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					October 7, 2010



Honorable David Michaels, PhD, MPH
Assistant Secretary for Occupational Safety and Health
U.S. Department of Labor
Occupational Safety and Health Administration
200 Constitution Avenue, N.W.
Washington, D.C. 20210

RE: Public Citizen Petition to OSHA Re Resident Work Hours

Dear Dr. Michaels:

I am writing on behalf of the American College of Physicians (ACP) to oppose a recent
petition from Public Citizen, the Committee of Interns and Residents/SEIU Healthcare, the
American Medical Student Association, and other individuals requesting that OSHA regulate
resident physicians’ and subspecialty resident physicians’ (fellows) work hours. ACP supports
the recent Accreditation Council on Graduate Medical Education’s (ACGME) proposed
revision of regulations on resident work hours and supervision. ACP also firmly believes that
it is the responsibility of the medical profession, through independent agencies such as the
ACGME, to self-regulate the training environment, including working hours.

The ACP, which represents over 130,000 internal medicine physicians and medical students,
including approximately 20,000 residents and fellows, has a long-standing commitment to
ensure that internal medicine residents and subspecialty fellows have a safe working
environment and positive educational experiences, with the ultimate goal of assuring the
highest quality of safe and effective care for patients. As the largest medical specialty society
and the second largest medical society in the United States, the ACP is particularly concerned
about the issue of resident duty hours, as well as the effects on educational goals, patient care,
and resident well-being.

The goal of residency training is to provide the best possible clinical education within the
context of providing the best patient care. Planning for changes in policy governing residency
training must be coordinated among the many jurisdictions responsible for maintaining this
balance, including directors of medical residencies, chairs of academic departments of
medicine, hospital directors and chiefs of staffs, the ACGME, and the appropriate residency
review committees. It is the responsibility of the medical profession to self-regulate resident
work hours and working conditions. The profession fulfills this responsibility largely through
the ACGME and its accreditation program. The ACGME already has a system in place to
regulate resident work hours and assure high-quality graduate medical education and training.
Changes recently proposed by the ACGME following a thorough and critical evaluation by its
Task Force on Duty Hours of all the issues that needed to be considered – including resident
safety and well-being, patient safety, professional responsibility to patients, and quality of the
educational experience – will further strengthen the nature and quality of training and patient
care, and the profession’s ability to improve monitoring, compliance, and enforcement.

We feel strongly that ACGME’s and the profession’s efforts should not be replaced by federal
or state regulatory bodies. This is consistent with a position expressed by OSHA in a 2004
letter to Public Citizen, in which John L. Henshaw stated, “OSHA believes that the ACGME
and other entities are well-suited to address work-duty restrictions of medical residents and
fellows. These entities have extensive experience in patient health, employee health, and
medical education and training. They are in a good position to address the issue in a manner
that comports with the complexity of the various interests. Moreover, ACGME has an
effective and precisely-focused enforcement tool: it can revoke a residency program’s
accreditation.”

ACGME first implemented work hour limitations in 2003 with a promise to the medical
community and public that the standards would be revised in five years. At the five year
anniversary, the Institute of Medicine released the report Resident Duty Hours: Enhancing
Sleep, Supervision, and Safety.1 This report not only focused on resident work hours but
highlighted other programmatic factors that promoted patient safety, including resident
supervision, transfers of patient care between residents, and a culture of safety. It was in this
environment that ACGME commissioned a 16-member task force to review relevant research,
hear testimony, and draft new standards that would address not only work hours but the entire
educational environment as it pertained to resident education and welfare and patient safety.
The task force received written position statements from more than 100 medical
organizations, heard testimony, and convened meetings with members of the Institute of
Medicine, patient advocates, sleep physiologists, experts on patient safety and quality of care,
educators, and international medical educators who had experience with more restrictive work
hour guidelines.2 These meetings produced awareness, consistent with the recent Institute of
Medicine report, that ensuring patient safety goes beyond restricting work hours. In keeping
with these findings, the proposed ACGME regulations further restrict resident work hours and
provide for resident supervision customized to residents’ level of competence, faculty
modeling of fitness for duty, and the creation of an institutional culture of safety and
reliability in which redundant systems prevent errors from reaching the patient.3

ACP is grateful to ACGME and its Task Force for presenting a most thoughtful and well
reasoned proposal. ACP recognizes the difficulties in simultaneously meeting the safety and
quality of care-related needs of patients, the educational and professional development needs
of residents, and the service needs of training institutions. Furthermore, ACP supports
ACGME’s newly proposed, comprehensive standards and firmly believes that they will
enhance the quality and safety of patient care in teaching hospitals, meet the need for a safe
training environment for residents, and benefit the future quality and safety of care when
residents trained under the new standards enter independent practice.

Sincerely,


Patrick C Alguire, MD, FACP
Acting Senior Vice President
Medical Education and Publishing
American College of Physicians

cc:    Phyllis Guze, MD, FACP
       Nitin Damle, MD, FACP
       Robin Luke, MD, MACP
       Steven Weinberger, MD, FACP
       Thomas Nasca, MD, MACP



References:
   1. Ulmer C, Wolman D, Johns M, eds. Resident duty hours: enhancing sleep,
       supervision, and safety. Washington, DC: National Academies Press, 2008.
   2. Nasca TJ, Day SH, Amis ES Jr; ACGME Duty Hour Task Force. The new
       recommendations on duty hours from the ACGME Task Force. N Engl J Med.
       2010;363(2):e3(1)-e3(6).
   3. http://acgme-2010standards.org/pdf/Proposed_Standards.pdf. Accessed September 4,
       2010.

				
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