EDITORIAL

J Oral Maxillofac Surg60:1387-1388, 2002

The Lure of the 80-Hour Work WeekRegulators of medical and surgical education have

increasingly recognized that resident fatigue and lackof resident supervision commonly put quality educa-tion and patient care in jeopardy at our nation’s teach-ing hospitals. In response to this, rules will now bepromulgated that have immediate broad implicationsfor the fundamental nature of residency educationand the subsequent nature of the professions that willevolve in the years after these changes. For oral andmaxillofacial surgery, which competes in its positionas both a surgical and a dental specialty, we must beprepared for swift change in 2003 that will requirethe active engagement of the residents, faculty, andpractice community to evolve a successful paththrough these regulations. Although oral and maxillo-facial surgery is only directly regulated by these rulesduring Accreditation Council for Graduate MedicalEducation (ACGME)-accredited years of training, thematching individual hospital rules to accommodatethese changes will likely require the adherence of allOMS residency programs. While our effective re-sponse to these new rules will likely ensure the futurestrength of oral and maxillofacial surgery in the aca-demic health center, our failure to do so will result ina spiral towards diminution.

At its September 2002 meeting, the ACGME boardaccepted the report from the Committee on ProgramRequirements regarding the proposed standard forresident duty hours and the work environment. TheACGME, which regulates all graduate medical educa-tion in the United States, has now opened a period ofpublic comment until December 31, 2002, that willculminate in the revision of this standard being putinto effect in July 2003. These standards are avail-able on the website http://www.acgme.org/new/resHrsLanguage.asp, but they are also summarizedhere. Briefly, these standards require the following:

1. “All patient care must be supervised by qualifiedfaculty. The program director must ensure di-rect . . . supervision of residents at all times.”

2. “Faculty schedules must be structured to pro-vide residents with continuous supervision andconsultation.”

3. “Duty hours (defined as all clinical and academicactivities related to the residency program) mustbe limited to 80 hours per week.”

4. “Continuous duty must not exceed 24 hours.”“A 10-hour period of rest must be provided forrest after every on-call or daily duty activity.”

“Residents must be provided with 1 day in 7 freefrom all . . . responsibilities.”

I see this as the culmination of a process that beganwith the Libby Zion case in New York state in 1984.In that case, a young woman presented to the emer-gency room with a compromise in neurologic status.A resident at work for many hours without directsupervision initiated an evaluation during which thepatient expired. The result was regulation in NewYork state, known as the “Bell rules” requiring thedirect supervision of residents and providing workrules limiting on-call hours to address the issue ofhouse staff fatigue.

We must support the ACGME in the developmentof these rules that will help ensure improved patientcare and residency education. There is no doubt thatresident fatigue is the most important single reasonfor patient care errors during their training. Wu andFolkman et al1 reported that 58% of residents re-ported job overload and 47% reported fatigue as rea-sons for their most serious mistakes. Of tragic signif-icance, the surveyed residents reported almost a thirdof these errors resulted in patient death. Althoughcritical errors will always be made, the principles ofrisk management and our ethical standards requirethat we do what is reasonably possible to diminish thechance of mistakes.

While we work towards these improvements, it iscertain the ACGME rules will fundamentally changeour OMS programs. For example:

● Trauma call schedules that require the presenceof multiple services may not be practical underthese rules. Hence, anatomically based scheduleswill not work well with the needs for residenteducation, ambulatory care, and operating roomcoverage.

● Faculty are required to offer direct supervision ofresidents at all times. This implies 24-hour activeengagement of on-call faculty to back up all res-ident calls. Minimally, this likely requires patient-specific, contemporaneous review of all care ren-dered by the resident. An increase in the numberof faculty and/or the engagement of voluntaryfaculty may be necessary to mitigate against fac-ulty fatigue.

● An emerging trend in many smaller programs isfor general practice residents to take primary call

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for oral and maxillofacial surgery. This problem islikely to grow with the ACGME rules. A betteralternative might be the use of “floater service”call where a single resident covers for more thanone surgical specialty.

● Recruitment of residents into oral and maxillofa-cial surgery will not be helped substantially bythese rules. Many of the very best dental gradu-ates now seek dental specialties with a muchshorter duration of training and more regularwork hours. Such lifestyle decisions are also oc-curring in medical specialties. Indeed one of thestrengths of the surgical specialties has been thesense of commitment and devotion that excep-tionally bright and motivated future surgeons ex-hibit. The ACGME work rules diminish that mys-tique, which may result in the unexpected resultof actually decreasing interest in the surgical spe-cialties. Alternatively, the 80-hour work weekmight seem like an improvement, but it high-lights a level of commitment that today’s gradu-ates are far less likely to make.

What can be done to see that the new ACGMEProgram Requirements result in more competitiveand more effective residency training in oral and max-illofacial surgery?

1. More of the smaller programs in areas with morethan one program need to combine to maintainthe presence of oral and maxillofacial surgery intheir hospitals while accommodating theACGME rules.

2. Voluntary and full-time faculty need to work

together to provide greater direct supervision ofOMS residents.

3. A greater number of faculty are needed to buildthe elective operating room experience. With alarger number of major cases, programs can ac-cept a sufficient number of residents to meet theACGME requirement as well as the Commissionon Dental Accreditation standards.

4. Faculty involvement is also needed for greaterdirect activity in the ambulatory care setting.Better organization of ambulatory care is neededto provide more efficient care during decreasedhours.

5. Faculty need to think creatively about offeringresidents increasing levels of responsibility eachyear during their training while ensuring contin-uous supervision.

Let us hope that our OMS programs work proac-tively individually and within the context of graduatemedical education in their institutions. OMS must bea key part of the institutional response to the ACGMErules. If we are not at the table for these discussionsand decisions, be assured we will be on the table.

LEON A. ASSAEL, DMD

Reference1. Wu AW, Folkman S, McPhee SJ, et al: Do house officers learn

from their mistakes? JAMA 265:2089, 1991

© 2002 American Association of Oral and Maxillofacial Surgeonsdoi:10.1053/joms.2002.37260

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