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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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