- Email: [email protected]
A Surge of Surgeons
EDITORIAL J Oral Maxillofac Surg 74:2333-2334, 2016
A Surge of Surgeons Surgery was the most difficult thing I could imagine. And so I became a surgeon. —Abraham Verghese, Cutting for Stone October 16th has long been hailed in certain quarters as a defining date in our specialty as well as in the history of surgery. It was on that date in 1846 that a dentist publicly demonstrated the effectiveness of ether anesthesia, rendering a patient senseless to tolerate an operation. So it is with historical irony that exactly 170 years later, on October 16, 2016, a noteworthy cohort of oral and maxillofacial surgeons was initiated as Fellows of the American College of Surgeons (ACS). Until this time, only those who trained with medical degrees and general surgery training were invited to join the ACS. On this particular occasion, however, all 58 inductees were ‘‘single-degree’’ oral and maxillofacial surgeons—myself included. Oral and maxillofacial surgeons have not been unwelcome in the ACS. There have been oral and maxillofacial surgeons with MD degrees in the ACS for many years. In 2012, our specialty accumulated the critical mass of members to warrant the formation of an oral and maxillofacial surgery (OMS) section in the ACS. But the language of the ACS charter divided our specialty, recognizing only those surgeons with an MD degree, successful completion of a general surgery program accredited by the Accreditation Council for Graduate Medical Education, and a full and unrestricted medical license. Thanks to the dedication of many advocates, the American Association of Oral and Maxillofacial Surgeons requested and received a waiver from the ACS recognizing the rigor of the path leading to board certification in OMS and acknowledging those of us with single-degree backgrounds among the fellowship of surgeons. This is a sensitive topic for me. Having spent my entire career in academics, I am an unflinching advocate for MD attainment in OMS training. The key benefit of this is that those who gain their medical degree can spend a year as a general surgery resident. If I have one regret, it is that I was never afforded this opportunity personally. I have witnessed the growth in my residents when they return to our service from their general surgery year. In most cases, there is a transformation that is palpable in their emotional capacity, thoughtfulness, and work ethic. Indeed, there is less whining about the rigors of OMS training in the junior and senior years.
On the other hand, I must point out that I have been fortunate in that my degree status has rarely, if ever, hampered my career as an academic, a researcher, or a surgeon. I have experienced equal status with other surgeons in the hospital, serving side-by-side on committees that make policy about surgical and quality standards. I have never been denied a job or hospital privileges because my degree status was questioned. I have always been treated collegially by my surgical peers. Over the years, I have shared patients and operated concurrently with a range of surgical specialists, including otolaryngologists, plastic surgeons, neurosurgeons, trauma surgeons, and surgical oncologists. My very first act 3 years ago as the new chair of my department—one that has gone back and forth over the past 50 years in offering single-, then double-, then single-degreed OMS training—was to propose a curriculum change from a 4-year single-degree program to a 6-year program offering the MD degree plus OMS certificate. Our medical school hailed our proposal under the banner of its ‘‘interdisciplinary’’ initiatives, streamlining the review, approval, and accreditation in just 10 months. One of my proudest moments as an educator was upon notification that all 3 of our first class of double-degree residents passed Part I of the United States Medical Licensing Examination. I remember with a cringe the very first time I took a knife to human tissue that was attached to a living, breathing person. I was a dental student and a poor college freshman named Paul, who had lost his 4 front teeth as a child, broke his appliance. By arrangement, I could supply him with a replacement at a cost that worked with his student budget provided that he placed himself in my well-meaning yet barely trained hands. He required a frenectomy. I’ve heard it said that ‘‘the first cut is the deepest.’’ Not so. Holding the scalpel in my hand, I became incredibly cognizant of the fact that I was somehow violating another human—albeit with his consent and local anesthetic. Slowly I severed what must have been one cell layer of tissue at a time. Some minutes or hours later, I finally reached the required depth. Miraculously, the patient was able to walk out of the clinic in time to face his economics midterm. This experience did nothing to dampen my enthusiasm for surgery. Following my honeymoon, I spent a full month on an OMS externship. My wife probably
2333
2334 mistook the spring in my step as a consequence of wedded bliss. Between us, my joy came in having found myself in OMS. I knew then that my calling was working with complex cases at the intersection of medicine and dentistry. I enjoyed the perspective of repair and restore, particularly in the realm of the face and jaw from which people derive so much of their identity and self-esteem. It required everything that, to me, made a profession worthwhile: an advanced skillset, broad knowledge base, stimulating peer group, physical endurance, comprehensive decision-making, service to humanity, and compassion. In an apt analogy to business, Henry Mintzberg said, ‘‘. you cannot teach surgery to somebody who’s not a surgeon.’’ I suspect there might be a surgeon gene because it is obvious when it is lacking. As disappointing as it is to lose a resident during training, I have seen a few well-meaning souls who clearly were not cut out to be surgeons go on to become successful in dermatology, pediatrics, radiology, orthodontics, and other medical or dental specialties. The process by which avaricious OMS wannabes get slotted into residency programs is as imperfect now as it was in my day when the ‘‘sorting hat’’ placed me at the University of California–San Francisco, then a 4-year single-degree program. I made every effort to mimic a double-degree education—even taking Part 1 of the medical board and applying as a medical school transfer student. It was not to be. I have great respect for those who pursued 4 years of medical education to gain their degrees on top of their dental credentials, something I was unable to do once ‘‘life
EDITORIAL
happened’’ and I found myself with a growing family to feed and a rapidly evolving academic practice. Nonetheless, I received outstanding training as an oral and maxillofacial surgeon and have yet to be restricted in practicing the full scope of my specialty. For this I am grateful. I applaud the leadership of the ACS, rising above historical attitudes relative to those trained in dentistry, to recognize the legitimacy of all OMS training programs in creating surgeons. It took leaders with special courage and a sense of adventure to make the leap that allows us to become Fellows of the ACS without caveat or prejudice. I want to recognize the herculean efforts of current OMS ACS Fellows who argued to the ACS leadership on our behalf the value that our specialty brings as a whole. I would encourage, with enthusiasm, that all within our specialty consider applying for Fellowship in the ACS. The process is not burdensome. The dividends to clinicians, educators, and trainees are countless. As a very small specialty, we benefit greatly from inclusion in this larger group, which has a persistent lobbying voice on Capitol Hill and a successful track record advocating on behalf of surgeons among state agencies and large insurers. THOMAS B. DODSON, DMD, MPH ASSOCIATE EDITOR
Ó 2016 American Association of Oral and Maxillofacial Surgeons http://dx.doi.org/10.1016/j.joms.2016.09.042
A Surge of Surgeons Surgery was the most difficult thing I could imagine. And so I became a surgeon. —Abraham Verghese, Cutting for Stone October 16th has long been hailed in certain quarters as a defining date in our specialty as well as in the history of surgery. It was on that date in 1846 that a dentist publicly demonstrated the effectiveness of ether anesthesia, rendering a patient senseless to tolerate an operation. So it is with historical irony that exactly 170 years later, on October 16, 2016, a noteworthy cohort of oral and maxillofacial surgeons was initiated as Fellows of the American College of Surgeons (ACS). Until this time, only those who trained with medical degrees and general surgery training were invited to join the ACS. On this particular occasion, however, all 58 inductees were ‘‘single-degree’’ oral and maxillofacial surgeons—myself included. Oral and maxillofacial surgeons have not been unwelcome in the ACS. There have been oral and maxillofacial surgeons with MD degrees in the ACS for many years. In 2012, our specialty accumulated the critical mass of members to warrant the formation of an oral and maxillofacial surgery (OMS) section in the ACS. But the language of the ACS charter divided our specialty, recognizing only those surgeons with an MD degree, successful completion of a general surgery program accredited by the Accreditation Council for Graduate Medical Education, and a full and unrestricted medical license. Thanks to the dedication of many advocates, the American Association of Oral and Maxillofacial Surgeons requested and received a waiver from the ACS recognizing the rigor of the path leading to board certification in OMS and acknowledging those of us with single-degree backgrounds among the fellowship of surgeons. This is a sensitive topic for me. Having spent my entire career in academics, I am an unflinching advocate for MD attainment in OMS training. The key benefit of this is that those who gain their medical degree can spend a year as a general surgery resident. If I have one regret, it is that I was never afforded this opportunity personally. I have witnessed the growth in my residents when they return to our service from their general surgery year. In most cases, there is a transformation that is palpable in their emotional capacity, thoughtfulness, and work ethic. Indeed, there is less whining about the rigors of OMS training in the junior and senior years.
On the other hand, I must point out that I have been fortunate in that my degree status has rarely, if ever, hampered my career as an academic, a researcher, or a surgeon. I have experienced equal status with other surgeons in the hospital, serving side-by-side on committees that make policy about surgical and quality standards. I have never been denied a job or hospital privileges because my degree status was questioned. I have always been treated collegially by my surgical peers. Over the years, I have shared patients and operated concurrently with a range of surgical specialists, including otolaryngologists, plastic surgeons, neurosurgeons, trauma surgeons, and surgical oncologists. My very first act 3 years ago as the new chair of my department—one that has gone back and forth over the past 50 years in offering single-, then double-, then single-degreed OMS training—was to propose a curriculum change from a 4-year single-degree program to a 6-year program offering the MD degree plus OMS certificate. Our medical school hailed our proposal under the banner of its ‘‘interdisciplinary’’ initiatives, streamlining the review, approval, and accreditation in just 10 months. One of my proudest moments as an educator was upon notification that all 3 of our first class of double-degree residents passed Part I of the United States Medical Licensing Examination. I remember with a cringe the very first time I took a knife to human tissue that was attached to a living, breathing person. I was a dental student and a poor college freshman named Paul, who had lost his 4 front teeth as a child, broke his appliance. By arrangement, I could supply him with a replacement at a cost that worked with his student budget provided that he placed himself in my well-meaning yet barely trained hands. He required a frenectomy. I’ve heard it said that ‘‘the first cut is the deepest.’’ Not so. Holding the scalpel in my hand, I became incredibly cognizant of the fact that I was somehow violating another human—albeit with his consent and local anesthetic. Slowly I severed what must have been one cell layer of tissue at a time. Some minutes or hours later, I finally reached the required depth. Miraculously, the patient was able to walk out of the clinic in time to face his economics midterm. This experience did nothing to dampen my enthusiasm for surgery. Following my honeymoon, I spent a full month on an OMS externship. My wife probably
2333
2334 mistook the spring in my step as a consequence of wedded bliss. Between us, my joy came in having found myself in OMS. I knew then that my calling was working with complex cases at the intersection of medicine and dentistry. I enjoyed the perspective of repair and restore, particularly in the realm of the face and jaw from which people derive so much of their identity and self-esteem. It required everything that, to me, made a profession worthwhile: an advanced skillset, broad knowledge base, stimulating peer group, physical endurance, comprehensive decision-making, service to humanity, and compassion. In an apt analogy to business, Henry Mintzberg said, ‘‘. you cannot teach surgery to somebody who’s not a surgeon.’’ I suspect there might be a surgeon gene because it is obvious when it is lacking. As disappointing as it is to lose a resident during training, I have seen a few well-meaning souls who clearly were not cut out to be surgeons go on to become successful in dermatology, pediatrics, radiology, orthodontics, and other medical or dental specialties. The process by which avaricious OMS wannabes get slotted into residency programs is as imperfect now as it was in my day when the ‘‘sorting hat’’ placed me at the University of California–San Francisco, then a 4-year single-degree program. I made every effort to mimic a double-degree education—even taking Part 1 of the medical board and applying as a medical school transfer student. It was not to be. I have great respect for those who pursued 4 years of medical education to gain their degrees on top of their dental credentials, something I was unable to do once ‘‘life
EDITORIAL
happened’’ and I found myself with a growing family to feed and a rapidly evolving academic practice. Nonetheless, I received outstanding training as an oral and maxillofacial surgeon and have yet to be restricted in practicing the full scope of my specialty. For this I am grateful. I applaud the leadership of the ACS, rising above historical attitudes relative to those trained in dentistry, to recognize the legitimacy of all OMS training programs in creating surgeons. It took leaders with special courage and a sense of adventure to make the leap that allows us to become Fellows of the ACS without caveat or prejudice. I want to recognize the herculean efforts of current OMS ACS Fellows who argued to the ACS leadership on our behalf the value that our specialty brings as a whole. I would encourage, with enthusiasm, that all within our specialty consider applying for Fellowship in the ACS. The process is not burdensome. The dividends to clinicians, educators, and trainees are countless. As a very small specialty, we benefit greatly from inclusion in this larger group, which has a persistent lobbying voice on Capitol Hill and a successful track record advocating on behalf of surgeons among state agencies and large insurers. THOMAS B. DODSON, DMD, MPH ASSOCIATE EDITOR
Ó 2016 American Association of Oral and Maxillofacial Surgeons http://dx.doi.org/10.1016/j.joms.2016.09.042