11. Louis Pasteur quotes. ThinkExist.com Web site. http://thinkexist.com/quotation/in_the_fields_of_observation_chance_favors_only/213374.html. Accessed July 21, 2009.
http://www.jaoa.org/cgi/content/full/110/3/111
LETTER
AOA Should Support IOM Report on Resident Work Hours
Jeremy H. Conklin, DO, MPH, MBA; Maj, USAF, MC, Medical Director
383rd Training Squadron, Sheppard Air Force Base, Texas
To the Editor:
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 findingswith a press release2 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 release2 and Dr DiMarco's remarks3both of which expressed opposition to the recommendations in the IOM report1are 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 Hill4 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 report5 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 Hill4 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 studiesmost 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 DiMarco3 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:
* Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA. 2005;294:1025-1033.
* Ayas NT, White DP, Al-Delaimy WK, Manson JE, Stampfer MJ, Speizer FE, et al. A prospective study of self-reported sleep duration and incident diabetes in women. Diabetes Care. 2003;26:380-384.
* Barden CB, Specht MC, McCarter MD, Daly JM, and Fahey TJ III. Effects of limited work hours on surgical training. J Am Coll Surg. 2002;195:531-538.
* Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, et al; Harvard Work Hours, Health, and Safety Group. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352:125-134.
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 Hill4 and the Surgeon General5 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 residentsmuch 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 release2 from December 2, 2008, the following statement regarding the AOA's position on resident work hours is given:
The AOA believes that differences in work flow between medical specialties and the geographic location of training programs necessitate a multidimensional policy versus a single policy applicable to all programs.
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 supportedand implementeda 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 release2:
In 2003, the AOA implemented policies governing resident work hours and conditions for all osteopathic graduate medical education programs. These requirements include limitations on resident work hours, scheduling revisions aimed at avoiding sleep deprivation and other steps designed to improve patient safety and the mental well-being of resident physicians.
These AOA requirements applying to all residency programs must have been successful, because Dr DiMarco3 stated the following in his March 10, 2009, blog entry:
AOA work hour standards, as developed by the Council on Osteopathic Postdoctoral Training (COPT), are currently more rigorous than what was originally recommended by the IOM.
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 programsperhaps because the IOM's suggested regulations were not developed by the AOA?
There is another problem with the AOA's press release2 from December 2, 2008, as highlighted by the following statement in the release:
The AOA believes that differences in work flow between medical specialties and the geographic location of training programs necessitate a multidimensional policy versus a single policy applicable to all programs. Any work hour policy should be based on research that is unambiguous, robust, valid and reliable, and must analyze the short term and long term quality tradeoffs.
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 report1 to draw conclusions from a sample population and apply those conclusions to a population of interest was work hourswhich 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:
The AOA remains committed to reducing errors, ensuring quality patient care, and providing comprehensive and continuous education opportunities to osteopathic physicians.
If the AOA is serious about reducing medical errors, it should refocus its energies and efforts on the following actions:
* 1. The AOA should endorse the IOM's recommendations contained in Resident Duty Hours.1 Furthermore, the AOA should assemble an ad hoc Residency Work Hour Committee composed of interns, residents, program directors, and safety experts (who have specific expertise in operator fatigue) to implement policies suggested by the IOM's report.1 This committee should be given a deadline of 90 days to publish its recommendations.
* 2. The AOA should lobby the US Congress to legislate the recommendations made by the proposed AOA ad hoc Residency Work Hour Committee. The AOA would not be successful if it had to solely implement and enforce the committee's recommendations. If the ACGME did not concomitantly implement the same resident work hour regulations as the AOA, many residency program directors might simply terminate their AOA-approved status in favor of ACGME accreditation.
Moreover, both the AOA and ACGME lack the necessary resources to inspect resident training programs to ensure that these programs are in compliance with work hour restrictions. The AOA should lobby for legislation similar to New York State's "Section 405" resident work hour restrictions (ie, random inspections by a government agency, anonymous reporting of violations, fines for noncompliance).9 With such restrictions in place, resident training programs would not lose accreditation status as a result of work hour violations. In addition, the possibility of financial penalties would make programs more likely to remain compliant with work hour restrictions.
* 3. The AOA should lobby the US Congress for increased funding for graduate medical education to help pay for the new resident work hour restrictions. This increased funding would likely be offset by decreased medical errors, resulting in decreased patient complications and decreased healthcare costs.
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 nothingor, even worse, tries to discredit the IOM report1legislation 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 programsjust as the IOM's To Err is Human report7 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 credibilityjust 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 arguments2,3 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 solutionseven 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 Pasteur11: "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.
References
1. Institute of Medicine. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: The National Academies Press; December 2008.
2. AOA applauds efforts of IOM to improve patient safety; questions one-size-fits-all approach [press release]. Washington, DC: American Osteopathic Association; December 2, 2008. http://www.osteopathic.org/index.cfm?PageID=mc_iomRelease. Accessed July 21, 2009.
3. DiMarco CJ. Question re: resident work hours. AOA President's Blog. March 10, 2009. http://blogs.do-online.org/aoapresident.php?blogid=3&archive=2009-03. Accessed July 21, 2009.
4. Doll R, Hill AB. Smoking and carcinoma of the lung: preliminary report. Br Med J. 1950;2:739-748. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2038856&blob-type=pdf. Accessed August 4, 2009.
5. US Dept of Health, Education and Welfare. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC: US Public Health Service, Office of the Surgeon General; 1964. PHS publication 1103. http://profiles.nlm.nih.gov/NN/B/B/M/Q/_/nnbbmq.pdf. Accessed August 4, 2009.
6. History of tobacco regulationthe ban on advertising. Schaffer Library of Drug Policy Web site. http://www.druglibrary.org/Schaffer/Library/studies/nc/nc2b_10.htm. Accessed August 4, 2009.
7. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: The National Academies Press;November 1999.
8. Hennekens CH, Buring JE. Epidemiology in Medicine. Boston, MA: Lippincott Williams & Wilkins;1987 .
9. New York State Dept of Health §405.4. http://www.health.state.ny.us/nysdoh/phforum/nycrr10.htm. Accessed August 4, 2009.
10. Sinclair U. I, Candidate for Governor: And How I Got Licked [reprint of 1935 edition]. Berkeley: University of California Press; 1994.
11. Louis Pasteur quotes. ThinkExist.com Web site. http://thinkexist.com/quotation/in_the_fields_of_observation_chance_favors_only/213374.html. Accessed July 21, 2009.
