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British association of oral surgeons
British Journal of Oral Surgery (1973), IO, 360-371
BRITISH ASSOCIATION OF ORAL S U R G E O N S REPORT OF A SUB-COMMITTEE FOR TRAINING IN ORAL SURGERY Professor G. R. Seward (Chairman), Professor G. L. Howe, Mr N. L. Rowe, Mr I. H. Heslop
P O S T G R A D U A T E E D U C A T I O N I N ORAL SURGERY THE categories of education which require to be considered are:
(a) Refresher course for general practitioner dental surgeons and limited specialised instruction for those who are in general practice but who have a special interest in minor oral surgery. (b) An organised training programme for aspirants to consultant status in the National Health Service. (c) An organised training programme for aspirants to senior academic appointments in University oral surgery departments. (d) The continuing education and exchange of ideas between established oral surgeons. POSTGRADUATE EDUCATION THE CONSULTANT TRAINEE SECTION I The Consultant and his Work I. It seems certain that in the majority of Regional Centres a dental consultant will continue to be required to give reliable advice on many aspects of dentistry. He will also be expected to undertake, or direct his juniors in the performance of advanced or time-consuming procedures which are not usually undertaken by the general dental practitioner. 2. There will continue to be relatively few centres in which individual consultants limit their field of practice to one aspect of dentistry. Such centres are likely to form a part of a major hospital complex. 3. An analysis of the work of four typical regional centres has produced the following information, which is based on patient numbers and not hours worked.
Diagnostic clinics Consultations followed by treatment at the centre Consultations for diagnosis and advice Treatment Minor oral surgery Routine dentistry for patients with systemic disease Oral medicine. Restorative dentistry (periodontal, endodontic and prosthetic) Maxillo-facial injuries Major oral surgery 360
66% 34% 40% 40% 12°/o
4"5%
3% 0.5%
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4. It therefore follows that the dental consultant should be a broadly educated and widely experienced clinician and diagnostician. He should have had a good basic training in all.aspects of dentistry, but since a major part of his work involves oral surgery, he must have a sound knowledge and broad experience in this field. 5. As in other specialities, candidates for consultant appointments must hold the appropriate higher dental qualification and should have spent the requisite time in approved training appointments. 6. A knowledge of medicine in general is necessary, because the physical state of an increasing number of patients is such that a decision on their correct management requires a detailed appreciation of problems outside the normal scope of dentistry. For this reason it is an advantage for the consultant to be a registered medical practitioner. 7. It is considered advisable that there should be a basic training in oral diagnosis, patient management and general dentistry which all aspiring dental consultants (including orthodontists) should pursue, irrespective of their ultimate type and degree of specialisation. S E C T I O N II • A potential consultant who has completed his training should ideally have acquired an adequate degree of competence in the following:
I. Medicine and surgery in general and the related aspects of pathology, microbiology, pharmacology, biochemistry and genetics. 2. Oral diagnosis, oral medicine and therapeutics. 3. Minor oral surgery. 4. Restorative dentistry including (a) the management of patients experiencing difficulty with dentures; (b) the construction of obturators, skull plates and other surgical prostheses; (c) the assessment of the relative indications for the use of advanced restorative treatments and appliances; (d) the diagnosis and treatment of common periodontal conditions. 5. Management of maxillo-facial injuries 6. Major oral surgery including the surgery of jaw deformity, the resection and reconstruction of the jaws and the surgery of the salivary glands. 7. Applied statistics. 8. Research and teaching. 9. Administration, management and jurisprudence. S E C T I O N III Sequence o f Appointments for a Consultant Dental Surgeon Trainee I. The dentally qualified trainee should hold the following appointments: (a) (b) (c) (d)
6 6 I 2
months non-resident house surgeon months resident house surgeon year senior house officer (Primary F.D.S.) years registrar (Final F.D.S.)
(e) 4 years senior registrar
-] (_
J
General experience Specialist training
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The medically and dentally qualified trainee should hold the following appointments: (a) I year medical pre-registration house appoint-] ments t General experience (b) 2½ years of House Officer, S.H.O. and registrar dental appointments (Final F.D.S.) 2.
(c)
4 years senior registrar
Specialist training
3. I f a non-medically qualified dental trainee started his postgraduate training at the age of 23, he would be 3 x by the time he finished his training for certification. Thus he would have ample time to broaden his experience with, for example, a year's research, overseas service, general practice, or teaching etc., and still achieve consultant status at a reasonable age. On the other hand it is likely that a medically and dentally qualified trainee would be at least 35 by the time he finished his basic training. It is not widely appreciated that the present pattern of medical and dental undergraduate education elongates the training to an unacceptable degree for a man who wishes to obtain both qualifications. Therefore, we would press for an undergraduate course which provides a sound basis for any career in dentistry and includes all relevant components of the medical course. SECTION IV Ideally: I. At least half of the time at house surgeon and senior house officer levels should be spent in a dental teaching institution gaining experience in a minimum of three specialities of dentistry. 2. The registrar appointment should be so arranged as to ensure that it provides experience in various aspects of dentistry. 3. Senior registrar appointments should if possible be linked so that the holder rotates between two different types of dental unit as specified below. The different types of dental units include: (a) Dental teaching hospitals separate from a general hospital. (b) Dental teaching hospitals, part of a general hospital. (c) Dental and oral surgical departments in Board of Governors teaching hospitals. (d) Dental and Oral surgical centres in Regional Hospital Board hospitals. 4. Despite the considerable advantages of linked appointments in that they ensure that a trainee has a varied experience and avoids too specialised an education, the difficulties of operating such a system must be recognised. 5. Research appointments should be established lasting for one year, these duties counting towards his speciality training requirements. Such posts should not carry more than a limited clinical commitment. Trainees who established a research programme of promise could then apply for a research grant from appropriate sources to foster the work over a second or third year to permit a higher university degree to be obtained.
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6. If trainees are to have instruction in all the theoretical subjects set out in
Section II, they will also have to have the chance to attend short intensive courses conducted by experts. It might be appropriate to organise some of these courses on a regional basis. The trainees would have to attend regularly and establishments would have to be adjusted to facilitate their release. Further, the lecturers and projectionists, etc., would have to be paid and funds made available for this purpose. 7. Some continuing education in the diagnostic and practical aspects of restorative dentistry would be an advantage. 8. As successful surgery is based on accurate diagnosis, care must be taken to ensure an adequate balance in the training programme between diagnostic and operative surgical experience. The result of a survey of four regional centres in which figures for staffing, workload, patient number, and procedures under LA in outpatients and those under GA in theatre have been recorded. This information is available on request. TRAINING PROGRAMME FOR UNIVERSITY APPOINTMENTS SECTION I
General Policy • I. The number of appointments for specialist oral surgeons in the universities is small compared with the hospital service. But in the fullness of time we are confident that all dental schools will have professorial units or departments in the specialty. 2. There are two permanent career grades in the university hierarchy; the professor/head of department and the senior lecturer with honorary consultant status. A few academics may have their special ability recognised by the award of personal chairs or readerships. The established appointment of reader in the University of London is equivalent to a senior lecturer with honorary consultant status of some years seniority in other universities. 3- It is usual to expect the holder of a clinical chair to be an outstanding clinician. Likewise it is expected that the professor will conduct research and advance knowledge in this field, be a teacher of merit and exhibit administrative and organising ability. As such a breadth of ability and training is seldom found in one person, it is fortunate that it is not essential. It is a professor's primary duty to develop a department, the staff of which produces achievements in all these directions. Thus it is one of the first requirements of a professor that he should have administrative and organising ability; the one facet of his work for which there is so far no proper course of instruction. 4. Good junior staff are attracted to a department which provides on the one hand, first-class clinical training and experience and on the other first-class research training and experience. The professor must personally participate in at least one of these activities. He may then hope to attract staff who will supply the expertise in other directions. It is therefore apparent that, provided he has reasonable administrative skill, it is only necessary for the professor of oral surgery to have outstanding ability either in the clinical field, or the research field. Nevertheless, even if the former is his forte he must be capable of advancing knowledge in his field.
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Senior academic staff are often criticised for deficiences in teaching skill. Much more is known today about the mechanics of teaching, and while it is an advantage to have a natural flair there is no reason why most university graduates should not be able to teach effectively after some instruction. 5. While it is reasonable to expect some departure from the ideal in appointees to university chairs, the same cannot be said of the physical facilities if a successful department is to be built up and an adequate training offered to junior staff. The professorial oral surgery department must be attached to a large general hospital and the department itself should have adequate bed, theatre, intensive care and emergency facilities in the main hospital. It is important that there should be a research programme in the department which is productive of a steady output of papers and theses. To facilitate this, there should be enough laboratory space, technical staff, equipment, offices and secretarial assistance. S E C T I O N II
,,
Training z. The clinical training of potential senior academic staff must be at least as thorough as that for hospital service trainees. This is necessary to ensure that the trainee is equipped to accept consultant responsibilities in due course, and to facilitate an easy transition into hospital appointments if the trainee so wishes. The training period before consultant status is attained therefore should be longer than that pursued by staff in the hospital service because of the need to spend time on teaching and research. 2. It is important that the future university teacher should become familiar with research methods and research tools as early as possible in his career. Certainly the aspirant should be engaged in research during the SHO/Registrar period, despite being preoccupied with the acquisition of an F.D.S. 3- All trainees will need to obtain a higher degree by thesis, but where the trainee wishes to make research his main interest he should seek to acquire a high reputation in this field. 4. Most universities now hold courses regularly in educational technology, and attendance at these together with in-service training, should produce a competent teacher. 5- There is an urgent need for a course in management and administratiqn for university teachers. The burden of this work in modern academic life is such that unless it is done effectively too much time is spent on this activity. Professors must also be in a position to undertake the Deanship of their school, without this appointment seriously interrupting their professional career. S E C T I O N III
Suggested Appointments r. The Dentally Qualified Trainee (a) 6 months non-resident house surgeon (b) 6 months resident house surgeon (c) I year senior house officer (Primary F.D.S.) (d) 2 years registrar (Final F.D.S.)
-~ [
f
General experience
B R I T I S H ASSOCIATION OF ORAL SURGEONS
4 years lecturer (higher degree by thesis) le)) 6 ~e:rs senior lecturer: years senior lecturer) (2 years senior lecturer with consultant status) (2 years reader or equivalent)
f
2. The Dentally and Medically Qualified Trainee (a) I year medical pre-registration house -~ appointments (b) 2½ years Dental House Officer SHO/Registrar| (Final F.D.S.) J (c) 3 years lecturer (higher degree by thesis) i (d) years senior lecturer: 5½(2 years senior lecturer) / (2 years senior lecturer with consultant " status) 1 (18 months reader or equivalent) ]
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Academic and specialist training
General experience
Academic a n d specialist training
U N D E R G R A D U A T E T R A I N I N G I N ORAL SURGERY
Introduction Two aspects of this subject need to be considered: (a) undergraduate training in oral surgery within the framework of current courses in dental surgery in this country, and (b) the way in which it is felt undergraduate courses should be modified to permit the future growth and development of oral surgery. SECTION I
Undergraduate Training in Oral Surgery and Current Courses It is unnecessary to outline in detail the courses which should be followed since the formulation of a course programme is the responsibility of the professor or the head of department in a particular school. Each head of department will produce different courses and time-tables dependent on the general scheme of education in the particular school and on his own approach to the subject. Such variations between schools are healthy and lead to progress in teaching. Furthermore, the constant advance of knowledge and changes of emphasis within dentistry requires frequent modification of the course. Certain principles however, can be set forth which currently govern the content of these courses. Broadly speaking, the undergraduate course must, on the one hand prepare a student for general practice, and on the other provide him with an insight into the specialised fields within dentistry and the research activities which are related to them. In this second respect the student should receive sufficient basic education to enable him to pursue a career in one of these specialised fields, or if he wishes to become a general dental practitioner, to become familiar with the ways in which the skills of the specialist dental surgeons may help his patients. A sound basic training in oral diagnosis is of prime importance since the practitioner is likely to advise the proper management, only if he can reach the
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correct conclusion as to the nature, or likely nature, of the pathological process with which his patient is affected. Furthermore, only then can he decide whether treatment is within his own field of competence, or whether the patient should be referred elsewhere. Teaching should therefore cover not only those conditions commonly met in general practice, but the whole spectrum of conditions of the teeth, mouth, jaws, face and associated parts. Undergraduates should be instructed in exodontia and those procedures of minor oral surgery which are commonly undertaken in general practice. They should also be taught local anaesthetic technique and given an adequate introduction to general anaesthesia, resuscitation methods and the use of sedatives. Treatment with drugs should be discussed where appropriate and instruction given in the art of intramuscular and intravenous injections. As an adjunct to both the diagnostic and practical sides of oral surgery, they should receive detailed training in oral radiography and radiology. All practical instruction should be supported by a full discussion of the principles upon which the techniques employed are based. In this way clinical practice is related to teaching in the basic sciences and is seen to be a rational application of these studies. Students should see patients who require and undergo major oral surgery so that they can appreciate the need for such surgery, the problems involved, the prognosis for the conditions treated and the results obtained, They should have some basic instruction in gowning, gloving and assisting in theatres, the management of in-patients and postoperative care. They should come to understand the principles involved in the treatment of emergency oral surgical conditions, including maxillo-facial injuries, and have the opportunity to see how such cases are handled. It is also important that students understand the inter-relationship between the patients' home circumstances, including their work and family responsibilities, and the disease and its treatment, since frequently the correct choice of treatment depends on a knowledge of these aspects of the patients' daily lives. Furthermore, since diseases elsewhere in the body and their treatment so often require a special consideration of the oral problems, these aspects of general medicine and surgery should be emphasised. Instruction should include an indication of the degree to which the informed general dental practitioner should shoulder the responsibility of treating such patients and when they should be referred to hospital. S E C T I O N II
Undergraduate Courses of the Future Oral surgeons require a proper training in surgical case management and the conduct of operations, as well as a full understanding of the diseases which affect the structures which form the oral cavity and its related parts. Linked to the latter study there must be a training in all the technical procedures of dentistry which are necessary for the proper treatment of these conditions. A mature specialty of oral surgery must take its proper place among the other special branches of surgery, and therefore it follows that its practitioners should have a training which is in every way comparable with that received by other specialist surgeons. Such a training can be approached in two ways: the trainee could take the undergraduate medical course, then follow a postgraduate training in surgery, and finally specialise in the field or oral surgery. The special anatomy,
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physiology, pathology and disease experience of the region together with the technical procedures used in their treatment would have to be learned as a postgraduate in the same way as E.N.T., ophthalmic and orthopaedic surgeons learn the arts and sciences of their respective specialities. Difficulties with this approach would stem from the varied and highly specialised structures to be found in the region, and the extensive and specialised dental technology which has evolved for their treatment. The lengthy study required to achieve an understanding of these matters is the reason for the present separate undergraduate course in dentistry. The other approach to the problem is to take a dental graduate and to give him postgraduate instruction in general and oral surgery. While it must be recognised that some leading members of our profession have pursued this course with distinction, for others there remains a limit to their achievements which stems from the lack of an undergraduate training in medicine and a postgraduate training in general surgery. There are also ways in which the legal status of medical and dental graduates is different, and this can, to a minor degree, affect the practice of oral surgery. It is of course true that the law could be changed if this were appropriate. Oral surgery is not the only specialty in which these limitations are experienced; in the fields of oral pathology, oral medicine, oral radiology and dental anaesthesia there are also practical and legal advantages to the possession of a medical qualification. It is these considerations which have led so many men to undertake both the dental and the medical undergraduate course. However, in doing so they spend much time repeating courses in a number of subjects, and therefore waste time which could be better used in postgraduate training. The result is that few doubly qualified men can afford the time to build to the maximum of their ability on their undergraduate studies. It follows therefore that a less wasteful undergraduate course must be devised. Several educational trends hold out hope for the establishment of such courses. Among these are the division of courses into course units which may be credited to the student and built together in a more flexible way than in the past. The Todd report applies this principle to medicine. Todd also puts forward the principle of continuing education so that more of the technical aspects of professional training can be carried forward into the postgraduate period. There is also a growing realisation that the whole field of medicine, surgery and obstetrics can no longer be taught at an undergraduate level, and that some degree of subject selection and therefore specialisatiou during the last part of the medical Course will become essential. Medical graduates trained in this way, and who wished to change radically the direction of their career, might have to take additional undergraduate course units before taking up their new postgraduate training programme. Certain dental schools in the USA have demonstrated that it is possible to cover the undergraduate dental course with carefully selected and dedicated students in far less time than the traditional five years. All these trends hold out hope for the fuU return of dentistry to the medical educational fold. Thus students could select course units which would give them an education in various aspects of general medicine, or ones which cover the basic medical sciences together with a course in human diseases, followed by units in the various aspects of dentistry.
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Others, during their undergraduate period, or later, could take sufficient course units to fit them for further training both in general surgery and in dental surgery. Such men would be well placed to follow a training programme in oral surgery, based on an initial postgraduate training in general surgery. C O N T I N U I N G E D U C A T I O N OF E S T A B L I S H E D ORAL SURGEONS Introduction
The pattern of education which has been built up in recent years fulfils most of the needs of the established oral surgeon, but there is still room for improvement in the details of the arrangements. The amount and type of in-service training varies at the different senior registrar training centres, and any deficiencies should be made good during the consultant's first few years in post. i. Societies and ffournals. The British and International Associations of Oral Surgeons have linked oral surgeons together in an admirable way and they organise extremely popular and well attended meetings. Various specialist journals provide a reasonable outlet for papers and adequate information for their readers. A number of aspects of these activities are worthy of comment. The value of informal contact between members at the time of such meetings can be easily underestimated. Person to person discussion of mutual problems can be most helpful. The cost to the participant should be kept down as far as it is practical to do so in order to encourage regular attendance, particularly by the recently appointed consultant and by trainees. This should be possible by means ofskilful administration, avoidance of expensive prestige functions and unnecessarily expensive venues. Employing authorities should be encouraged to continue their financial support for those attending such meetings. An adequate system of cover should also be devised to permit regional consultants and their staff to attend meetings regularly. 2. Postgraduate Meetings and Symposia. Various official bodies, and notably the Royal Colleges, organise formal postgraduate meetings and symposia. These also are popular and well attended and enable the participants to hear the views of authorities on the subjects concerned. It would expand the scope and usefulness of some of these meetings if finance could be found to bring in lecturers from abroad as appropriate. In order to supplement, or fill gaps in the young consultant's previous inservice training, and to bring up to date the older consultant, short intensive courses are required, given by groups of experts. 3. Informal Meetings and Symposia. A number of informal meetings have been organised by the Postgraduate Federation and these have been particularly valuable. Groups of people with a known common interest are invited to meet and certain of their number chosen to open the discussion on various aspects of the topic to be debated. As no formal record is kept, and the whole meeting is kept on a friendly footing, a frank exchange of views can result. There are, of course, no experts from outside the chosen group in this type of symposium and the occasion is more like an extended seminar. 4. Major Lectures. Various bodies sponsor major lectures. Many of these are not as well attended as they might be and both the timing and advertising of such lectures should be reviewed.
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5. Personal Visits to Colleagues and Experts. It can be more difficult for established consultants than for trainees to obtain financial assistance to travel and visit colleagues at home and abroad. Indeed some grant-giving bodies impose an age and seniority limit on such grants and others will only make a grant where the purpose of the visit is for an exchange of information on research and not the advancement of professional skills. A visit to one or two selected colleagues to talk to them in their own environments, to watch them operate and sit in at their clinics, can prove to be an invaluable experience for any consultant. Such visits should ideally be a regular feature of professional life. 6. Research. By research the consultant advances not only his own knowledge, but that of the whole profession. Currently trainees tend to concentrate on the attainment of a proper degree of clinical training and receive only rudimentary instruction in research methods. Hence, if they try to pursue a research project during their consultant years they tend to become discouraged. Readily available advice, help and encouragement in the early stages would often ensure the satisfactory completion of these projects. 7. Sabbatical Leave. Universities in this country generously make certain grants towards the cost of attendance at conferences, courses and meetings at home and abroad. Few, ifany, make provision for the academic to take a longer period o f leave in lieu of several shorter ones. Sabbatical leave given in order to travel to another centre or another country and follow without interruption a particular piece of research, can be a valuable and refreshing experience, particularly for senior teachers. There are obvious practical difficulties for the school in permitting a member of staff to be absent for some months, but universities in other countries appear to have surmounted them. REFRESHER COURSE FOR GENERAL D E N T A L P R A C T I T I O N E R Introduction All general dental practitioners should, from time to time, have refresher courses in various aspects of dental practice. Some may wish to study a particular subject in greater depth so that they can increase the range of procedures of which they are capable to the maximum compatible with the environment provided by a general practice surgery. Courses for general practitioners are amongst the most difficult to arrange satisfactorily. Those attending the course are often of widely different ages and abilities. They may well have lost the habit of regular intensive study and may, with practice and family responsibilities to cope with, find difficulty in achieving sustained background reading. What is more, they are usually most interested in the practical aspects of the course. For various administrative and legal reasons, practical instruction in refresher courses is often confined to demonstrations and simulated surgery.
SECTION I Refresher Courses r. Objectives. The objectives of a refresher course is to remind the practitioner of things which he has probably learnt as an undergraduate, but may have forgotten,
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and to acquaint him with new matter which has been introduced into undergraduate courses since he qualified. 2. Difficulties. The major difficulty is to maintain the interest of the participants. These may be on the one hand the man who has considerable experience and who has established methods for coping with most problems, and on the other, the recent graduate to whom what is being taught is a familiar theme. The older practitioner must be persuaded of the value of new theoretical material and new techniques of operating. The new graduate must be convinced that he can extend his range of practical procedures. A good deal of ground familiar to all must be covered in order to make the instruction a coherent and intelligent whole. The important and new material must be highlighted, but unfortunately the items which fall into these categories can vary between participant and participant. Because the degree of practical skill and experience of the individual participants is unknown to the instructors, practical work on patients is difficult to arrange. Furthermore, there are legal difficulties in permitting the participants to operate on the patients of certain hospitals. 3. Methods. Multiple choice examinations can be helpful in persuading students on a course of their deficiences, and perhaps making them more receptive of theoretical tuition. Reading lists can stimulate home learning and simulated surgery can be useful as a means of giving instruction to practitioners exhibiting varying degrees of skill. It is probably best to recognise the difficulty of fitting practical work on patients into this particular type of course and to arrange this separately for smaller groups. Tutorial classes in which the teacher persuades the participants to talk and ask questions are a good medium for teaching groups of varying ability.
SECTION II
Limited Specialist Training I. Objectives. The objectives of limited specialist training are to build up a practitioner's theoretical knowledge, diagnostic ability and surgical skill to the poinrthat he can pursue the specialty to the maximum of the facilities which are to be found in private practice or small private nursing homes. 2. Difficulties. Postgraduate students of this type must be willing to study seriously, in order to equip themselves intellectually for their greater clinical responsibilities. It is an obvious advantage if such training is within the framework of a recognised course for a higher degree, or diploma, since the achievement of such a qualification is an assurance to all that a certain standard has been reached. It may be, however, that the student must hold certain junior hospital appointments, or attend a course of full-time study for a sizeable interval of time, in order to fulfil the regulations for such exams. To do this could be difficult for a man with an established practice. Training of this type, particularly the clinical and operative aspects, requires close supervision and a I to i staff-student ratio is desirable. 3. Methods. Practitioners wishing this type of training must be selected with some care, and should be registered postgraduate students of the institution in which they work. T h e y must be prepared to work consistently and in a disciplined
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fashion. Two students as a maximum should be attached to a recognised expert in the field for personal instruction in diagnostic and operative procedures. The teacher should also spend a minimum of three hours per week holding tutorials to guide the student's reading and expand his theoretical knowledge. SECTION III Suggested Future Organisations
Worthwhile teaching requires time, organisation and money. The present staffs of undergraduate teaching departments should be fully committed with their undergraduate teaching, clinical practice, research and administration. Nevertheless, postgraduate teaching is a valuable, almost essential, stimulus to organised thinking on the part of a teacher in the more advanced aspects of his subject. Discussion with postgraduate students is a valuable means of developing new ideas. In addition most undergraduate schools tend to have referred to them an excess of patients requiring work which is beyond the routine scope and facilities of general practice. This work is also beyond the skill of the undergraduate and may prove a heavy clinical load for the available qualified hospital staff. Each undergraduate school should be equipped therefore with a graduate clinic and the staff establishment expanded to permit all staff to take a share in postgraduate training. It should be possible to organise well-grounded refresher courses in such clinics, so that the practitioner-students can be taught to manage some of the cases currently referred to hospital. The regional consultant centre would seem to be very suitable for those requiring further skills in their chosen specialty, but again such responsibilities should be covered by adequate establishments, facilities, and finance. A regional postgraduate tutor could have overaU supervisory responsibility, and a regional postgraduate organisation hold the student's registration as a postgraduate student.
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BRITISH ASSOCIATION OF ORAL S U R G E O N S REPORT OF A SUB-COMMITTEE FOR TRAINING IN ORAL SURGERY Professor G. R. Seward (Chairman), Professor G. L. Howe, Mr N. L. Rowe, Mr I. H. Heslop
P O S T G R A D U A T E E D U C A T I O N I N ORAL SURGERY THE categories of education which require to be considered are:
(a) Refresher course for general practitioner dental surgeons and limited specialised instruction for those who are in general practice but who have a special interest in minor oral surgery. (b) An organised training programme for aspirants to consultant status in the National Health Service. (c) An organised training programme for aspirants to senior academic appointments in University oral surgery departments. (d) The continuing education and exchange of ideas between established oral surgeons. POSTGRADUATE EDUCATION THE CONSULTANT TRAINEE SECTION I The Consultant and his Work I. It seems certain that in the majority of Regional Centres a dental consultant will continue to be required to give reliable advice on many aspects of dentistry. He will also be expected to undertake, or direct his juniors in the performance of advanced or time-consuming procedures which are not usually undertaken by the general dental practitioner. 2. There will continue to be relatively few centres in which individual consultants limit their field of practice to one aspect of dentistry. Such centres are likely to form a part of a major hospital complex. 3. An analysis of the work of four typical regional centres has produced the following information, which is based on patient numbers and not hours worked.
Diagnostic clinics Consultations followed by treatment at the centre Consultations for diagnosis and advice Treatment Minor oral surgery Routine dentistry for patients with systemic disease Oral medicine. Restorative dentistry (periodontal, endodontic and prosthetic) Maxillo-facial injuries Major oral surgery 360
66% 34% 40% 40% 12°/o
4"5%
3% 0.5%
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4. It therefore follows that the dental consultant should be a broadly educated and widely experienced clinician and diagnostician. He should have had a good basic training in all.aspects of dentistry, but since a major part of his work involves oral surgery, he must have a sound knowledge and broad experience in this field. 5. As in other specialities, candidates for consultant appointments must hold the appropriate higher dental qualification and should have spent the requisite time in approved training appointments. 6. A knowledge of medicine in general is necessary, because the physical state of an increasing number of patients is such that a decision on their correct management requires a detailed appreciation of problems outside the normal scope of dentistry. For this reason it is an advantage for the consultant to be a registered medical practitioner. 7. It is considered advisable that there should be a basic training in oral diagnosis, patient management and general dentistry which all aspiring dental consultants (including orthodontists) should pursue, irrespective of their ultimate type and degree of specialisation. S E C T I O N II • A potential consultant who has completed his training should ideally have acquired an adequate degree of competence in the following:
I. Medicine and surgery in general and the related aspects of pathology, microbiology, pharmacology, biochemistry and genetics. 2. Oral diagnosis, oral medicine and therapeutics. 3. Minor oral surgery. 4. Restorative dentistry including (a) the management of patients experiencing difficulty with dentures; (b) the construction of obturators, skull plates and other surgical prostheses; (c) the assessment of the relative indications for the use of advanced restorative treatments and appliances; (d) the diagnosis and treatment of common periodontal conditions. 5. Management of maxillo-facial injuries 6. Major oral surgery including the surgery of jaw deformity, the resection and reconstruction of the jaws and the surgery of the salivary glands. 7. Applied statistics. 8. Research and teaching. 9. Administration, management and jurisprudence. S E C T I O N III Sequence o f Appointments for a Consultant Dental Surgeon Trainee I. The dentally qualified trainee should hold the following appointments: (a) (b) (c) (d)
6 6 I 2
months non-resident house surgeon months resident house surgeon year senior house officer (Primary F.D.S.) years registrar (Final F.D.S.)
(e) 4 years senior registrar
-] (_
J
General experience Specialist training
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The medically and dentally qualified trainee should hold the following appointments: (a) I year medical pre-registration house appoint-] ments t General experience (b) 2½ years of House Officer, S.H.O. and registrar dental appointments (Final F.D.S.) 2.
(c)
4 years senior registrar
Specialist training
3. I f a non-medically qualified dental trainee started his postgraduate training at the age of 23, he would be 3 x by the time he finished his training for certification. Thus he would have ample time to broaden his experience with, for example, a year's research, overseas service, general practice, or teaching etc., and still achieve consultant status at a reasonable age. On the other hand it is likely that a medically and dentally qualified trainee would be at least 35 by the time he finished his basic training. It is not widely appreciated that the present pattern of medical and dental undergraduate education elongates the training to an unacceptable degree for a man who wishes to obtain both qualifications. Therefore, we would press for an undergraduate course which provides a sound basis for any career in dentistry and includes all relevant components of the medical course. SECTION IV Ideally: I. At least half of the time at house surgeon and senior house officer levels should be spent in a dental teaching institution gaining experience in a minimum of three specialities of dentistry. 2. The registrar appointment should be so arranged as to ensure that it provides experience in various aspects of dentistry. 3. Senior registrar appointments should if possible be linked so that the holder rotates between two different types of dental unit as specified below. The different types of dental units include: (a) Dental teaching hospitals separate from a general hospital. (b) Dental teaching hospitals, part of a general hospital. (c) Dental and oral surgical departments in Board of Governors teaching hospitals. (d) Dental and Oral surgical centres in Regional Hospital Board hospitals. 4. Despite the considerable advantages of linked appointments in that they ensure that a trainee has a varied experience and avoids too specialised an education, the difficulties of operating such a system must be recognised. 5. Research appointments should be established lasting for one year, these duties counting towards his speciality training requirements. Such posts should not carry more than a limited clinical commitment. Trainees who established a research programme of promise could then apply for a research grant from appropriate sources to foster the work over a second or third year to permit a higher university degree to be obtained.
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6. If trainees are to have instruction in all the theoretical subjects set out in
Section II, they will also have to have the chance to attend short intensive courses conducted by experts. It might be appropriate to organise some of these courses on a regional basis. The trainees would have to attend regularly and establishments would have to be adjusted to facilitate their release. Further, the lecturers and projectionists, etc., would have to be paid and funds made available for this purpose. 7. Some continuing education in the diagnostic and practical aspects of restorative dentistry would be an advantage. 8. As successful surgery is based on accurate diagnosis, care must be taken to ensure an adequate balance in the training programme between diagnostic and operative surgical experience. The result of a survey of four regional centres in which figures for staffing, workload, patient number, and procedures under LA in outpatients and those under GA in theatre have been recorded. This information is available on request. TRAINING PROGRAMME FOR UNIVERSITY APPOINTMENTS SECTION I
General Policy • I. The number of appointments for specialist oral surgeons in the universities is small compared with the hospital service. But in the fullness of time we are confident that all dental schools will have professorial units or departments in the specialty. 2. There are two permanent career grades in the university hierarchy; the professor/head of department and the senior lecturer with honorary consultant status. A few academics may have their special ability recognised by the award of personal chairs or readerships. The established appointment of reader in the University of London is equivalent to a senior lecturer with honorary consultant status of some years seniority in other universities. 3- It is usual to expect the holder of a clinical chair to be an outstanding clinician. Likewise it is expected that the professor will conduct research and advance knowledge in this field, be a teacher of merit and exhibit administrative and organising ability. As such a breadth of ability and training is seldom found in one person, it is fortunate that it is not essential. It is a professor's primary duty to develop a department, the staff of which produces achievements in all these directions. Thus it is one of the first requirements of a professor that he should have administrative and organising ability; the one facet of his work for which there is so far no proper course of instruction. 4. Good junior staff are attracted to a department which provides on the one hand, first-class clinical training and experience and on the other first-class research training and experience. The professor must personally participate in at least one of these activities. He may then hope to attract staff who will supply the expertise in other directions. It is therefore apparent that, provided he has reasonable administrative skill, it is only necessary for the professor of oral surgery to have outstanding ability either in the clinical field, or the research field. Nevertheless, even if the former is his forte he must be capable of advancing knowledge in his field.
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Senior academic staff are often criticised for deficiences in teaching skill. Much more is known today about the mechanics of teaching, and while it is an advantage to have a natural flair there is no reason why most university graduates should not be able to teach effectively after some instruction. 5. While it is reasonable to expect some departure from the ideal in appointees to university chairs, the same cannot be said of the physical facilities if a successful department is to be built up and an adequate training offered to junior staff. The professorial oral surgery department must be attached to a large general hospital and the department itself should have adequate bed, theatre, intensive care and emergency facilities in the main hospital. It is important that there should be a research programme in the department which is productive of a steady output of papers and theses. To facilitate this, there should be enough laboratory space, technical staff, equipment, offices and secretarial assistance. S E C T I O N II
,,
Training z. The clinical training of potential senior academic staff must be at least as thorough as that for hospital service trainees. This is necessary to ensure that the trainee is equipped to accept consultant responsibilities in due course, and to facilitate an easy transition into hospital appointments if the trainee so wishes. The training period before consultant status is attained therefore should be longer than that pursued by staff in the hospital service because of the need to spend time on teaching and research. 2. It is important that the future university teacher should become familiar with research methods and research tools as early as possible in his career. Certainly the aspirant should be engaged in research during the SHO/Registrar period, despite being preoccupied with the acquisition of an F.D.S. 3- All trainees will need to obtain a higher degree by thesis, but where the trainee wishes to make research his main interest he should seek to acquire a high reputation in this field. 4. Most universities now hold courses regularly in educational technology, and attendance at these together with in-service training, should produce a competent teacher. 5- There is an urgent need for a course in management and administratiqn for university teachers. The burden of this work in modern academic life is such that unless it is done effectively too much time is spent on this activity. Professors must also be in a position to undertake the Deanship of their school, without this appointment seriously interrupting their professional career. S E C T I O N III
Suggested Appointments r. The Dentally Qualified Trainee (a) 6 months non-resident house surgeon (b) 6 months resident house surgeon (c) I year senior house officer (Primary F.D.S.) (d) 2 years registrar (Final F.D.S.)
-~ [
f
General experience
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4 years lecturer (higher degree by thesis) le)) 6 ~e:rs senior lecturer: years senior lecturer) (2 years senior lecturer with consultant status) (2 years reader or equivalent)
f
2. The Dentally and Medically Qualified Trainee (a) I year medical pre-registration house -~ appointments (b) 2½ years Dental House Officer SHO/Registrar| (Final F.D.S.) J (c) 3 years lecturer (higher degree by thesis) i (d) years senior lecturer: 5½(2 years senior lecturer) / (2 years senior lecturer with consultant " status) 1 (18 months reader or equivalent) ]
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Academic and specialist training
General experience
Academic a n d specialist training
U N D E R G R A D U A T E T R A I N I N G I N ORAL SURGERY
Introduction Two aspects of this subject need to be considered: (a) undergraduate training in oral surgery within the framework of current courses in dental surgery in this country, and (b) the way in which it is felt undergraduate courses should be modified to permit the future growth and development of oral surgery. SECTION I
Undergraduate Training in Oral Surgery and Current Courses It is unnecessary to outline in detail the courses which should be followed since the formulation of a course programme is the responsibility of the professor or the head of department in a particular school. Each head of department will produce different courses and time-tables dependent on the general scheme of education in the particular school and on his own approach to the subject. Such variations between schools are healthy and lead to progress in teaching. Furthermore, the constant advance of knowledge and changes of emphasis within dentistry requires frequent modification of the course. Certain principles however, can be set forth which currently govern the content of these courses. Broadly speaking, the undergraduate course must, on the one hand prepare a student for general practice, and on the other provide him with an insight into the specialised fields within dentistry and the research activities which are related to them. In this second respect the student should receive sufficient basic education to enable him to pursue a career in one of these specialised fields, or if he wishes to become a general dental practitioner, to become familiar with the ways in which the skills of the specialist dental surgeons may help his patients. A sound basic training in oral diagnosis is of prime importance since the practitioner is likely to advise the proper management, only if he can reach the
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correct conclusion as to the nature, or likely nature, of the pathological process with which his patient is affected. Furthermore, only then can he decide whether treatment is within his own field of competence, or whether the patient should be referred elsewhere. Teaching should therefore cover not only those conditions commonly met in general practice, but the whole spectrum of conditions of the teeth, mouth, jaws, face and associated parts. Undergraduates should be instructed in exodontia and those procedures of minor oral surgery which are commonly undertaken in general practice. They should also be taught local anaesthetic technique and given an adequate introduction to general anaesthesia, resuscitation methods and the use of sedatives. Treatment with drugs should be discussed where appropriate and instruction given in the art of intramuscular and intravenous injections. As an adjunct to both the diagnostic and practical sides of oral surgery, they should receive detailed training in oral radiography and radiology. All practical instruction should be supported by a full discussion of the principles upon which the techniques employed are based. In this way clinical practice is related to teaching in the basic sciences and is seen to be a rational application of these studies. Students should see patients who require and undergo major oral surgery so that they can appreciate the need for such surgery, the problems involved, the prognosis for the conditions treated and the results obtained, They should have some basic instruction in gowning, gloving and assisting in theatres, the management of in-patients and postoperative care. They should come to understand the principles involved in the treatment of emergency oral surgical conditions, including maxillo-facial injuries, and have the opportunity to see how such cases are handled. It is also important that students understand the inter-relationship between the patients' home circumstances, including their work and family responsibilities, and the disease and its treatment, since frequently the correct choice of treatment depends on a knowledge of these aspects of the patients' daily lives. Furthermore, since diseases elsewhere in the body and their treatment so often require a special consideration of the oral problems, these aspects of general medicine and surgery should be emphasised. Instruction should include an indication of the degree to which the informed general dental practitioner should shoulder the responsibility of treating such patients and when they should be referred to hospital. S E C T I O N II
Undergraduate Courses of the Future Oral surgeons require a proper training in surgical case management and the conduct of operations, as well as a full understanding of the diseases which affect the structures which form the oral cavity and its related parts. Linked to the latter study there must be a training in all the technical procedures of dentistry which are necessary for the proper treatment of these conditions. A mature specialty of oral surgery must take its proper place among the other special branches of surgery, and therefore it follows that its practitioners should have a training which is in every way comparable with that received by other specialist surgeons. Such a training can be approached in two ways: the trainee could take the undergraduate medical course, then follow a postgraduate training in surgery, and finally specialise in the field or oral surgery. The special anatomy,
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physiology, pathology and disease experience of the region together with the technical procedures used in their treatment would have to be learned as a postgraduate in the same way as E.N.T., ophthalmic and orthopaedic surgeons learn the arts and sciences of their respective specialities. Difficulties with this approach would stem from the varied and highly specialised structures to be found in the region, and the extensive and specialised dental technology which has evolved for their treatment. The lengthy study required to achieve an understanding of these matters is the reason for the present separate undergraduate course in dentistry. The other approach to the problem is to take a dental graduate and to give him postgraduate instruction in general and oral surgery. While it must be recognised that some leading members of our profession have pursued this course with distinction, for others there remains a limit to their achievements which stems from the lack of an undergraduate training in medicine and a postgraduate training in general surgery. There are also ways in which the legal status of medical and dental graduates is different, and this can, to a minor degree, affect the practice of oral surgery. It is of course true that the law could be changed if this were appropriate. Oral surgery is not the only specialty in which these limitations are experienced; in the fields of oral pathology, oral medicine, oral radiology and dental anaesthesia there are also practical and legal advantages to the possession of a medical qualification. It is these considerations which have led so many men to undertake both the dental and the medical undergraduate course. However, in doing so they spend much time repeating courses in a number of subjects, and therefore waste time which could be better used in postgraduate training. The result is that few doubly qualified men can afford the time to build to the maximum of their ability on their undergraduate studies. It follows therefore that a less wasteful undergraduate course must be devised. Several educational trends hold out hope for the establishment of such courses. Among these are the division of courses into course units which may be credited to the student and built together in a more flexible way than in the past. The Todd report applies this principle to medicine. Todd also puts forward the principle of continuing education so that more of the technical aspects of professional training can be carried forward into the postgraduate period. There is also a growing realisation that the whole field of medicine, surgery and obstetrics can no longer be taught at an undergraduate level, and that some degree of subject selection and therefore specialisatiou during the last part of the medical Course will become essential. Medical graduates trained in this way, and who wished to change radically the direction of their career, might have to take additional undergraduate course units before taking up their new postgraduate training programme. Certain dental schools in the USA have demonstrated that it is possible to cover the undergraduate dental course with carefully selected and dedicated students in far less time than the traditional five years. All these trends hold out hope for the fuU return of dentistry to the medical educational fold. Thus students could select course units which would give them an education in various aspects of general medicine, or ones which cover the basic medical sciences together with a course in human diseases, followed by units in the various aspects of dentistry.
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Others, during their undergraduate period, or later, could take sufficient course units to fit them for further training both in general surgery and in dental surgery. Such men would be well placed to follow a training programme in oral surgery, based on an initial postgraduate training in general surgery. C O N T I N U I N G E D U C A T I O N OF E S T A B L I S H E D ORAL SURGEONS Introduction
The pattern of education which has been built up in recent years fulfils most of the needs of the established oral surgeon, but there is still room for improvement in the details of the arrangements. The amount and type of in-service training varies at the different senior registrar training centres, and any deficiencies should be made good during the consultant's first few years in post. i. Societies and ffournals. The British and International Associations of Oral Surgeons have linked oral surgeons together in an admirable way and they organise extremely popular and well attended meetings. Various specialist journals provide a reasonable outlet for papers and adequate information for their readers. A number of aspects of these activities are worthy of comment. The value of informal contact between members at the time of such meetings can be easily underestimated. Person to person discussion of mutual problems can be most helpful. The cost to the participant should be kept down as far as it is practical to do so in order to encourage regular attendance, particularly by the recently appointed consultant and by trainees. This should be possible by means ofskilful administration, avoidance of expensive prestige functions and unnecessarily expensive venues. Employing authorities should be encouraged to continue their financial support for those attending such meetings. An adequate system of cover should also be devised to permit regional consultants and their staff to attend meetings regularly. 2. Postgraduate Meetings and Symposia. Various official bodies, and notably the Royal Colleges, organise formal postgraduate meetings and symposia. These also are popular and well attended and enable the participants to hear the views of authorities on the subjects concerned. It would expand the scope and usefulness of some of these meetings if finance could be found to bring in lecturers from abroad as appropriate. In order to supplement, or fill gaps in the young consultant's previous inservice training, and to bring up to date the older consultant, short intensive courses are required, given by groups of experts. 3. Informal Meetings and Symposia. A number of informal meetings have been organised by the Postgraduate Federation and these have been particularly valuable. Groups of people with a known common interest are invited to meet and certain of their number chosen to open the discussion on various aspects of the topic to be debated. As no formal record is kept, and the whole meeting is kept on a friendly footing, a frank exchange of views can result. There are, of course, no experts from outside the chosen group in this type of symposium and the occasion is more like an extended seminar. 4. Major Lectures. Various bodies sponsor major lectures. Many of these are not as well attended as they might be and both the timing and advertising of such lectures should be reviewed.
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5. Personal Visits to Colleagues and Experts. It can be more difficult for established consultants than for trainees to obtain financial assistance to travel and visit colleagues at home and abroad. Indeed some grant-giving bodies impose an age and seniority limit on such grants and others will only make a grant where the purpose of the visit is for an exchange of information on research and not the advancement of professional skills. A visit to one or two selected colleagues to talk to them in their own environments, to watch them operate and sit in at their clinics, can prove to be an invaluable experience for any consultant. Such visits should ideally be a regular feature of professional life. 6. Research. By research the consultant advances not only his own knowledge, but that of the whole profession. Currently trainees tend to concentrate on the attainment of a proper degree of clinical training and receive only rudimentary instruction in research methods. Hence, if they try to pursue a research project during their consultant years they tend to become discouraged. Readily available advice, help and encouragement in the early stages would often ensure the satisfactory completion of these projects. 7. Sabbatical Leave. Universities in this country generously make certain grants towards the cost of attendance at conferences, courses and meetings at home and abroad. Few, ifany, make provision for the academic to take a longer period o f leave in lieu of several shorter ones. Sabbatical leave given in order to travel to another centre or another country and follow without interruption a particular piece of research, can be a valuable and refreshing experience, particularly for senior teachers. There are obvious practical difficulties for the school in permitting a member of staff to be absent for some months, but universities in other countries appear to have surmounted them. REFRESHER COURSE FOR GENERAL D E N T A L P R A C T I T I O N E R Introduction All general dental practitioners should, from time to time, have refresher courses in various aspects of dental practice. Some may wish to study a particular subject in greater depth so that they can increase the range of procedures of which they are capable to the maximum compatible with the environment provided by a general practice surgery. Courses for general practitioners are amongst the most difficult to arrange satisfactorily. Those attending the course are often of widely different ages and abilities. They may well have lost the habit of regular intensive study and may, with practice and family responsibilities to cope with, find difficulty in achieving sustained background reading. What is more, they are usually most interested in the practical aspects of the course. For various administrative and legal reasons, practical instruction in refresher courses is often confined to demonstrations and simulated surgery.
SECTION I Refresher Courses r. Objectives. The objectives of a refresher course is to remind the practitioner of things which he has probably learnt as an undergraduate, but may have forgotten,
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and to acquaint him with new matter which has been introduced into undergraduate courses since he qualified. 2. Difficulties. The major difficulty is to maintain the interest of the participants. These may be on the one hand the man who has considerable experience and who has established methods for coping with most problems, and on the other, the recent graduate to whom what is being taught is a familiar theme. The older practitioner must be persuaded of the value of new theoretical material and new techniques of operating. The new graduate must be convinced that he can extend his range of practical procedures. A good deal of ground familiar to all must be covered in order to make the instruction a coherent and intelligent whole. The important and new material must be highlighted, but unfortunately the items which fall into these categories can vary between participant and participant. Because the degree of practical skill and experience of the individual participants is unknown to the instructors, practical work on patients is difficult to arrange. Furthermore, there are legal difficulties in permitting the participants to operate on the patients of certain hospitals. 3. Methods. Multiple choice examinations can be helpful in persuading students on a course of their deficiences, and perhaps making them more receptive of theoretical tuition. Reading lists can stimulate home learning and simulated surgery can be useful as a means of giving instruction to practitioners exhibiting varying degrees of skill. It is probably best to recognise the difficulty of fitting practical work on patients into this particular type of course and to arrange this separately for smaller groups. Tutorial classes in which the teacher persuades the participants to talk and ask questions are a good medium for teaching groups of varying ability.
SECTION II
Limited Specialist Training I. Objectives. The objectives of limited specialist training are to build up a practitioner's theoretical knowledge, diagnostic ability and surgical skill to the poinrthat he can pursue the specialty to the maximum of the facilities which are to be found in private practice or small private nursing homes. 2. Difficulties. Postgraduate students of this type must be willing to study seriously, in order to equip themselves intellectually for their greater clinical responsibilities. It is an obvious advantage if such training is within the framework of a recognised course for a higher degree, or diploma, since the achievement of such a qualification is an assurance to all that a certain standard has been reached. It may be, however, that the student must hold certain junior hospital appointments, or attend a course of full-time study for a sizeable interval of time, in order to fulfil the regulations for such exams. To do this could be difficult for a man with an established practice. Training of this type, particularly the clinical and operative aspects, requires close supervision and a I to i staff-student ratio is desirable. 3. Methods. Practitioners wishing this type of training must be selected with some care, and should be registered postgraduate students of the institution in which they work. T h e y must be prepared to work consistently and in a disciplined
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fashion. Two students as a maximum should be attached to a recognised expert in the field for personal instruction in diagnostic and operative procedures. The teacher should also spend a minimum of three hours per week holding tutorials to guide the student's reading and expand his theoretical knowledge. SECTION III Suggested Future Organisations
Worthwhile teaching requires time, organisation and money. The present staffs of undergraduate teaching departments should be fully committed with their undergraduate teaching, clinical practice, research and administration. Nevertheless, postgraduate teaching is a valuable, almost essential, stimulus to organised thinking on the part of a teacher in the more advanced aspects of his subject. Discussion with postgraduate students is a valuable means of developing new ideas. In addition most undergraduate schools tend to have referred to them an excess of patients requiring work which is beyond the routine scope and facilities of general practice. This work is also beyond the skill of the undergraduate and may prove a heavy clinical load for the available qualified hospital staff. Each undergraduate school should be equipped therefore with a graduate clinic and the staff establishment expanded to permit all staff to take a share in postgraduate training. It should be possible to organise well-grounded refresher courses in such clinics, so that the practitioner-students can be taught to manage some of the cases currently referred to hospital. The regional consultant centre would seem to be very suitable for those requiring further skills in their chosen specialty, but again such responsibilities should be covered by adequate establishments, facilities, and finance. A regional postgraduate tutor could have overaU supervisory responsibility, and a regional postgraduate organisation hold the student's registration as a postgraduate student.
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