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Are oral and maxillofacial surgeons an endangered species?
Editorial Are oral and maxillofacial surgeons an endangered species? There can be few who would argue with the Darwinian principle that for a species to survive, it must adapt to its ever-changing environment. Whereas through time, cataclysmic ecological changes have resulted in extinction, more subtle or gradual changes in habitat must evoke adaptive changes for survival. Examples of contemporary ecological threats may be planet-wide such as global warming, or more localised such as the threats to wildlife of farming methods and chemicals or the competition for habitat by another species or the emergence of predators. The massive environmental changes imposed by the Health Service reforms have affected the entire spectrum of primary, community and secondary sector health care delivery, familiar and challenging to all species working therein. The global competition for finite resources is intense and seemingly unstoppable. exacerbated by increased demands and new, expensive technology. The introduction of alternative resources by the various forms of PFI-Private Finance Initiative to reduce public spending on capital projects and the likely expansion of private funding of core health care services will no doubt delay the meltdown of the NHS as we have known it. Local but devastating threats to the survival of individual specialties in some localities arise from unpredictable and sometimes illogical changes in purchasing strategies. Oral and Maxillofacial Surgery is subject to any of the foregoing ‘ecological’ changes, in addition to the competition for our natural ‘habitat’ by other, similar species, reminiscent of the effects of the introduction of the grey squirrel! We are all aware of what is our natural habitatthe comprehensive range of services that we offer and we are aware of the evolutionary changes we have undergone to secure that habitat-double qualification, general surgical training, the FRCS and Intercollegiate examination, all of which it must be stated, have faced and overcome internal opposition. Again, we are aware of different models of evolution of the specialty in different parts of the world. For example, on a recent visit to Volgograd (formerly Stalingrad), I discovered that all medical students must enter one of three medical faculties as school leavers: general medicine/surgery, paediatric medicine or stomatology/maxillofacial surgery. A further 5 years postgraduate specialisation follows graduation. This model reflects the perceived need for the specialty in a part of the world where plastic surgery has yet to emerge and where otorhinolaryngology is relatively weak. At the other extreme, some
Scandinavian countries and the USA until quite recently, have experienced great difficulties in developing a specialty of oral and maxillofacial surgery based on a dual qualification, due to a different evolutionary process. However, both in the Eastern block model and in the majority Western world model, one fundamental reason for the existence of the specialty is the unique expertise required for the understanding and management of oral diseases, whether this expertise is acquired by virtue of a full dental qualification or a period of education and training in ‘dental art’. Compare this situation of a comprehensive specialty embracing subspecialties with the current rapid evolution from general surgery of subspecialties such as vascular surgery and cola-rectal surgery, no different from the earlier emergence of urological surgery and cardiothoracic surgery as specialties in their own right and also with the effects of the CDO’s report promoting the emergence of dental subspecialties. Consider also the overlapping interests of our specialty with others such as ENT and plastic surgery. It is at once apparent that in evolutionary terms, not only is the environment changing rapidly, but grey squirrels are competing for our habitat and an urgent strategy of adaptation is required. To suggest that these factors may signal a threat of extinction, albeit locally, may not be overstating the case, as evidenced by recent events in Humberside. Anticipating the need to mark out our habitat, Council launched, through the audit committee, a simple data collection exercise last year, based on a highly successful model organised by the British Orthopaedic Association, to determine the nationwide demand for our services and hence our manpower requirements, in addition to measuring clinical activity to determine how well or otherwise we are meeting that demand. Such an exercise required high compliance and failed for that reason. A second attempt to harvest these data is currently in hand. If that fails, we must expect the Humberside phenomenon to occur elsewhere without warning and without the means of challenge. There are those among us who may be complacent and worse, those who may regard such initiatives as paranoid. Surely, a corporate strategy is required for the specialty as a whole, rather than the insular attitudes of individuals geared to short-term local advantages. The game has to be more important than an individual player. To explore the situation further, a SWOT analysis and option appraisal may be helpful. 345
346
British
Journal
of Oral
and Maxillofacial
Surgery
Strengths Undoubtedly, our dental base and with it our unique referral base are major advantages. There is wide international agreement that the specialty should require a dual medical and dental education and qualification. The strengthening of our training programmes by the positive response of our SAC to the Calman proposals is producing young specialists of exceptional calibre, with the option to develop special interests. Our range of activity brings us into close professional working relationships with colleagues of many other disciplines. Weaknesses There is still a wide variation in practice from unit to unit across the country which sometimes leads to misconceptions of our potential contribution, Our relatively small numbers, few beds and long waiting lists may encourage host purchasers to seek alternatives. In this respect, the dual standards of the willingness of some to be involved with dento-alveolar surgery in the NHS and private sectors are usually well known to chief executives and are difficult to condone. Having established ourselves as a DGH based specialty, we now have to adapt to a hub and spoke reconfiguration, made more urgent and logical by the emergence of day stay surgery, junior doctors’ hours requirements, the expense of maintaining inpatient services at neighbouring sites and a perception that less complex surgery can be conducted outside the hospital service. Paradoxically, we have found this adaptation more difficult than have some former subregional specialties such as plastic surgery, who fit more neatly into the hub and spoke model. A significant weakness is our remarkable difficulty in finding a title that conveys to the public, to managers and even to professional colleagues exactly what we do. In the space of a generation we have been known officially within the NHS as Dental Surgeons, Oral Surgeons and Oral and Maxillofacial Surgeons. Within the European Medical Directives the specialty has been known globally as ‘Stomatology and Dental and Oro-maxillofacial Surgery’ concurrent with ‘Oral Surgery’ being recognised within the Dental Directives! At the same time, General Orthopaedics, Urology, Swm-y, Neurosurgery, Plastic Surgery and others have preserved their nomenclature. However, we are not alone in having a titular identity crisis. Within the UK, ENT Surgery has adopted its Latin translation of Otorhinolaryngology (ORL), recently infiltrating cephalad and caudad in a different language to become ‘ORL and Head and Neck Surgery’. Interestingly, the European Board of ‘ORL and Cervicofacial Surgery’ has been ordered by the UEMS Management Council to restrict its title to that which appears in the Medical Directives: Otorhinolaryngology.
Whilst a hospital department or a specialty in any country is perfectly free to fiddle with its title, others find this behaviour confusing, thus defeating the object. Is the usage of differing titles (e.g. Maxillofacial Unit, Department of Oral and Facial Surgery, Oral and Maxillofacial Unit, etc.) for our own departments in anyone’s best interests? Perhaps it is time to reflect and standardise. In so doing, one major consideration must be the retention or otherwise of the word ‘Oral’. If abandoned, even in our title, oral surgery may be legitimately claimed by a new genre and although such practitioners will undoubtedly face the same need to have a medical base as we did 30 years ago, one must be mindful of the emergence of stomatology based on a single dental qualification in France and Italy as a specialty conducting orthognathic surgery and other relatively complex procedures that we regard as the province of oral and maxillofacial surgeons. Should we challenge the inclusion of ‘Head and Neck’ by others? Certainly, whatever we call ourselves, we must remember the confusion that is engendered by establishing named subspecialties such as has happened in Plastic Surgery, where there is the British Association of Plastic Surgeons (BAPS) and the British Association of Aesthetic Plastic Surgeons (BAAPS‘AA’ pronounced as in Aardvark). Our name must reflect what we do, but first, we must agree with a wide consensus what we do.
Opportunities Having a unique dual background and solid training programmes that equip our young specialists as never before, places our specialty in a strong position to embrace a legitimately wide clinical spectrum, having evolved formerly from the need for specialist maxillofacial trauma services. Having ‘arrived’ as a recognised surgical specialty, there are still great opportunities to be gained from a collaborative approach with colleagues from other disciplines, greater than by confrontation. Direct conflict among specialties not only inflicts wounds but is an embarrassment to colleagues and managers, usually resulting in losers as well as winners. Collaboration is less likely to result in losers and most likely to benefit the patient. The many overlapping surgical areas where we have a legitimate interest and expertise include cranial base, orbital, facial reconstructive and cosmetic surgery in addition to our traditional core areas. With a mature approach and mutual respect by all parties, the maxillofacial surgeon assumes an indispensable role for the best quality of care. It is noteworthy that a young maxillofacial trainee has been appointed to the country’s first training post in craniofacial surgery open to all relevant specialties. On a broader front, it is also noteworthy that so many maxillofacial surgeons hold significant office locally as clinical directors and chief executives and within the Collegiate and BMA structures.
Editorial
Threats
341
surgeons and would lead to a contraction of oral and maxillofacial surgery to its earlier, more limited role. Hand surgery and spinal surgery are examples of developed clinical areas open to those of different backgrounds where it is accepted that the majority of orthopaedic surgeons and plastic surgeons do not engage in hand surgery and the majority of neurosurgeons and orthopaedic surgeons do not engage in spinal surgery. 3. Abandon our traditional dental base as in the southern European model. This may have logic and could be attractive to NHS managers and commissioners, expediting as it would the privatisation or devolution of secondary ‘dental’ care in line with current trends. However, this approach flies in the face of international professional agreement and again would lead to a contracted and weakened specialty.
Perhaps the most significant contemporary threat is imposed by the CDO’s report with its untested presumption that much of our traditional routine work can be delivered by less comprehensively trained people outside the hospital setting. This may or may not be true, but it is up to the specialty to become involved in the training and supervision of such people and in the delivery of a quality service at low cost, whether or not this involves sessional commitments outside our hospital departments. As always, some of the greatest threats come from within our own family: confrontational attitudes, tunnel vision and a refusal to adapt to change have no place. The external threats of other endangered species fighting for the same territory are not peculiar to our own specialty nor to the UK. A recent minute of the European Board of ORL referred to the ‘predation’ of presumed ORL territory by maxillofacial and plastic surgeons. If this sort of cock-fighting is not controlled from within, then others will do so. The current interdisciplinary Liaison Group on Head and Neck Surgery of the JCHST is a good example of the way forward. I conclude with thoughts on an option appraisal that, whilst not exhaustive, may help to focus attention on the need for an identity understood by all:
Whichever option seems the most appropriate, we must pursue a corporate strategy so that the specialty preserves an identified role. Retaining a distinctive plumage may well ruffle the feathers of others, but is essential for survival. Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either daring adventure, or nothing. Helen Keller.
1. Retain ‘oral surgery’ within oral and maxillofacial surgery and continue to broaden the remit of the specialty by collaborative methods as well as ‘niche marketing’ strategies. 2. Encourage the development of a new specialty of ‘head and neck surgery’. This would not be the exclusive habitat of oral and maxillofacial
Peter Leopard President-Elect Maxillofacial Surgery North Staffs Royal Infirmary COPD Stoke-on-Trent UK
Scandinavian countries and the USA until quite recently, have experienced great difficulties in developing a specialty of oral and maxillofacial surgery based on a dual qualification, due to a different evolutionary process. However, both in the Eastern block model and in the majority Western world model, one fundamental reason for the existence of the specialty is the unique expertise required for the understanding and management of oral diseases, whether this expertise is acquired by virtue of a full dental qualification or a period of education and training in ‘dental art’. Compare this situation of a comprehensive specialty embracing subspecialties with the current rapid evolution from general surgery of subspecialties such as vascular surgery and cola-rectal surgery, no different from the earlier emergence of urological surgery and cardiothoracic surgery as specialties in their own right and also with the effects of the CDO’s report promoting the emergence of dental subspecialties. Consider also the overlapping interests of our specialty with others such as ENT and plastic surgery. It is at once apparent that in evolutionary terms, not only is the environment changing rapidly, but grey squirrels are competing for our habitat and an urgent strategy of adaptation is required. To suggest that these factors may signal a threat of extinction, albeit locally, may not be overstating the case, as evidenced by recent events in Humberside. Anticipating the need to mark out our habitat, Council launched, through the audit committee, a simple data collection exercise last year, based on a highly successful model organised by the British Orthopaedic Association, to determine the nationwide demand for our services and hence our manpower requirements, in addition to measuring clinical activity to determine how well or otherwise we are meeting that demand. Such an exercise required high compliance and failed for that reason. A second attempt to harvest these data is currently in hand. If that fails, we must expect the Humberside phenomenon to occur elsewhere without warning and without the means of challenge. There are those among us who may be complacent and worse, those who may regard such initiatives as paranoid. Surely, a corporate strategy is required for the specialty as a whole, rather than the insular attitudes of individuals geared to short-term local advantages. The game has to be more important than an individual player. To explore the situation further, a SWOT analysis and option appraisal may be helpful. 345
346
British
Journal
of Oral
and Maxillofacial
Surgery
Strengths Undoubtedly, our dental base and with it our unique referral base are major advantages. There is wide international agreement that the specialty should require a dual medical and dental education and qualification. The strengthening of our training programmes by the positive response of our SAC to the Calman proposals is producing young specialists of exceptional calibre, with the option to develop special interests. Our range of activity brings us into close professional working relationships with colleagues of many other disciplines. Weaknesses There is still a wide variation in practice from unit to unit across the country which sometimes leads to misconceptions of our potential contribution, Our relatively small numbers, few beds and long waiting lists may encourage host purchasers to seek alternatives. In this respect, the dual standards of the willingness of some to be involved with dento-alveolar surgery in the NHS and private sectors are usually well known to chief executives and are difficult to condone. Having established ourselves as a DGH based specialty, we now have to adapt to a hub and spoke reconfiguration, made more urgent and logical by the emergence of day stay surgery, junior doctors’ hours requirements, the expense of maintaining inpatient services at neighbouring sites and a perception that less complex surgery can be conducted outside the hospital service. Paradoxically, we have found this adaptation more difficult than have some former subregional specialties such as plastic surgery, who fit more neatly into the hub and spoke model. A significant weakness is our remarkable difficulty in finding a title that conveys to the public, to managers and even to professional colleagues exactly what we do. In the space of a generation we have been known officially within the NHS as Dental Surgeons, Oral Surgeons and Oral and Maxillofacial Surgeons. Within the European Medical Directives the specialty has been known globally as ‘Stomatology and Dental and Oro-maxillofacial Surgery’ concurrent with ‘Oral Surgery’ being recognised within the Dental Directives! At the same time, General Orthopaedics, Urology, Swm-y, Neurosurgery, Plastic Surgery and others have preserved their nomenclature. However, we are not alone in having a titular identity crisis. Within the UK, ENT Surgery has adopted its Latin translation of Otorhinolaryngology (ORL), recently infiltrating cephalad and caudad in a different language to become ‘ORL and Head and Neck Surgery’. Interestingly, the European Board of ‘ORL and Cervicofacial Surgery’ has been ordered by the UEMS Management Council to restrict its title to that which appears in the Medical Directives: Otorhinolaryngology.
Whilst a hospital department or a specialty in any country is perfectly free to fiddle with its title, others find this behaviour confusing, thus defeating the object. Is the usage of differing titles (e.g. Maxillofacial Unit, Department of Oral and Facial Surgery, Oral and Maxillofacial Unit, etc.) for our own departments in anyone’s best interests? Perhaps it is time to reflect and standardise. In so doing, one major consideration must be the retention or otherwise of the word ‘Oral’. If abandoned, even in our title, oral surgery may be legitimately claimed by a new genre and although such practitioners will undoubtedly face the same need to have a medical base as we did 30 years ago, one must be mindful of the emergence of stomatology based on a single dental qualification in France and Italy as a specialty conducting orthognathic surgery and other relatively complex procedures that we regard as the province of oral and maxillofacial surgeons. Should we challenge the inclusion of ‘Head and Neck’ by others? Certainly, whatever we call ourselves, we must remember the confusion that is engendered by establishing named subspecialties such as has happened in Plastic Surgery, where there is the British Association of Plastic Surgeons (BAPS) and the British Association of Aesthetic Plastic Surgeons (BAAPS‘AA’ pronounced as in Aardvark). Our name must reflect what we do, but first, we must agree with a wide consensus what we do.
Opportunities Having a unique dual background and solid training programmes that equip our young specialists as never before, places our specialty in a strong position to embrace a legitimately wide clinical spectrum, having evolved formerly from the need for specialist maxillofacial trauma services. Having ‘arrived’ as a recognised surgical specialty, there are still great opportunities to be gained from a collaborative approach with colleagues from other disciplines, greater than by confrontation. Direct conflict among specialties not only inflicts wounds but is an embarrassment to colleagues and managers, usually resulting in losers as well as winners. Collaboration is less likely to result in losers and most likely to benefit the patient. The many overlapping surgical areas where we have a legitimate interest and expertise include cranial base, orbital, facial reconstructive and cosmetic surgery in addition to our traditional core areas. With a mature approach and mutual respect by all parties, the maxillofacial surgeon assumes an indispensable role for the best quality of care. It is noteworthy that a young maxillofacial trainee has been appointed to the country’s first training post in craniofacial surgery open to all relevant specialties. On a broader front, it is also noteworthy that so many maxillofacial surgeons hold significant office locally as clinical directors and chief executives and within the Collegiate and BMA structures.
Editorial
Threats
341
surgeons and would lead to a contraction of oral and maxillofacial surgery to its earlier, more limited role. Hand surgery and spinal surgery are examples of developed clinical areas open to those of different backgrounds where it is accepted that the majority of orthopaedic surgeons and plastic surgeons do not engage in hand surgery and the majority of neurosurgeons and orthopaedic surgeons do not engage in spinal surgery. 3. Abandon our traditional dental base as in the southern European model. This may have logic and could be attractive to NHS managers and commissioners, expediting as it would the privatisation or devolution of secondary ‘dental’ care in line with current trends. However, this approach flies in the face of international professional agreement and again would lead to a contracted and weakened specialty.
Perhaps the most significant contemporary threat is imposed by the CDO’s report with its untested presumption that much of our traditional routine work can be delivered by less comprehensively trained people outside the hospital setting. This may or may not be true, but it is up to the specialty to become involved in the training and supervision of such people and in the delivery of a quality service at low cost, whether or not this involves sessional commitments outside our hospital departments. As always, some of the greatest threats come from within our own family: confrontational attitudes, tunnel vision and a refusal to adapt to change have no place. The external threats of other endangered species fighting for the same territory are not peculiar to our own specialty nor to the UK. A recent minute of the European Board of ORL referred to the ‘predation’ of presumed ORL territory by maxillofacial and plastic surgeons. If this sort of cock-fighting is not controlled from within, then others will do so. The current interdisciplinary Liaison Group on Head and Neck Surgery of the JCHST is a good example of the way forward. I conclude with thoughts on an option appraisal that, whilst not exhaustive, may help to focus attention on the need for an identity understood by all:
Whichever option seems the most appropriate, we must pursue a corporate strategy so that the specialty preserves an identified role. Retaining a distinctive plumage may well ruffle the feathers of others, but is essential for survival. Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either daring adventure, or nothing. Helen Keller.
1. Retain ‘oral surgery’ within oral and maxillofacial surgery and continue to broaden the remit of the specialty by collaborative methods as well as ‘niche marketing’ strategies. 2. Encourage the development of a new specialty of ‘head and neck surgery’. This would not be the exclusive habitat of oral and maxillofacial
Peter Leopard President-Elect Maxillofacial Surgery North Staffs Royal Infirmary COPD Stoke-on-Trent UK