- Email: [email protected]
Dual-degree Oral and Maxillofacial Surgery Training in the United States: “Back to the Future”
SPECIAL CONTRIBUTION
Dual-degree Oral and Maxillofacial Surgery Training in the United States: ‘‘Back to the Future’’ Leonard B. Kaban, DMD, MD,* and David H. Perrott, DDS, MD, MBAy In the present report, we trace the history of education and training of oral and maxillofacial surgeons as it has evolved from the mid-19th century to the present. We consider the effects of the discovery of ether anesthesia, the separation of medicine and dentistry, and other milestones such as antisepsis (Lister), antibiotics (Fleming) and surgical progress during wartime. The main emphasis, however, is on the background, development, and implementation of current dual-degree oral and maxillofacial surgery training programs, the first 5 programs, the pioneer advocates for this training, and progress and challenges for the future. Ó 2019 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-11, 2019 At the 100th anniversary of the American Association of Oral and Maxillofacial Surgeons (AAOMS), looking back on the history of oral and maxillofacial surgery (OMS) training and the evolution of ‘‘dual-degree’’ programs are important exercises that broaden our perspective on education and the development of the specialty. We demonstrate that examining the rise of American doctor of medicine (MD) programs in the context of the increasing scope of OMS, since the early 19th century, is an exercise in looking ‘‘back to the future.’’1 The modern era of surgery began in the 1800s with the discovery of ether anesthesia. It is there that we begin this story because of the connection between these events and dentistry and the evolution of OMS training. The discovery of ether anesthesia has been called the most significant medical breakthrough in the history of humankind. The state of surgery in the 19th century was primitive. Operations were infrequent and had to be performed with lightning speed. Mortality rates were
exceedingly high. The variables of pain, hemorrhage, shock, and infection were the major obstacles to successful outcomes and patient survival.
Surgical Training in the Early 19th Century It is important to understand surgical training in the early 1800s to understand where we are today. The most common dental surgical operation was tooth extraction. Dental and physician surgeons also performed debridement of wounds, excision of tumors, drainage of neck space infections, and treatment of pain by nerve transection or neurectomy. Physicians and non-healthcare providers (eg, barbers, blacksmiths who apprenticed to established surgeons [MDs] or dental surgeons) performed these procedures. There were no dental schools and the existing medical schools had no strict entry requirements. There were no regulations and no clinical studies or
*Walter C. Guralnick Distinguished Professor and Chief Emeritus,
Address correspondence and reprint requests to Dr Kaban:
Department of Oral and Maxillofacial Surgery, Massachusetts
Department of Department of Oral and Maxillofacial Surgery, Massa-
General Hospital, Harvard School of Dental Medicine, Boston, MA.
chusetts General Hospital, Boston, MA 02114; e-mail: kaban.
ySacramento, CA.
[email protected]
Presented, in part, by Dr Kaban at the Resident Organization Sym-
Received August 7 2019
posium, 100th Annual Meeting of the American Association of Oral and Maxillofacial Surgeons, Chicago, IL, October 13, 2018.
Accepted August 11 2019 Ó 2019 American Association of Oral and Maxillofacial Surgeons
The present study was supported by the Department of Oral and
0278-2391/19/31051-1
Maxillofacial Surgery, Massachusetts General Hospital Education and
https://doi.org/10.1016/j.joms.2019.08.026
Research Fund. Conflict of Interest Disclosures: None of the authors have any relevant financial relationship(s) with a commercial interest.
1
2 evidenced-based medicine principles as we know them today. The obstacle of pain and the need for surgeons to perform operations with great speed ended with the landmark demonstration of ether at Massachusetts General Hospital (MGH) in October 1846.2-4 The solutions to the other major obstacles in the evolution of modern surgery came later: 1) antisepsis described by Joseph Lister in 18675,6; 2) antibiotics and the discovery of penicillin by Alexander Fleming in 19287; 3) the first human organ transplant in 19558,9; and 4) advances in fluid and electrolyte management.10 It required this entire series of milestones and advances, among others, to allow surgery to progress through its phases of development, including excision, reconstruction, transplantation, induction, and regeneration, to its current state.11 However, the discovery of anesthesia was especially relevant to surgical training, because it allowed surgeons to perform complex operations with careful attention to precise execution, without the patient writhing in pain. It was this progress that necessitated expanded and more sophisticated education for the modern surgeon. Furthermore, the role of dental surgeons was critical in this story of ether anesthesia and its first demonstration, which, ultimately, had a major effect on the training of dental and oral and maxillofacial surgeons.
Discovery and Dissemination of Ether Anesthesia William Morton, a Boston dentist credited with the first public demonstration and documentation of ether anesthesia on October 16, 1846, is shown in Figure 1. The Robert C. Hinkley painting (1893) of the first demonstration of ether is presented in Figure 2. The painting illustrates the patient on the table, observers in the gallery, Morton with the ether flask, John Collins Warren, the surgeon, and Henry J. Bigelow, the assistant. Warren ligated the feeding vessels and ‘‘undersewed a vascular malformation’’ of the submandibular region.2,12 The patient did not stir or react to the operation. After the procedure, Warren turned to the audience and uttered his now famous words: ‘‘This is no humbug, gentlemen!’’ Despite Warren’s words, some were still skeptical because ligation and oversewing of the vascular malformation and subsequent removal of a neck lipoma were superficial operations. It was not until the third operation, a below-the-knee amputation a few days later by Dr Charles Heywood, that ether was accepted as a viable technique for the relief of pain during surgical procedures.2,12,13
HISTORY OF DUAL-DEGREE OMS TRAINING
FIGURE 1. A photograph of William Morton, the Boston dentist credited with the first demonstration of ether anesthesia—to be reported publicly. Crawford Long, a general surgeon in Atlanta, might have preceded Morton. Long was apparently using ether anesthesia for general surgery procedures but never reported it and, therefore, did not receive credit for the discovery. The major teaching hospital for Emory University Medical School in Atlanta is named after Crawford Long. (Reprinted from the MGH Archives). Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
Once the concept of ether anesthesia was accepted, the technique and knowledge had to be disseminated. However, Morton was not a highly respected practitioner and was generally regarded as unethical and unscrupulous. Nathan Cooley Keep, however, was a renowned and gifted dental practitioner and the most highly regarded dental surgeon of the time in Boston (Fig 3). He came to be the one who popularized ether anesthesia. His role is not well known and has rarely been recorded.2 Keep apprenticed to John Randall, MD, a Harvard Medical School (HMS) graduate, to learn dentistry. At the same time, he had enrolled in HMS and received his MD degree in 1827. As noted, the most common method of training of surgeons and dental surgeons was for physicians with an MD degree, or blacksmiths or barbers, to apprentice with a local practitioner. Keep had many tuition-paying apprentices who learned his techniques. Among those were William Morton and Horace Wells (of nitrous oxide fame). All 3 of these men recognized the importance and
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FIGURE 2. The Robert C. Hinkley painting (oil on canvas, 1893) of the first demonstration of ether illustrates the patient on the table, observers in the gallery, Morton with the ether flask, and Warren, the surgeon. He ‘‘undersewed a vascular malformation’’ of the submandibular region with the patient under ether anesthesia. The patient did not react to the operation. John Collins Warren then turned to the audience after the procedure and uttered his now famous words: ‘‘This is no humbug, gentlemen!.’’ (Reprinted from the Francis A. Countway Library of Medicine, Harvard Medical School). Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
significance of the discovery of a technique to alleviate the pain and suffering of dental and surgical procedures.2 After the demonstration of ether, Keep hired Morton, and they advertised their practice of ‘‘painless dentistry’’ in the local newspapers. However, Keep soon came to realize that Morton was unethical and fired him because of his attempts to patent ether anesthesia and collect royalties for its use. Subsequently, Morton went downhill and eventually died a poor, indigent alcoholic. However, Keep continued to provide anesthesia for local general surgeons and for dental extractions in his own office. His anesthesia services became very much in demand. He also became the first to administer ether for obstetric anesthesia. The pregnant patient was Fanny Longfellow, wife of Henry Wadsworth Longfellow, the famous poet. The infant girl was delivered at their home in Cambridge, Massachusetts.2 In April 1847, just 6 months after the first demonstration of ether, Keep reported a case series in the Boston Medical and Surgical Journal (precursor of the New England Journal of Medicine) of 200 patients who had undergone anesthesia for a variety of general, oral, and obstetric surgical procedures.4 This extensive series illustrated how much in demand Keep’s services had become after the initial demonstration of ether. Parenthetically, it also illustrated the
FIGURE 3. Print of Nathan Cooley Keep, 1867. (Reproduced from Koch CRE: History of Dental Surgery, Contributions by Various Authors. Vol. 2. Chicago: National Art Publishing Company; 1909, p 114; and Guralnick WC, Kaban LB: Keeping ether ‘‘en-vogue’’: The role of Nathan Cooley Keep in the history of ether anesthesia. J Oral Maxillofac Surg 69:1892, 2011). Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
short turnover time for the report of a clinical outcome study in the mid-1800s.
Formation of a University-affiliated and Degree-granting Dental School The other half of this history was the formation of a university-affiliated and degree-granting dental school, which separated dentistry and medicine and, therefore, dental surgery from surgery in general. This dichotomy has prevailed to this day, although it is undergoing some revision in the current healthcare environment. Keep was a member of the staff of the MGH. He was a founding member and became the first president of the Massachusetts Dental Society. He championed the cause of formal dental education and the need for universities and colleges to train dentists. He stated: ‘‘My own predilection would favor a thorough and united dental and medical education. I should hope in such a case that the degree of MD would be the lawful appendage to the names of those young
4 men [note, young men only] who enter our specialty. If this, however, is not attainable, it may not be entirely out of place to inquire whether Harvard University might not appoint professors of dentistry and confer upon proper candidates the degree of doctor of dental surgery’’ (DDS). However, the HMS and Harvard University did not agree to award the MD degree to students of dentistry. Instead, Harvard opened the first medical school and university-affiliated dental school in the United States in 1867, with Keep as the first dean.2 The University conferred the doctor of dental medicine (DMD) degree. Baltimore Dental College, a free-standing, at that time non–university-affiliated dental school, was established earlier. These 2 schools provided the opportunity for a practitioner with a DDS (Baltimore) or DMD (Harvard) degree to practice dental surgery. Although Harvard rejected Keep’s first choice, the University allowed him to fulfill his second option. It is ‘‘back to the future’’ and further ironic that in 1971, 104 years later that the same medical school and university approved a program to finally award oral and maxillofacial surgeons an MD degree as their ‘‘lawful appendage.’’ Keep finally got his first choice.
Milestones for the Specialty of OMS The evolution of the specialty occurred over time because OMSs and our organizations always appreciated the need to improve education, training, and standards of practice.14 The following are some of the milestones that set the stage for the evolution of our training, the establishment of dual-degree programs, and the recent acceptance of American Board of Oral and Maxillofacial Surgery (ABOMS) certification as a legitimate credential for fellowship in the American College of Surgeons. As noted, in the 19th century, exodontists were physicians, dentists, barbers, and other nonprofessionals who did extractions. As they expanded the field in the 20th century, they changed the specialty and organizational names to reflect these changes in scope, including the American Society of Exodontists, American Society of Exodontists and Oral Surgeons, American Society of Oral Surgeons, and American Association of Oral and Maxillofacial Surgeons. Wartime experiences helped advance and expand OMS’s scope and recognition, especially because of OMSs’ work in trauma. During World War I (WWI), Varaztad Kazanjian, ‘‘miracle man of the Western Front,’’ made significant advances in the management of maxillofacial fractures and other traumatic defects. Further advances in the management of maxillofacial injuries occurred during World War II (WWII), the Korean conflict, and the Vietnam War and continued through the conflicts in Afghanistan and Iraq. The
HISTORY OF DUAL-DEGREE OMS TRAINING
technical and scientific advances in trauma management and the treatment of specific craniomaxillofacial fractures and soft tissue injuries expanded the scope of OMS as a specialty and resulted in the need for broader residency training. The evolving treatment modalities and expanding scope stimulated an interest in the development of ‘‘dual-degree’’ training programs and fellowship training in head and neck cancer, cleft/craniofacial and orthognathic surgery, pediatric maxillofacial surgery, cosmetic surgery, reconstructive surgery, and temporomandibular joint surgery. The ABOMS improved the sophistication and standardization of the certifying examination, and the AAOMS developed the OMS in-service training examination (first administered in 1977) to evaluate residents as they advanced through their levels of training.15 Finally, all these advances were accompanied by an increase in the duration and scope of OMS training and the birth of the modern MD OMS training program.
Evolution of OMS Training Programs Until the 1930s, 1-year internships, apprenticeships, and limiting practice to OMS were the norms for training. Most formal programs included a 1-year OMS internship and a second year spent taking didactic courses in anatomy, physiology, and so forth at a dental school. This was followed by a second clinical year, considered the residency, often at a different institution.16 In 1967, the American Society of Oral Surgeons (ASOS) Committee on Graduate Training, as a result of a number of educational workshops, recommended a revision of the Essentials of an Adequate Advanced Training Program in Oral Surgery. The new Essentials mandated a 3-year integrated program, which included a 1-year OMS internship, followed by 1 year of hospital rotations in medicine (3 months), surgery (3 months), anesthesia (3 months), and an elective (3 months). The third year was the residency year. All programs had to provide a progression of complexity and responsibility in training at the home institution. The Commission on Dental Accreditation (CODA) approved this change.16 In 1985, the AAOMS House of Delegates approved a resolution to increase OMS training from 3 to 4 years. The resolution mandated that all programs follow a 4-year integrated curriculum consisting of a 1-year OMS internship, followed by 1 year of off-service rotations (3 months of medicine, 3 months of surgery, 4 months of anesthesia, and 2 months of an elective) and then 24 months of OMS at the junior and senior resident level. These changes were approved by the CODA in December 1986.16 Over the years, the
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anesthesia requirement has continued to increase, and a requirement for scholarly activity was instituted.
Development of the Modern Dual-degree OMS Program: Background In the late 1960s, Walter Guralnick (Fig 4), chief of oral surgery at MGH and the Harvard School of Dental Medicine (HSDM) and chair of the American Society of Oral Surgeons Committee on Graduate Training (later to become the Committee on Residency Education and Training), concluded that dual-degree training would be important for oral and maxillofacial surgeons. His opinion on this subject had evolved, because, as late as 1967, he was not in favor of dual-degree training. To his great credit, I (L.B.K.) believe an emergency in the operating room that he did not feel comfortable managing and that one of the general surgeons had to help control changed his perspective on the training of OMS residents.
FIGURE 4. Photograph of Walter C. Guralnick, circa 2013 (photograph MGH Archives). Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
5 Guralnick14 described, in a study reported in the Journal of Oral and Maxillofacial Surgery in 1973, the rationale for the MGH/Harvard MD OMS program proposed and approved at MGH and Harvard in 1970 and implemented in full in 1971. He concluded that the increasingly complex scope of OMS as a specialty required a major change in training.14 He made the following points: 1) ‘‘. there is an educational deficit in OMS training programs consisting of insufficient general medical and surgical background’’; 2) this deficiency would best be corrected by ‘‘obtaining a medical degree and general surgery training, in addition to the OMS experience’’; 3) ‘‘.this is consistent with the direction of our specialty and our standards of training’’; and 4) he recognized that: ‘‘A major curricular change cannot be made without considerable trauma to the group affected by it.’’ He observed that ever since the days of the American Society of Exodontists and Oral Surgeons, its evolution to the ASOS and then AAOMS and the birth of the ABOMS, ‘‘there has been a continuous and successful movement to improve OMS training, standards and practice.’’ James Hayward,17 at the time editor-in-chief of the Journal of Oral Surgery and the chair of oral surgery at University of Michigan, wrote in regard to the implementation of dual-degree programs: ‘‘.we fully appreciate that our particular goals in education require the teamwork of agencies in dentistry, medicine, and hospitals.’’14,17 During my (L.B.K.) many discussions with Guralnick about the ‘‘dual-degree’’ program, during our 50-year relationship, he always maintained that the MD degree and at least 1 year of legitimate general surgery training would lead to a more confident and competent surgeon, better patient care, and a better education for our residents. His forward thinking was also evidenced in that he was one of a few OMS chiefs to appreciate the importance of the ‘‘full-time’’ faculty model. In the 1960s, most OMS programs had predominantly part-time faculty whose primary responsibilities were in their private practices. Guralnick was confident that dual-degree training and the full-time faculty model would significantly improve the status of OMS as a specialty in the hospital and university and would allow us to eventually be integrated into the mainstream of American surgery. Up until 2016, fellowship in the American College of Surgeons was limited to ABOMS certified dualdegree OMSs who had gone through a complex double-tiered admissions process. Edward Hinds was the first OMS to become a fellow in the American College of Surgeons (ACS). However, he was board certified in general surgery. The first non–general surgeon OMS admitted to fellowship was Donald Leake in 1974 and, thereafter, Leonard Kaban in 1980. In
6 1990, the next 3 OMSs admitted were James Bertz, R. Bruce Donoff, and Harry Schwartz. As many as 45 to 50 dual-degree OMSs became fellows over the years through this process. In 2016, the ACS, working with Ghali Ghali and a special committee of the AAOMS, simplified the admission process for dualdegree OMSs. Soon thereafter, a pathway for singledegree OMSs to attain fellowship was established. The number of fellows dramatically increased, and an OMS section was established. OMSs joined the mainstream of American surgery just as Guralnick had predicted.
Individual Surgeons Who Sought an MD Degree and General Surgery Training After WWII In the 1940s and through the 1970s, some pioneer OMSs had independently enrolled in medical school and obtained an MD degree to enhance their training. No specific records are available to identify these OMSs. However, those we were able to document are listed in Table 1. Marsh Robinson received his dental degree in 1942 and his medical degree in 1946, both from the University of Southern California (USC). He did an internship at Los Angeles County Hospital and then apprenticed to Arthur Smith, an OMS, for 5 years. In 1954, he became chair of OMS at the USC, overseeing a 3-year postgraduate program. To the best of our knowledge, no effort was made to develop an MD OMS program at the USC during this time.18 At the University of Alabama (UAB), the first full-time chair of the OMS department was Joseph Peter Lazansky. He was a European-trained surgeon with both DDS and MD degrees from Czechoslovakia. He remained chair until 1958. Charles McCallum received his DMD degree from Tufts University and completed his OMS residency at the UAB in 1954. He then matriculated at the UAB medical school for his MD degree and had a subsequent 1 year of general surgery training. In 1958, he was appointed full-time chair of OMS at the UAB. However, no attempt was made to start an integrated dual-degree program at the UAB at that time.19 H. David Hall succeeded McCallum at the UAB in 1965 and then left in 1968 to become chair of OMS at Vanderbilt University. At Vanderbilt, according to his wife Kay, he was influenced by the ear, nose, and throat (ENT) and plastic surgeons and decided to develop an MD OMS residency program.20 He had some difficulty obtaining approval for an integrated dual-degree program at Vanderbilt. However, he was able to get Jonathan Jacobs, a HSDM graduate, admitted to Vanderbilt Medical School in 1970. Jacobs obtained his MD degree and 1 year of general surgery residency and then completed the Vanderbilt OMS program in 1975. This was a 5-year program, similar
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Table 1. ORAL SURGEONS WHO ATTENDED MEDICAL SCHOOL ON THEIR OWN FROM 1930 TO 1975
Surgeon William Harrigan
Edward Hinds*
Marsh Robinson
Charles McCallum
Morton Goldberg
Donald Leake* Victor Matukasy
Norman Trieger H. David Hally
James Bird James Bertz* Roger Meyer*,z
Description DDS, University of Pennsylvania, 1938; MD, New York University, 1942; Chief, Bellevue Hospital, 1950 DDS, 1940; MD, 1945 Baylor University; Chairman, University of Texas Houston, 1948 DDS, 1942; MD, 1946, University of Southern California; Chairman, University Southern California, 1954 DMD, Tufts, 1952; MD, University of Alabama, 1957; Chairman, University of Alabama, 1958 DMD, Harvard, 1958; MD, Albany Medical College, 1961; Chief, Hartford Hospital, 1971 DMD, Harvard 1962; MD, Stanford University, 1969; Chief, HarborUCLA Medical Center, 1970 DMD, Loyola University, New Orleans; MD, University of Colorado, 1968; Department Chair, University of Alabama, 1985 DMD, Harvard, 1954; MD, Albert Einstein, 1974; Chief, Montefiore Medical Center, 1973 DMD, Harvard, 1957; MD, University of Alabama, 1977; Chairman, University of Alabama, 1958; Chairman, Vanderbilt University, 1968 DDS, University of Nebraska, 1969; MD, University of Nebraska, 1973 DDS, Ohio State University, 1961; MD, Baylor University, 1974 DDS, University of Washington, 1963; MD, Creighton University, 1975; Chair, Emory University, 1979
Abbreviations: DDS, doctor of dental surgery; DMD, doctor of dental medicine; MD, doctor of medicine. * Fellow, American College of Surgeons. y Started dual-degree program: Vanderbilt (Hall), Alabama (Matukas). z Received approval for dual-degree program at Emory University. Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
to that at Harvard University. Several others of Hall’s residents were able to obtain an MD degree and general surgery training at Vanderbilt after completing the standard 36-month OMS program. Hall ultimately
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established the formal integrated MD OMS program at Vanderbilt in 1974, and Joseph McMullen was the first resident. Vanderbilt maintained 2 training tracks: the MD OMS program and a single-degree 4-year program. Hall took a leave of absence from 1975 to 1977 and obtained his MD degree at the UAB. During this time, Jonathon Jacobs was the chair of OMS at Vanderbilt University.20 Most of the ‘ dual-degree’’ OMSs from the 1940s through the 1970s went into academic practice, although some had private practices on the side, and became program directors and department chairs (Table 1). Of this group, Hall at Vanderbilt was the first to implement an MD OMS program. Victor Matukas, who had received his MD degree from University of Colorado was appointed OMS program director at the UAB in 1975 and department chair in 1981. Under his leadership, the dual-degree program at UAB received formal approval and accepted its first residents in 1977. Roger Meyer, while chair at Emory (1979 to 1986), proposed and, ultimately, obtained approval from the medical school for an MD OMS program, although it was not implemented during his tenure. Others had attended medical school for their training but did not pursue the development of a dual-degree program at their institutions and might not have appreciated the significance of this for the specialty in general and for the future of OMS. Edward Hinds, chair at the University of Texas, Houston, beginning in 1948, is one example. He received his DDS degree from Baylor in 1940 and his MD degree in 1945 from Baylor College of Medicine and stated: ‘‘The properly trained dentist has an important role to play in the management of disease and injuries of the oral and maxillofacial region. We will establish a program that will provide the opportunity for interested dentists to obtain the necessary training to assume that role.’’ He made no mention of an MD degree nor commented on its desirability for an OMS, and starting an MD OMS training program was not attempted.21 William Harrigan, Donald Leake, Morton Goldberg, and Norman Treiger (Table 1) were others who had obtained medical degrees and were department chairs or hospital chiefs who did not seek to develop a dualdegree program for their trainees. Goldberg desired to start an MD program but was not able to get approval. However, he was able to obtain a full year of general surgery residency for his trainees in a single-degree program at Hartford Hospital in Connecticut. Ultimately, James Hupp established a combined dual-degree program at the University of Connecticut. Objections to dual-degree training in the 1960s and 1970s included that 1) specialized OMS training might be impaired by shortening its length to devote time to the MD degree and general surgery residency; 2) the
expense and time involved would be overwhelming and discourage potential applicants, and 3) the OMS field might experience a potential of loss of residents to other specialties.
Early Dual-degree Programs: The First Five HARVARD PLAN
The Harvard plan was conceived in the late 1960s and approved in 1970 and enrolled its first resident into the full program as written in 1971.14,22 To achieve approval for the program, Guralnick, not only had the support of the deans of the dental and medical schools, but also the strong support of the then surgeon-in-chief at MGH, W. Gerald Austen. His commitment of preliminary general surgery positions for OMS trainees was critical. To satisfy the objections to dual-degree training, the Harvard plan initially included only HSDM students because they had spent their first 2 years completing the HMS basic science curriculum and could be completely integrated as medical students. Therefore, they were only required to spend 1 additional year in medical school, completing the principal clinical year, to receive the MD degree. They received 1 year of elective credit for their experience as an OMS intern, which included 3 months of anesthesia training. The program was 5 years in duration. In 1985, HMS approved the acceptance of non-HSDM students into the program. The HSDM students continued with the 5-year program and the non-HSDM students were accepted into a 6-year program with 2 years of medical school. In 1995, under the leadership of Kaban and program director David Perrott, the program was modified such that all residents completed 2 years of medical school for a 6-year residency, regardless of where they had attended dental school. The HSDM students completed years 3 and 4 and the nonHSDM students completed years 2 and 3 of the HMS curriculum. In 1999, with Thomas Dodson as the program director, the curriculum was revised and unified. All residents, both HSDM and non-HSDM graduates, were required to complete years 3 and 4 of the HMS curriculum to receive the MD degree (Table 2). On completion of the MGH/Harvard program, the resident received an OMS certificate, MD degree, and credit for 2 years of general surgery and 32 months of OMS. The key points are that postgraduate year (PGY) 1 is 12 months of OMS and 20 of the last 24 months are devoted to OMS. This has been a template for many dual-degree programs. However, other programs have not provided the same continuity of OMS experience because the time is disrupted by the medical school rotations. A summary of the current MGH/Harvard MD program is presented in Table 2.
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Table 2. MASSACHUSETTS GENERAL HOSPITAL, HARVARD MD ORAL AND MAXILLOFACIAL SURGERY PROGRAM*
Current form: PGY 1, OMS Intern, 12 months PGY 2, Harvard Medical School third year PGY 3, Harvard Medical School fourth year Anesthesia, 4 months PGY 4, MGH general surgery PGY 2 PGY 5, MGH general surgery PGY 3, 4 months (1 month SICU) OMS junior, 8 months PGY 6, OMS chief resident, 4 months OMS senior resident, 4 months Children’s Hospital senior, 4 months First year and 20 months of final 24 months, uninterrupted OMS Credit for 2 years of general surgery Abbreviations: MD, doctor of medicine; MGH, Massachusetts General Hospital; OMS, oral and maxillofacial surgery; PGY, postgraduate year; SICU, surgical intensive care unit. * Started in 1971, modified in 1986 and 1999, 6 years: classic program as written; some changes will occur in the enrollment years in medical school (eg, second and third rather than third and fourth) based on a new Harvard Medical School curriculum; however, the basic 6-year template will remain the same. Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
The fear of the loss of residents during the training proved not to be a significant issue. Only 4 of the first 55 resident (7.1%) and 1 of the second 55 residents (1.8%) failed to complete the program. This compares favorably to any surgical program of 6 years’ duration for which the loss of some residents can occur during the long training period.22 The MGH program was arguably the first contemporary dual-degree program accepted by its medical school, dental school, and university. As noted, some irony exists in the fact that the university first responsible for the split between medicine and dentistry finally let the fields come together in the OMS program. After the program’s approval in 1970, Bruce Donoff, Steven Roser, Edward Seldin, and Leonard Kaban were allowed to matriculate at HMS on completion of their OMS training at MGH. They then completed an additional year of general surgery at MGH. John P. W. Kelly was the first resident to matriculate in the program as written in 1971. He subsequently became OMS program director at MGH (1983 to 1993).14,22 UNIVERSITY OF NEBRASKA
Contemporaneously with the development of the MGH dual-degree program, Dr Chester Singer, chair of OMS at the University of Nebraska Medical Center
(UNMC), sought to develop an MD OMS program. With support from the chair of surgery, Merle Musselman, and the medical school, the dual-degree program at the UNMC was approved in 1970, and the first residents were enrolled in 1971: Richard Temporo and Gregory Sears. Leon Davis and Stuart Heydt were allowed to matriculate at the University of Nebraska Medical School after they had completed their OMS training.23 Since 1971, all residents have trained in the fully integrated dual-degree program. The next programs to begin were at the University of Washington in Seattle (first resident, Joseph Piecuch, 1972), Vanderbilt University (first resident, McMullen, 1974), University of Alabama (first residents, John Braun, Alan Harvey, 1977).19,20,23-25 The numbers of dual-degree training programs increased from 2 in 1971 (MGH/Harvard and University of Nebraska) to 5 (MGH/Harvard, University of Nebraska, Vanderbilt, UAB, and, for a short time, the University of Washington) in 1981. The University of Washington program was closed in 1982 but was restarted under the leadership of professor and chair Dodson in 2015. The current number of dual-degree programs is 46 of a total of 101 accredited programs (45%), according to the AAOMS data.26 There are a total of 55 single-degree programs and 23 programs that offer options of an MD degree or OMS certificate only.26 Of the 1167 enrolled OMS residents in 2018, 487 (42%) were in MD programs and 680 (58%) in single-degree programs. In 2018, 237 residents graduated, and of those, 91 (37%) had been in MD and 156 (63%) in certificate programs. The 5-year trend (2014 to 2018) of AAOMS data for graduating residents revealed that approximately two thirds of residents are in singledegree and one third in dual-degree programs.26
Discussion Multiple factors have contributed to the evolution of the scope and growth of the modern specialty of OMS. These have included experience with the management of severe traumatic injuries, beginning in WWI and extending through WWII and the Korean, Vietnam, Afghan, and Iraq wars, improvements in education and teaching, improvements in measuring the outcomes of training, the full-time faculty model in tertiary care medical centers, and dual-degree training programs. The dual-degree concept has truly changed the ‘‘face’’ of our specialty. It has contributed to the development of advanced training fellowships in head and neck and reconstructive surgery, cleft and craniofacial surgery, pediatric maxillofacial surgery, cosmetic surgery, and temporomandibular joint surgery. As predicted by Guralnick in his early writings, the MD degree, general surgery training, the full-time faculty
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model, and a broader scope have resulted in broader acceptance of OMS as a surgical specialty by universities, medical schools, and hospitals and have equalized our position in the overall discipline of surgery. It is common now for ENT, plastic surgery, and general surgery residents to rotate on OMS services during their early years. This allows them to gain familiarity, knowledge, and respect for our field. The full-time faculty model has integrated OMS into the medical centers where we function. Many OMS faculty have occupied leadership positions in medical center faculty group practices. All this has led to the acceptance of ABOMS certification as a credential for fellowship eligibility in the ACS. Four OMSs have been chairs of the Joint Commission on Accreditation of Healthcare Organizations (Charles McCallum, John Helfrick, David Whiston, and David Perrott). CHALLENGES FOR DUAL-DEGREE TRAINING
With all the advances we have witnessed, persistent and new challenges exist for dual-degree training. First, fundamental changes have occurred in medical school curricula, eliminating the 2-year basic science plus 2-year clinical experience model and substituting a 4-year integrated concept. This could potentially add 1 to 2 additional years to the time OMS residents are required to spend in medical school. Second, these curriculum changes have also made it more difficult to transfer OMS residents into the third year of medical school. Some medical schools have completely suspended the acceptance of transfer students because of the difficulty of integrating them into the new style curricula. Third, the trend of state licensing boards to require 2 years or more of American Council for Graduate Medical Education (ACGME) approved training for a full medical license is important: At least 3 states require 3 years after MD training and 19 require at least 2 years. These factors will lead to an increase in the costs and time for OMS training and could affect our applicant pool in the future. This brings us to the concept of the cost bubble in medical education.’’27 A cost bubble is created when assets (in this case college, medical, and dental education and residency training) are bought at ever increasing costs (tuition, room and board, loan repayment), which investors (students and trainees) optimistically pay because they anticipate selling their services in the future at prices high enough to repay their loans and support their desired lifestyle.27 At this time, despite requiring the payment of 2 years of medical school tuition, additional years of training and other expenses, in addition to the 8 years for college and dental school, dual-degree programs have remained strong. Also, the number of qualified
9 applicants has remained adequate. This is because sufficient optimism exists regarding the future value of this education and training. The question is: How long will this last? Asch et al27 reported the ratio of average debt of a graduating student/trainee to the average annual income in general medicine and surgery and specialties on entry into the workforce. This ratio reflects what students must borrow and, therefore, how much debt they will have accumulated after their education and training. The cost of becoming a physician is similar whether one ultimately becomes a pediatrician or an orthopedic surgeon; however, debt to income ratio is much higher for pediatricians because they are paid less than orthopedists.27 Similarly, it costs the same to become a dentist, regardless of the specialty chosen after graduation. However, the debt to income ratio will vary among dental specialists depending on the number of years of training, the cost of postgraduate tuition, and the starting salary. The burden of becoming a dual-degree OMS is greater than that of becoming a single-degree OMS owing to tuition cost of obtaining the medical degree and an additional 2 to 3 years of training. The cost of becoming a dual-degree OMS could also be greater than the cost of becoming an orthodontist, prosthodontist, periodontist, or endodontist because OMS training requires a longer duration and the starting salaries of orthodontists and endodontists are especially high. The ratio of debt to income also reflects the relationship between what schools charge for tuition and what OMSs can charge and collect from patients for services at the completion of training. We are all familiar with the high-tech stock bubble of the 1990s and the real estate bubble of 2008. Stock and housing can be sold at unrealistically high prices only to people who think they can resell the commodity at even higher prices. Colleges, medical schools, and dental schools can sustain their high tuitions only if their students are convinced they will earn a high income paid by their future patients for services. In recent years, some private liberal arts colleges have experienced reduced numbers of applicants because potential students have been considering that the cost and accumulating debt of an undergraduate liberal arts education may not make economic sense for them. This could also happen to dental schools and medical schools. For the same reasons, students might be more likely to choose public institutions of higher education over private alternatives. The cost of education for 1 of us (L.B.K.) from 1961 to 1974 compared with what it would cost (2000 to 2014) if attending the same schools is presented in Table 3. However, the data included in Table 3 do not include room and board and other expenses and, thus, underestimate the true cost: 4 years of college,
10 Table 3. COST OF ONE AUTHOR’S EDUCATION AND TRAINING: THEN AND NOW
Cost of education: 1961-1973 College: CUNY $50.00 4 years = $200 HSDM: $1200 + $1250 + $1500 + $1500 = $5450 HMS: $2500 Total: $8150 Intern salary (1969): $6000 First job: $30,000 Debt (debt/income ratio): $1500 (5%) Cost of education: 2000-2014 College: CUNY $6000 4 = $24,000 HSDM: $40,000 + $42,000 + $42,000 + $45,000 = $169,000 HMS: 42,000 + 45,000 = $87,000 Total: $284,000 Intern salary (2014): $58,000 First job: $200,000 Debt (debt/income ratio): $200,000 (100%) Abbreviations: CUNY, City University of New York; HMS, Harvard Medical School; HSDM, Harvard School of Dental Medicine. Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
4 years of HSDM, 1 year of HMS, 3 years of OMS, and 1 additional year of general surgery for a total cost of $8150, debt of $1500, and starting salary of $30,000. The debt to income ratio was 1/20 or 5%. For the same education and training from 2000 to 2014: 4 years of college, 4 years of HSDM, 2 years of HMS, 4 years of OMS, and 1 year of general surgery for a total cost of $284,000, theoretical debt of $200,000, and theoretical starting salary of $200,000. Thus, the debt to income ratio would be 1/1 or 100%. At a $300,000 annual salary and $200,000 of debt, the ratio would be 66%. If the debt were $300,000 and the starting salary $200,000, the debt to income ratio would be 133%. The challenge is how to reconcile the increasing cost pressures of education, duration of training, earning potential, and future income of young surgeons with the major push to contain the cost of health care in the United States. In 2017, spending for physician and clinical services increased 4.2% to 694.3 billion, representing 20% of total expenditures.28 Future physician and clinical services have been projected to increase at an average annual rate of 5.4% from 2018 to 2027.29 If health care costs are increasing faster than physician/ surgeon income, the bubble could burst when potential students realize they will not be able to recoup their investment. Applicants will decrease, and the best and brightest will explore options other than careers in medicine, dentistry, or surgery. The other challenge is the change in the structure and curriculum of today’s medical schools. No
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arbitrary division is present between the 2 years of basic science followed by 2 years of clinical science. That organization was ideal for OMS students transferring to the third year of medical school. At this time, that model has begun to collapse, and we must develop new models to prevent making OMS training prohibitively long and expensive. The solutions will not be easy, but we must begin thinking about these problems. We believe the following goals for the specialty should be considered: Aim to keep programs to 6 years in duration and no more Aim to develop new ideas on how to integrate or connect dental school curricula to the new format of medical school education; an integrated approach will allow for better transfer of OMS residents into medical school with advanced standing Aim to develop new ideas on how to integrate OMS residents into the new sequence of courses demanded by new medical school curricula Do not compromise the specific OMS training time Attempt to maintain continuity of OMS training Address 2- and 3-year ACGME accredited, post-MD training requirements of state medical licensing boards by considering OMS accreditation by the ACGME or joint ACGME and CODA With ACS accepting ABOMS certification as equivalent to ACGME-accredited board certification, state boards could be lobbied to accept ABOMS certification and allow for CODA-accredited training time to count toward medical licensure requirements In conclusion, the future of OMS as a specialty is bright. We are now entering a ‘‘golden age’’ for the specialty based on the scope of practice, new technology, innovation, and research. Although no easy solutions are available to the challenges we have outlined, we are optimistic about the future. We have a strong group of trainees and young surgeons who will solve these problems and move OMS forward with great success. Acknowledgments No significant written record is available on the evolution of oral and maxillofacial surgery training and, in particular, the development of dual-degree programs. Therefore, the information we obtained by conversations with, and e-mails and letters from, the following surgeons was invaluable in the completion of the present study: Drs Samuel McKenna, Peter Waite, Thomas Dodson, Morton Goldberg, James Hupp, Bruce Donoff, Ghali Ghali, Charles McCallum, Roger Meyer, Robert Mraule, Valmont Desa, Joseph Piecuch, and John Helfrick and Ms Kitty Robinson. We thank them for their help and encouragement.
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References 1. Kaban LB: History of Dual Degree Training in the United States: ‘ Back to the Future.’’ Presented at the ROAAOMS Symposium at the 100th Meeting of the American Association of Oral and Maxillofacial Surgeons, October 2018, Chicago, IL. Available at: https://www.aaoms.org/meetings-exhibitions/ annual-meeting/100th-annual-meeting. Accessed October 13, 2018 2. Guralnick WC, Kaban LB: Keeping ether ‘ en-vogue’’: The role of Nathan Cooley Keep in the history of ether anesthesia. J Oral Maxillofac Surg 69:1892, 2011 3. Bigelow HJ: Insensibility during surgical operations produced by inhalation. Boston Med Surg J 35:309, 1846 4. Keep NC: Inhalation of ethereal vapor for mitigating human suffering in surgical operations and acute diseases. Boston Med Surg J 36:199, 1847 5. Lister J: On a new method of treating compound fracture, abscess, &c., with observations on the conditions of suppuration. Lancet I i:336, 1867 6. Lister J: Further evidence regarding the effects of the antiseptic system of treatment upon the salubrity of a surgical hospital. Lancet II ii:287, 1870 7. Fleming A: On the antibacterial action of cultures of a penicillium, with special reference to their use in the isolation of B. influenzae. Br J Exp Pathol 10:226, 1929 8. Murray JE, Merrill JP, Harrison JH: Renal homotransplantation in identical twins. Surg Forum 6:432, 1956 9. Merrill JP, Murray JE, Harrison JH, Guild WR: Successful homotransplantations of the human kidney between identical twins. JAMA 160:277, 1956 10. Moore FD: Metabolic Care of the Surgical Patient. Philadelphia, WB Saunders, 1959 11. Murray JE: Presidential Address: Boston Surgical Society, Boston, MA, 1979. Available at: https://www.bostonsurgicalsociety. com/. Accessed June 4, 2018 12. Warren JC: Operative note for patient Gilbert Abbott, 21-yearold printer. Massachusetts General Hospital Archives, October 16, 1846 13. Van Dam LD: Charles Frederick Heywood, house surgeon at the ether demonstration. Anesthesiology 82:772, 1995 14. Guralnick WC: The combined oral surgery-MD program: The Harvard plan. J Oral Surg 31:271, 1973
11 15. Alling CC, Hayward JR (co-editors): The building of a specialty: Oral and maxillofacial surgery in the United States, 1918-1998. J Oral Maxillofac Surg 47(Suppl):168, 1998 16. Alling CC, Hayward JR (co-editors): The building of a specialty: Oral and maxillofacial surgery in the United States, 1918-1998. J Oral Maxillofac Surg 47(Suppl):120, 1998 17. Hayward JR: Strains on a bridging specialty. J Oral Surg 29:837, 1971 18. Alling CC, Hayward JR (co-editors): The building of a specialty: Oral and maxillofacial surgery in the United States, 1918-1998. J Oral Maxillofac Surg 47(Suppl):287, 1998 19. Waite PD: The University of Alabama oral and maxillofacial surgery program. J Oral Maxillofac Surg 65(3), 2007 20. Personal communication: Samuel McKenna, DMD, MD, Chair, Department of OMS Vanderbilt University, Nashville TN, 2018 21. Debes RR, Butler DP: Looking Back: A History of the Oral and Maxillary Surgery Program University of Texas-Houston 19491999. Houston, TX, University of Texas-Houston Dental Branch Department, 1999, pp 25–27 22. Dodson TB, Guralnick WC, Donoff RB, Kaban LB: Massachusetts General Hospital/Harvard Medical School MD oral and maxillofacial surgery program: A 30-year review. J Oral Maxillofac Surg 62:62, 2004 23. Personal communication: Valmont Desa, DMD, MD, Division Chief and Program Director, OMS University of Nebraska, Lincoln, NE, 2018 24. Personal communication: Joseph Piecuch, DMD, MD, Simsbury, CT, 2018 25. Personal communication: Peter D. Waite, DDS, MD, Chair, Department of OMS University of Alabama, Birmingham, AB, 2018 26. American Association of Oral and Maxillofacial Surgeons Data, 2014-2018. Available at: aaoms.org. Accessed June 4, 2018 27. Asch DA, Nicholson S, Vujicic M: Are we in a medical education bubble market? N Engl J Med 369:1973, 2013 28. Centers for Medicare and Medicaid Services. CMS Office of the Actuary Releases 2017 National Health Expenditures. Available at: https://www.cms.gov/newsroom/press-releases/cms-officeactuary-releases-2017-national-health-expenditures 29. Centers for Medicare and Medicaid Services. CMS Office of the Actuary Releases 2018-2027 Projections of National Health Expenditures. Available at: https://www.cms.gov/newsroom/ press-releases/cms-office-actuary-releases-2018-2027-projections-national-health-expenditures
Dual-degree Oral and Maxillofacial Surgery Training in the United States: ‘‘Back to the Future’’ Leonard B. Kaban, DMD, MD,* and David H. Perrott, DDS, MD, MBAy In the present report, we trace the history of education and training of oral and maxillofacial surgeons as it has evolved from the mid-19th century to the present. We consider the effects of the discovery of ether anesthesia, the separation of medicine and dentistry, and other milestones such as antisepsis (Lister), antibiotics (Fleming) and surgical progress during wartime. The main emphasis, however, is on the background, development, and implementation of current dual-degree oral and maxillofacial surgery training programs, the first 5 programs, the pioneer advocates for this training, and progress and challenges for the future. Ó 2019 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-11, 2019 At the 100th anniversary of the American Association of Oral and Maxillofacial Surgeons (AAOMS), looking back on the history of oral and maxillofacial surgery (OMS) training and the evolution of ‘‘dual-degree’’ programs are important exercises that broaden our perspective on education and the development of the specialty. We demonstrate that examining the rise of American doctor of medicine (MD) programs in the context of the increasing scope of OMS, since the early 19th century, is an exercise in looking ‘‘back to the future.’’1 The modern era of surgery began in the 1800s with the discovery of ether anesthesia. It is there that we begin this story because of the connection between these events and dentistry and the evolution of OMS training. The discovery of ether anesthesia has been called the most significant medical breakthrough in the history of humankind. The state of surgery in the 19th century was primitive. Operations were infrequent and had to be performed with lightning speed. Mortality rates were
exceedingly high. The variables of pain, hemorrhage, shock, and infection were the major obstacles to successful outcomes and patient survival.
Surgical Training in the Early 19th Century It is important to understand surgical training in the early 1800s to understand where we are today. The most common dental surgical operation was tooth extraction. Dental and physician surgeons also performed debridement of wounds, excision of tumors, drainage of neck space infections, and treatment of pain by nerve transection or neurectomy. Physicians and non-healthcare providers (eg, barbers, blacksmiths who apprenticed to established surgeons [MDs] or dental surgeons) performed these procedures. There were no dental schools and the existing medical schools had no strict entry requirements. There were no regulations and no clinical studies or
*Walter C. Guralnick Distinguished Professor and Chief Emeritus,
Address correspondence and reprint requests to Dr Kaban:
Department of Oral and Maxillofacial Surgery, Massachusetts
Department of Department of Oral and Maxillofacial Surgery, Massa-
General Hospital, Harvard School of Dental Medicine, Boston, MA.
chusetts General Hospital, Boston, MA 02114; e-mail: kaban.
ySacramento, CA.
[email protected]
Presented, in part, by Dr Kaban at the Resident Organization Sym-
Received August 7 2019
posium, 100th Annual Meeting of the American Association of Oral and Maxillofacial Surgeons, Chicago, IL, October 13, 2018.
Accepted August 11 2019 Ó 2019 American Association of Oral and Maxillofacial Surgeons
The present study was supported by the Department of Oral and
0278-2391/19/31051-1
Maxillofacial Surgery, Massachusetts General Hospital Education and
https://doi.org/10.1016/j.joms.2019.08.026
Research Fund. Conflict of Interest Disclosures: None of the authors have any relevant financial relationship(s) with a commercial interest.
1
2 evidenced-based medicine principles as we know them today. The obstacle of pain and the need for surgeons to perform operations with great speed ended with the landmark demonstration of ether at Massachusetts General Hospital (MGH) in October 1846.2-4 The solutions to the other major obstacles in the evolution of modern surgery came later: 1) antisepsis described by Joseph Lister in 18675,6; 2) antibiotics and the discovery of penicillin by Alexander Fleming in 19287; 3) the first human organ transplant in 19558,9; and 4) advances in fluid and electrolyte management.10 It required this entire series of milestones and advances, among others, to allow surgery to progress through its phases of development, including excision, reconstruction, transplantation, induction, and regeneration, to its current state.11 However, the discovery of anesthesia was especially relevant to surgical training, because it allowed surgeons to perform complex operations with careful attention to precise execution, without the patient writhing in pain. It was this progress that necessitated expanded and more sophisticated education for the modern surgeon. Furthermore, the role of dental surgeons was critical in this story of ether anesthesia and its first demonstration, which, ultimately, had a major effect on the training of dental and oral and maxillofacial surgeons.
Discovery and Dissemination of Ether Anesthesia William Morton, a Boston dentist credited with the first public demonstration and documentation of ether anesthesia on October 16, 1846, is shown in Figure 1. The Robert C. Hinkley painting (1893) of the first demonstration of ether is presented in Figure 2. The painting illustrates the patient on the table, observers in the gallery, Morton with the ether flask, John Collins Warren, the surgeon, and Henry J. Bigelow, the assistant. Warren ligated the feeding vessels and ‘‘undersewed a vascular malformation’’ of the submandibular region.2,12 The patient did not stir or react to the operation. After the procedure, Warren turned to the audience and uttered his now famous words: ‘‘This is no humbug, gentlemen!’’ Despite Warren’s words, some were still skeptical because ligation and oversewing of the vascular malformation and subsequent removal of a neck lipoma were superficial operations. It was not until the third operation, a below-the-knee amputation a few days later by Dr Charles Heywood, that ether was accepted as a viable technique for the relief of pain during surgical procedures.2,12,13
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FIGURE 1. A photograph of William Morton, the Boston dentist credited with the first demonstration of ether anesthesia—to be reported publicly. Crawford Long, a general surgeon in Atlanta, might have preceded Morton. Long was apparently using ether anesthesia for general surgery procedures but never reported it and, therefore, did not receive credit for the discovery. The major teaching hospital for Emory University Medical School in Atlanta is named after Crawford Long. (Reprinted from the MGH Archives). Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
Once the concept of ether anesthesia was accepted, the technique and knowledge had to be disseminated. However, Morton was not a highly respected practitioner and was generally regarded as unethical and unscrupulous. Nathan Cooley Keep, however, was a renowned and gifted dental practitioner and the most highly regarded dental surgeon of the time in Boston (Fig 3). He came to be the one who popularized ether anesthesia. His role is not well known and has rarely been recorded.2 Keep apprenticed to John Randall, MD, a Harvard Medical School (HMS) graduate, to learn dentistry. At the same time, he had enrolled in HMS and received his MD degree in 1827. As noted, the most common method of training of surgeons and dental surgeons was for physicians with an MD degree, or blacksmiths or barbers, to apprentice with a local practitioner. Keep had many tuition-paying apprentices who learned his techniques. Among those were William Morton and Horace Wells (of nitrous oxide fame). All 3 of these men recognized the importance and
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3
FIGURE 2. The Robert C. Hinkley painting (oil on canvas, 1893) of the first demonstration of ether illustrates the patient on the table, observers in the gallery, Morton with the ether flask, and Warren, the surgeon. He ‘‘undersewed a vascular malformation’’ of the submandibular region with the patient under ether anesthesia. The patient did not react to the operation. John Collins Warren then turned to the audience after the procedure and uttered his now famous words: ‘‘This is no humbug, gentlemen!.’’ (Reprinted from the Francis A. Countway Library of Medicine, Harvard Medical School). Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
significance of the discovery of a technique to alleviate the pain and suffering of dental and surgical procedures.2 After the demonstration of ether, Keep hired Morton, and they advertised their practice of ‘‘painless dentistry’’ in the local newspapers. However, Keep soon came to realize that Morton was unethical and fired him because of his attempts to patent ether anesthesia and collect royalties for its use. Subsequently, Morton went downhill and eventually died a poor, indigent alcoholic. However, Keep continued to provide anesthesia for local general surgeons and for dental extractions in his own office. His anesthesia services became very much in demand. He also became the first to administer ether for obstetric anesthesia. The pregnant patient was Fanny Longfellow, wife of Henry Wadsworth Longfellow, the famous poet. The infant girl was delivered at their home in Cambridge, Massachusetts.2 In April 1847, just 6 months after the first demonstration of ether, Keep reported a case series in the Boston Medical and Surgical Journal (precursor of the New England Journal of Medicine) of 200 patients who had undergone anesthesia for a variety of general, oral, and obstetric surgical procedures.4 This extensive series illustrated how much in demand Keep’s services had become after the initial demonstration of ether. Parenthetically, it also illustrated the
FIGURE 3. Print of Nathan Cooley Keep, 1867. (Reproduced from Koch CRE: History of Dental Surgery, Contributions by Various Authors. Vol. 2. Chicago: National Art Publishing Company; 1909, p 114; and Guralnick WC, Kaban LB: Keeping ether ‘‘en-vogue’’: The role of Nathan Cooley Keep in the history of ether anesthesia. J Oral Maxillofac Surg 69:1892, 2011). Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
short turnover time for the report of a clinical outcome study in the mid-1800s.
Formation of a University-affiliated and Degree-granting Dental School The other half of this history was the formation of a university-affiliated and degree-granting dental school, which separated dentistry and medicine and, therefore, dental surgery from surgery in general. This dichotomy has prevailed to this day, although it is undergoing some revision in the current healthcare environment. Keep was a member of the staff of the MGH. He was a founding member and became the first president of the Massachusetts Dental Society. He championed the cause of formal dental education and the need for universities and colleges to train dentists. He stated: ‘‘My own predilection would favor a thorough and united dental and medical education. I should hope in such a case that the degree of MD would be the lawful appendage to the names of those young
4 men [note, young men only] who enter our specialty. If this, however, is not attainable, it may not be entirely out of place to inquire whether Harvard University might not appoint professors of dentistry and confer upon proper candidates the degree of doctor of dental surgery’’ (DDS). However, the HMS and Harvard University did not agree to award the MD degree to students of dentistry. Instead, Harvard opened the first medical school and university-affiliated dental school in the United States in 1867, with Keep as the first dean.2 The University conferred the doctor of dental medicine (DMD) degree. Baltimore Dental College, a free-standing, at that time non–university-affiliated dental school, was established earlier. These 2 schools provided the opportunity for a practitioner with a DDS (Baltimore) or DMD (Harvard) degree to practice dental surgery. Although Harvard rejected Keep’s first choice, the University allowed him to fulfill his second option. It is ‘‘back to the future’’ and further ironic that in 1971, 104 years later that the same medical school and university approved a program to finally award oral and maxillofacial surgeons an MD degree as their ‘‘lawful appendage.’’ Keep finally got his first choice.
Milestones for the Specialty of OMS The evolution of the specialty occurred over time because OMSs and our organizations always appreciated the need to improve education, training, and standards of practice.14 The following are some of the milestones that set the stage for the evolution of our training, the establishment of dual-degree programs, and the recent acceptance of American Board of Oral and Maxillofacial Surgery (ABOMS) certification as a legitimate credential for fellowship in the American College of Surgeons. As noted, in the 19th century, exodontists were physicians, dentists, barbers, and other nonprofessionals who did extractions. As they expanded the field in the 20th century, they changed the specialty and organizational names to reflect these changes in scope, including the American Society of Exodontists, American Society of Exodontists and Oral Surgeons, American Society of Oral Surgeons, and American Association of Oral and Maxillofacial Surgeons. Wartime experiences helped advance and expand OMS’s scope and recognition, especially because of OMSs’ work in trauma. During World War I (WWI), Varaztad Kazanjian, ‘‘miracle man of the Western Front,’’ made significant advances in the management of maxillofacial fractures and other traumatic defects. Further advances in the management of maxillofacial injuries occurred during World War II (WWII), the Korean conflict, and the Vietnam War and continued through the conflicts in Afghanistan and Iraq. The
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technical and scientific advances in trauma management and the treatment of specific craniomaxillofacial fractures and soft tissue injuries expanded the scope of OMS as a specialty and resulted in the need for broader residency training. The evolving treatment modalities and expanding scope stimulated an interest in the development of ‘‘dual-degree’’ training programs and fellowship training in head and neck cancer, cleft/craniofacial and orthognathic surgery, pediatric maxillofacial surgery, cosmetic surgery, reconstructive surgery, and temporomandibular joint surgery. The ABOMS improved the sophistication and standardization of the certifying examination, and the AAOMS developed the OMS in-service training examination (first administered in 1977) to evaluate residents as they advanced through their levels of training.15 Finally, all these advances were accompanied by an increase in the duration and scope of OMS training and the birth of the modern MD OMS training program.
Evolution of OMS Training Programs Until the 1930s, 1-year internships, apprenticeships, and limiting practice to OMS were the norms for training. Most formal programs included a 1-year OMS internship and a second year spent taking didactic courses in anatomy, physiology, and so forth at a dental school. This was followed by a second clinical year, considered the residency, often at a different institution.16 In 1967, the American Society of Oral Surgeons (ASOS) Committee on Graduate Training, as a result of a number of educational workshops, recommended a revision of the Essentials of an Adequate Advanced Training Program in Oral Surgery. The new Essentials mandated a 3-year integrated program, which included a 1-year OMS internship, followed by 1 year of hospital rotations in medicine (3 months), surgery (3 months), anesthesia (3 months), and an elective (3 months). The third year was the residency year. All programs had to provide a progression of complexity and responsibility in training at the home institution. The Commission on Dental Accreditation (CODA) approved this change.16 In 1985, the AAOMS House of Delegates approved a resolution to increase OMS training from 3 to 4 years. The resolution mandated that all programs follow a 4-year integrated curriculum consisting of a 1-year OMS internship, followed by 1 year of off-service rotations (3 months of medicine, 3 months of surgery, 4 months of anesthesia, and 2 months of an elective) and then 24 months of OMS at the junior and senior resident level. These changes were approved by the CODA in December 1986.16 Over the years, the
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anesthesia requirement has continued to increase, and a requirement for scholarly activity was instituted.
Development of the Modern Dual-degree OMS Program: Background In the late 1960s, Walter Guralnick (Fig 4), chief of oral surgery at MGH and the Harvard School of Dental Medicine (HSDM) and chair of the American Society of Oral Surgeons Committee on Graduate Training (later to become the Committee on Residency Education and Training), concluded that dual-degree training would be important for oral and maxillofacial surgeons. His opinion on this subject had evolved, because, as late as 1967, he was not in favor of dual-degree training. To his great credit, I (L.B.K.) believe an emergency in the operating room that he did not feel comfortable managing and that one of the general surgeons had to help control changed his perspective on the training of OMS residents.
FIGURE 4. Photograph of Walter C. Guralnick, circa 2013 (photograph MGH Archives). Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
5 Guralnick14 described, in a study reported in the Journal of Oral and Maxillofacial Surgery in 1973, the rationale for the MGH/Harvard MD OMS program proposed and approved at MGH and Harvard in 1970 and implemented in full in 1971. He concluded that the increasingly complex scope of OMS as a specialty required a major change in training.14 He made the following points: 1) ‘‘. there is an educational deficit in OMS training programs consisting of insufficient general medical and surgical background’’; 2) this deficiency would best be corrected by ‘‘obtaining a medical degree and general surgery training, in addition to the OMS experience’’; 3) ‘‘.this is consistent with the direction of our specialty and our standards of training’’; and 4) he recognized that: ‘‘A major curricular change cannot be made without considerable trauma to the group affected by it.’’ He observed that ever since the days of the American Society of Exodontists and Oral Surgeons, its evolution to the ASOS and then AAOMS and the birth of the ABOMS, ‘‘there has been a continuous and successful movement to improve OMS training, standards and practice.’’ James Hayward,17 at the time editor-in-chief of the Journal of Oral Surgery and the chair of oral surgery at University of Michigan, wrote in regard to the implementation of dual-degree programs: ‘‘.we fully appreciate that our particular goals in education require the teamwork of agencies in dentistry, medicine, and hospitals.’’14,17 During my (L.B.K.) many discussions with Guralnick about the ‘‘dual-degree’’ program, during our 50-year relationship, he always maintained that the MD degree and at least 1 year of legitimate general surgery training would lead to a more confident and competent surgeon, better patient care, and a better education for our residents. His forward thinking was also evidenced in that he was one of a few OMS chiefs to appreciate the importance of the ‘‘full-time’’ faculty model. In the 1960s, most OMS programs had predominantly part-time faculty whose primary responsibilities were in their private practices. Guralnick was confident that dual-degree training and the full-time faculty model would significantly improve the status of OMS as a specialty in the hospital and university and would allow us to eventually be integrated into the mainstream of American surgery. Up until 2016, fellowship in the American College of Surgeons was limited to ABOMS certified dualdegree OMSs who had gone through a complex double-tiered admissions process. Edward Hinds was the first OMS to become a fellow in the American College of Surgeons (ACS). However, he was board certified in general surgery. The first non–general surgeon OMS admitted to fellowship was Donald Leake in 1974 and, thereafter, Leonard Kaban in 1980. In
6 1990, the next 3 OMSs admitted were James Bertz, R. Bruce Donoff, and Harry Schwartz. As many as 45 to 50 dual-degree OMSs became fellows over the years through this process. In 2016, the ACS, working with Ghali Ghali and a special committee of the AAOMS, simplified the admission process for dualdegree OMSs. Soon thereafter, a pathway for singledegree OMSs to attain fellowship was established. The number of fellows dramatically increased, and an OMS section was established. OMSs joined the mainstream of American surgery just as Guralnick had predicted.
Individual Surgeons Who Sought an MD Degree and General Surgery Training After WWII In the 1940s and through the 1970s, some pioneer OMSs had independently enrolled in medical school and obtained an MD degree to enhance their training. No specific records are available to identify these OMSs. However, those we were able to document are listed in Table 1. Marsh Robinson received his dental degree in 1942 and his medical degree in 1946, both from the University of Southern California (USC). He did an internship at Los Angeles County Hospital and then apprenticed to Arthur Smith, an OMS, for 5 years. In 1954, he became chair of OMS at the USC, overseeing a 3-year postgraduate program. To the best of our knowledge, no effort was made to develop an MD OMS program at the USC during this time.18 At the University of Alabama (UAB), the first full-time chair of the OMS department was Joseph Peter Lazansky. He was a European-trained surgeon with both DDS and MD degrees from Czechoslovakia. He remained chair until 1958. Charles McCallum received his DMD degree from Tufts University and completed his OMS residency at the UAB in 1954. He then matriculated at the UAB medical school for his MD degree and had a subsequent 1 year of general surgery training. In 1958, he was appointed full-time chair of OMS at the UAB. However, no attempt was made to start an integrated dual-degree program at the UAB at that time.19 H. David Hall succeeded McCallum at the UAB in 1965 and then left in 1968 to become chair of OMS at Vanderbilt University. At Vanderbilt, according to his wife Kay, he was influenced by the ear, nose, and throat (ENT) and plastic surgeons and decided to develop an MD OMS residency program.20 He had some difficulty obtaining approval for an integrated dual-degree program at Vanderbilt. However, he was able to get Jonathan Jacobs, a HSDM graduate, admitted to Vanderbilt Medical School in 1970. Jacobs obtained his MD degree and 1 year of general surgery residency and then completed the Vanderbilt OMS program in 1975. This was a 5-year program, similar
HISTORY OF DUAL-DEGREE OMS TRAINING
Table 1. ORAL SURGEONS WHO ATTENDED MEDICAL SCHOOL ON THEIR OWN FROM 1930 TO 1975
Surgeon William Harrigan
Edward Hinds*
Marsh Robinson
Charles McCallum
Morton Goldberg
Donald Leake* Victor Matukasy
Norman Trieger H. David Hally
James Bird James Bertz* Roger Meyer*,z
Description DDS, University of Pennsylvania, 1938; MD, New York University, 1942; Chief, Bellevue Hospital, 1950 DDS, 1940; MD, 1945 Baylor University; Chairman, University of Texas Houston, 1948 DDS, 1942; MD, 1946, University of Southern California; Chairman, University Southern California, 1954 DMD, Tufts, 1952; MD, University of Alabama, 1957; Chairman, University of Alabama, 1958 DMD, Harvard, 1958; MD, Albany Medical College, 1961; Chief, Hartford Hospital, 1971 DMD, Harvard 1962; MD, Stanford University, 1969; Chief, HarborUCLA Medical Center, 1970 DMD, Loyola University, New Orleans; MD, University of Colorado, 1968; Department Chair, University of Alabama, 1985 DMD, Harvard, 1954; MD, Albert Einstein, 1974; Chief, Montefiore Medical Center, 1973 DMD, Harvard, 1957; MD, University of Alabama, 1977; Chairman, University of Alabama, 1958; Chairman, Vanderbilt University, 1968 DDS, University of Nebraska, 1969; MD, University of Nebraska, 1973 DDS, Ohio State University, 1961; MD, Baylor University, 1974 DDS, University of Washington, 1963; MD, Creighton University, 1975; Chair, Emory University, 1979
Abbreviations: DDS, doctor of dental surgery; DMD, doctor of dental medicine; MD, doctor of medicine. * Fellow, American College of Surgeons. y Started dual-degree program: Vanderbilt (Hall), Alabama (Matukas). z Received approval for dual-degree program at Emory University. Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
to that at Harvard University. Several others of Hall’s residents were able to obtain an MD degree and general surgery training at Vanderbilt after completing the standard 36-month OMS program. Hall ultimately
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established the formal integrated MD OMS program at Vanderbilt in 1974, and Joseph McMullen was the first resident. Vanderbilt maintained 2 training tracks: the MD OMS program and a single-degree 4-year program. Hall took a leave of absence from 1975 to 1977 and obtained his MD degree at the UAB. During this time, Jonathon Jacobs was the chair of OMS at Vanderbilt University.20 Most of the ‘ dual-degree’’ OMSs from the 1940s through the 1970s went into academic practice, although some had private practices on the side, and became program directors and department chairs (Table 1). Of this group, Hall at Vanderbilt was the first to implement an MD OMS program. Victor Matukas, who had received his MD degree from University of Colorado was appointed OMS program director at the UAB in 1975 and department chair in 1981. Under his leadership, the dual-degree program at UAB received formal approval and accepted its first residents in 1977. Roger Meyer, while chair at Emory (1979 to 1986), proposed and, ultimately, obtained approval from the medical school for an MD OMS program, although it was not implemented during his tenure. Others had attended medical school for their training but did not pursue the development of a dual-degree program at their institutions and might not have appreciated the significance of this for the specialty in general and for the future of OMS. Edward Hinds, chair at the University of Texas, Houston, beginning in 1948, is one example. He received his DDS degree from Baylor in 1940 and his MD degree in 1945 from Baylor College of Medicine and stated: ‘‘The properly trained dentist has an important role to play in the management of disease and injuries of the oral and maxillofacial region. We will establish a program that will provide the opportunity for interested dentists to obtain the necessary training to assume that role.’’ He made no mention of an MD degree nor commented on its desirability for an OMS, and starting an MD OMS training program was not attempted.21 William Harrigan, Donald Leake, Morton Goldberg, and Norman Treiger (Table 1) were others who had obtained medical degrees and were department chairs or hospital chiefs who did not seek to develop a dualdegree program for their trainees. Goldberg desired to start an MD program but was not able to get approval. However, he was able to obtain a full year of general surgery residency for his trainees in a single-degree program at Hartford Hospital in Connecticut. Ultimately, James Hupp established a combined dual-degree program at the University of Connecticut. Objections to dual-degree training in the 1960s and 1970s included that 1) specialized OMS training might be impaired by shortening its length to devote time to the MD degree and general surgery residency; 2) the
expense and time involved would be overwhelming and discourage potential applicants, and 3) the OMS field might experience a potential of loss of residents to other specialties.
Early Dual-degree Programs: The First Five HARVARD PLAN
The Harvard plan was conceived in the late 1960s and approved in 1970 and enrolled its first resident into the full program as written in 1971.14,22 To achieve approval for the program, Guralnick, not only had the support of the deans of the dental and medical schools, but also the strong support of the then surgeon-in-chief at MGH, W. Gerald Austen. His commitment of preliminary general surgery positions for OMS trainees was critical. To satisfy the objections to dual-degree training, the Harvard plan initially included only HSDM students because they had spent their first 2 years completing the HMS basic science curriculum and could be completely integrated as medical students. Therefore, they were only required to spend 1 additional year in medical school, completing the principal clinical year, to receive the MD degree. They received 1 year of elective credit for their experience as an OMS intern, which included 3 months of anesthesia training. The program was 5 years in duration. In 1985, HMS approved the acceptance of non-HSDM students into the program. The HSDM students continued with the 5-year program and the non-HSDM students were accepted into a 6-year program with 2 years of medical school. In 1995, under the leadership of Kaban and program director David Perrott, the program was modified such that all residents completed 2 years of medical school for a 6-year residency, regardless of where they had attended dental school. The HSDM students completed years 3 and 4 and the nonHSDM students completed years 2 and 3 of the HMS curriculum. In 1999, with Thomas Dodson as the program director, the curriculum was revised and unified. All residents, both HSDM and non-HSDM graduates, were required to complete years 3 and 4 of the HMS curriculum to receive the MD degree (Table 2). On completion of the MGH/Harvard program, the resident received an OMS certificate, MD degree, and credit for 2 years of general surgery and 32 months of OMS. The key points are that postgraduate year (PGY) 1 is 12 months of OMS and 20 of the last 24 months are devoted to OMS. This has been a template for many dual-degree programs. However, other programs have not provided the same continuity of OMS experience because the time is disrupted by the medical school rotations. A summary of the current MGH/Harvard MD program is presented in Table 2.
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Table 2. MASSACHUSETTS GENERAL HOSPITAL, HARVARD MD ORAL AND MAXILLOFACIAL SURGERY PROGRAM*
Current form: PGY 1, OMS Intern, 12 months PGY 2, Harvard Medical School third year PGY 3, Harvard Medical School fourth year Anesthesia, 4 months PGY 4, MGH general surgery PGY 2 PGY 5, MGH general surgery PGY 3, 4 months (1 month SICU) OMS junior, 8 months PGY 6, OMS chief resident, 4 months OMS senior resident, 4 months Children’s Hospital senior, 4 months First year and 20 months of final 24 months, uninterrupted OMS Credit for 2 years of general surgery Abbreviations: MD, doctor of medicine; MGH, Massachusetts General Hospital; OMS, oral and maxillofacial surgery; PGY, postgraduate year; SICU, surgical intensive care unit. * Started in 1971, modified in 1986 and 1999, 6 years: classic program as written; some changes will occur in the enrollment years in medical school (eg, second and third rather than third and fourth) based on a new Harvard Medical School curriculum; however, the basic 6-year template will remain the same. Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
The fear of the loss of residents during the training proved not to be a significant issue. Only 4 of the first 55 resident (7.1%) and 1 of the second 55 residents (1.8%) failed to complete the program. This compares favorably to any surgical program of 6 years’ duration for which the loss of some residents can occur during the long training period.22 The MGH program was arguably the first contemporary dual-degree program accepted by its medical school, dental school, and university. As noted, some irony exists in the fact that the university first responsible for the split between medicine and dentistry finally let the fields come together in the OMS program. After the program’s approval in 1970, Bruce Donoff, Steven Roser, Edward Seldin, and Leonard Kaban were allowed to matriculate at HMS on completion of their OMS training at MGH. They then completed an additional year of general surgery at MGH. John P. W. Kelly was the first resident to matriculate in the program as written in 1971. He subsequently became OMS program director at MGH (1983 to 1993).14,22 UNIVERSITY OF NEBRASKA
Contemporaneously with the development of the MGH dual-degree program, Dr Chester Singer, chair of OMS at the University of Nebraska Medical Center
(UNMC), sought to develop an MD OMS program. With support from the chair of surgery, Merle Musselman, and the medical school, the dual-degree program at the UNMC was approved in 1970, and the first residents were enrolled in 1971: Richard Temporo and Gregory Sears. Leon Davis and Stuart Heydt were allowed to matriculate at the University of Nebraska Medical School after they had completed their OMS training.23 Since 1971, all residents have trained in the fully integrated dual-degree program. The next programs to begin were at the University of Washington in Seattle (first resident, Joseph Piecuch, 1972), Vanderbilt University (first resident, McMullen, 1974), University of Alabama (first residents, John Braun, Alan Harvey, 1977).19,20,23-25 The numbers of dual-degree training programs increased from 2 in 1971 (MGH/Harvard and University of Nebraska) to 5 (MGH/Harvard, University of Nebraska, Vanderbilt, UAB, and, for a short time, the University of Washington) in 1981. The University of Washington program was closed in 1982 but was restarted under the leadership of professor and chair Dodson in 2015. The current number of dual-degree programs is 46 of a total of 101 accredited programs (45%), according to the AAOMS data.26 There are a total of 55 single-degree programs and 23 programs that offer options of an MD degree or OMS certificate only.26 Of the 1167 enrolled OMS residents in 2018, 487 (42%) were in MD programs and 680 (58%) in single-degree programs. In 2018, 237 residents graduated, and of those, 91 (37%) had been in MD and 156 (63%) in certificate programs. The 5-year trend (2014 to 2018) of AAOMS data for graduating residents revealed that approximately two thirds of residents are in singledegree and one third in dual-degree programs.26
Discussion Multiple factors have contributed to the evolution of the scope and growth of the modern specialty of OMS. These have included experience with the management of severe traumatic injuries, beginning in WWI and extending through WWII and the Korean, Vietnam, Afghan, and Iraq wars, improvements in education and teaching, improvements in measuring the outcomes of training, the full-time faculty model in tertiary care medical centers, and dual-degree training programs. The dual-degree concept has truly changed the ‘‘face’’ of our specialty. It has contributed to the development of advanced training fellowships in head and neck and reconstructive surgery, cleft and craniofacial surgery, pediatric maxillofacial surgery, cosmetic surgery, and temporomandibular joint surgery. As predicted by Guralnick in his early writings, the MD degree, general surgery training, the full-time faculty
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model, and a broader scope have resulted in broader acceptance of OMS as a surgical specialty by universities, medical schools, and hospitals and have equalized our position in the overall discipline of surgery. It is common now for ENT, plastic surgery, and general surgery residents to rotate on OMS services during their early years. This allows them to gain familiarity, knowledge, and respect for our field. The full-time faculty model has integrated OMS into the medical centers where we function. Many OMS faculty have occupied leadership positions in medical center faculty group practices. All this has led to the acceptance of ABOMS certification as a credential for fellowship eligibility in the ACS. Four OMSs have been chairs of the Joint Commission on Accreditation of Healthcare Organizations (Charles McCallum, John Helfrick, David Whiston, and David Perrott). CHALLENGES FOR DUAL-DEGREE TRAINING
With all the advances we have witnessed, persistent and new challenges exist for dual-degree training. First, fundamental changes have occurred in medical school curricula, eliminating the 2-year basic science plus 2-year clinical experience model and substituting a 4-year integrated concept. This could potentially add 1 to 2 additional years to the time OMS residents are required to spend in medical school. Second, these curriculum changes have also made it more difficult to transfer OMS residents into the third year of medical school. Some medical schools have completely suspended the acceptance of transfer students because of the difficulty of integrating them into the new style curricula. Third, the trend of state licensing boards to require 2 years or more of American Council for Graduate Medical Education (ACGME) approved training for a full medical license is important: At least 3 states require 3 years after MD training and 19 require at least 2 years. These factors will lead to an increase in the costs and time for OMS training and could affect our applicant pool in the future. This brings us to the concept of the cost bubble in medical education.’’27 A cost bubble is created when assets (in this case college, medical, and dental education and residency training) are bought at ever increasing costs (tuition, room and board, loan repayment), which investors (students and trainees) optimistically pay because they anticipate selling their services in the future at prices high enough to repay their loans and support their desired lifestyle.27 At this time, despite requiring the payment of 2 years of medical school tuition, additional years of training and other expenses, in addition to the 8 years for college and dental school, dual-degree programs have remained strong. Also, the number of qualified
9 applicants has remained adequate. This is because sufficient optimism exists regarding the future value of this education and training. The question is: How long will this last? Asch et al27 reported the ratio of average debt of a graduating student/trainee to the average annual income in general medicine and surgery and specialties on entry into the workforce. This ratio reflects what students must borrow and, therefore, how much debt they will have accumulated after their education and training. The cost of becoming a physician is similar whether one ultimately becomes a pediatrician or an orthopedic surgeon; however, debt to income ratio is much higher for pediatricians because they are paid less than orthopedists.27 Similarly, it costs the same to become a dentist, regardless of the specialty chosen after graduation. However, the debt to income ratio will vary among dental specialists depending on the number of years of training, the cost of postgraduate tuition, and the starting salary. The burden of becoming a dual-degree OMS is greater than that of becoming a single-degree OMS owing to tuition cost of obtaining the medical degree and an additional 2 to 3 years of training. The cost of becoming a dual-degree OMS could also be greater than the cost of becoming an orthodontist, prosthodontist, periodontist, or endodontist because OMS training requires a longer duration and the starting salaries of orthodontists and endodontists are especially high. The ratio of debt to income also reflects the relationship between what schools charge for tuition and what OMSs can charge and collect from patients for services at the completion of training. We are all familiar with the high-tech stock bubble of the 1990s and the real estate bubble of 2008. Stock and housing can be sold at unrealistically high prices only to people who think they can resell the commodity at even higher prices. Colleges, medical schools, and dental schools can sustain their high tuitions only if their students are convinced they will earn a high income paid by their future patients for services. In recent years, some private liberal arts colleges have experienced reduced numbers of applicants because potential students have been considering that the cost and accumulating debt of an undergraduate liberal arts education may not make economic sense for them. This could also happen to dental schools and medical schools. For the same reasons, students might be more likely to choose public institutions of higher education over private alternatives. The cost of education for 1 of us (L.B.K.) from 1961 to 1974 compared with what it would cost (2000 to 2014) if attending the same schools is presented in Table 3. However, the data included in Table 3 do not include room and board and other expenses and, thus, underestimate the true cost: 4 years of college,
10 Table 3. COST OF ONE AUTHOR’S EDUCATION AND TRAINING: THEN AND NOW
Cost of education: 1961-1973 College: CUNY $50.00 4 years = $200 HSDM: $1200 + $1250 + $1500 + $1500 = $5450 HMS: $2500 Total: $8150 Intern salary (1969): $6000 First job: $30,000 Debt (debt/income ratio): $1500 (5%) Cost of education: 2000-2014 College: CUNY $6000 4 = $24,000 HSDM: $40,000 + $42,000 + $42,000 + $45,000 = $169,000 HMS: 42,000 + 45,000 = $87,000 Total: $284,000 Intern salary (2014): $58,000 First job: $200,000 Debt (debt/income ratio): $200,000 (100%) Abbreviations: CUNY, City University of New York; HMS, Harvard Medical School; HSDM, Harvard School of Dental Medicine. Kaban and Perrott. History of Dual-degree OMS Training. J Oral Maxillofac Surg 2019.
4 years of HSDM, 1 year of HMS, 3 years of OMS, and 1 additional year of general surgery for a total cost of $8150, debt of $1500, and starting salary of $30,000. The debt to income ratio was 1/20 or 5%. For the same education and training from 2000 to 2014: 4 years of college, 4 years of HSDM, 2 years of HMS, 4 years of OMS, and 1 year of general surgery for a total cost of $284,000, theoretical debt of $200,000, and theoretical starting salary of $200,000. Thus, the debt to income ratio would be 1/1 or 100%. At a $300,000 annual salary and $200,000 of debt, the ratio would be 66%. If the debt were $300,000 and the starting salary $200,000, the debt to income ratio would be 133%. The challenge is how to reconcile the increasing cost pressures of education, duration of training, earning potential, and future income of young surgeons with the major push to contain the cost of health care in the United States. In 2017, spending for physician and clinical services increased 4.2% to 694.3 billion, representing 20% of total expenditures.28 Future physician and clinical services have been projected to increase at an average annual rate of 5.4% from 2018 to 2027.29 If health care costs are increasing faster than physician/ surgeon income, the bubble could burst when potential students realize they will not be able to recoup their investment. Applicants will decrease, and the best and brightest will explore options other than careers in medicine, dentistry, or surgery. The other challenge is the change in the structure and curriculum of today’s medical schools. No
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arbitrary division is present between the 2 years of basic science followed by 2 years of clinical science. That organization was ideal for OMS students transferring to the third year of medical school. At this time, that model has begun to collapse, and we must develop new models to prevent making OMS training prohibitively long and expensive. The solutions will not be easy, but we must begin thinking about these problems. We believe the following goals for the specialty should be considered: Aim to keep programs to 6 years in duration and no more Aim to develop new ideas on how to integrate or connect dental school curricula to the new format of medical school education; an integrated approach will allow for better transfer of OMS residents into medical school with advanced standing Aim to develop new ideas on how to integrate OMS residents into the new sequence of courses demanded by new medical school curricula Do not compromise the specific OMS training time Attempt to maintain continuity of OMS training Address 2- and 3-year ACGME accredited, post-MD training requirements of state medical licensing boards by considering OMS accreditation by the ACGME or joint ACGME and CODA With ACS accepting ABOMS certification as equivalent to ACGME-accredited board certification, state boards could be lobbied to accept ABOMS certification and allow for CODA-accredited training time to count toward medical licensure requirements In conclusion, the future of OMS as a specialty is bright. We are now entering a ‘‘golden age’’ for the specialty based on the scope of practice, new technology, innovation, and research. Although no easy solutions are available to the challenges we have outlined, we are optimistic about the future. We have a strong group of trainees and young surgeons who will solve these problems and move OMS forward with great success. Acknowledgments No significant written record is available on the evolution of oral and maxillofacial surgery training and, in particular, the development of dual-degree programs. Therefore, the information we obtained by conversations with, and e-mails and letters from, the following surgeons was invaluable in the completion of the present study: Drs Samuel McKenna, Peter Waite, Thomas Dodson, Morton Goldberg, James Hupp, Bruce Donoff, Ghali Ghali, Charles McCallum, Roger Meyer, Robert Mraule, Valmont Desa, Joseph Piecuch, and John Helfrick and Ms Kitty Robinson. We thank them for their help and encouragement.
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References 1. Kaban LB: History of Dual Degree Training in the United States: ‘ Back to the Future.’’ Presented at the ROAAOMS Symposium at the 100th Meeting of the American Association of Oral and Maxillofacial Surgeons, October 2018, Chicago, IL. Available at: https://www.aaoms.org/meetings-exhibitions/ annual-meeting/100th-annual-meeting. Accessed October 13, 2018 2. Guralnick WC, Kaban LB: Keeping ether ‘ en-vogue’’: The role of Nathan Cooley Keep in the history of ether anesthesia. J Oral Maxillofac Surg 69:1892, 2011 3. Bigelow HJ: Insensibility during surgical operations produced by inhalation. Boston Med Surg J 35:309, 1846 4. Keep NC: Inhalation of ethereal vapor for mitigating human suffering in surgical operations and acute diseases. Boston Med Surg J 36:199, 1847 5. Lister J: On a new method of treating compound fracture, abscess, &c., with observations on the conditions of suppuration. Lancet I i:336, 1867 6. Lister J: Further evidence regarding the effects of the antiseptic system of treatment upon the salubrity of a surgical hospital. Lancet II ii:287, 1870 7. Fleming A: On the antibacterial action of cultures of a penicillium, with special reference to their use in the isolation of B. influenzae. Br J Exp Pathol 10:226, 1929 8. Murray JE, Merrill JP, Harrison JH: Renal homotransplantation in identical twins. Surg Forum 6:432, 1956 9. Merrill JP, Murray JE, Harrison JH, Guild WR: Successful homotransplantations of the human kidney between identical twins. JAMA 160:277, 1956 10. Moore FD: Metabolic Care of the Surgical Patient. Philadelphia, WB Saunders, 1959 11. Murray JE: Presidential Address: Boston Surgical Society, Boston, MA, 1979. Available at: https://www.bostonsurgicalsociety. com/. Accessed June 4, 2018 12. Warren JC: Operative note for patient Gilbert Abbott, 21-yearold printer. Massachusetts General Hospital Archives, October 16, 1846 13. Van Dam LD: Charles Frederick Heywood, house surgeon at the ether demonstration. Anesthesiology 82:772, 1995 14. Guralnick WC: The combined oral surgery-MD program: The Harvard plan. J Oral Surg 31:271, 1973
11 15. Alling CC, Hayward JR (co-editors): The building of a specialty: Oral and maxillofacial surgery in the United States, 1918-1998. J Oral Maxillofac Surg 47(Suppl):168, 1998 16. Alling CC, Hayward JR (co-editors): The building of a specialty: Oral and maxillofacial surgery in the United States, 1918-1998. J Oral Maxillofac Surg 47(Suppl):120, 1998 17. Hayward JR: Strains on a bridging specialty. J Oral Surg 29:837, 1971 18. Alling CC, Hayward JR (co-editors): The building of a specialty: Oral and maxillofacial surgery in the United States, 1918-1998. J Oral Maxillofac Surg 47(Suppl):287, 1998 19. Waite PD: The University of Alabama oral and maxillofacial surgery program. J Oral Maxillofac Surg 65(3), 2007 20. Personal communication: Samuel McKenna, DMD, MD, Chair, Department of OMS Vanderbilt University, Nashville TN, 2018 21. Debes RR, Butler DP: Looking Back: A History of the Oral and Maxillary Surgery Program University of Texas-Houston 19491999. Houston, TX, University of Texas-Houston Dental Branch Department, 1999, pp 25–27 22. Dodson TB, Guralnick WC, Donoff RB, Kaban LB: Massachusetts General Hospital/Harvard Medical School MD oral and maxillofacial surgery program: A 30-year review. J Oral Maxillofac Surg 62:62, 2004 23. Personal communication: Valmont Desa, DMD, MD, Division Chief and Program Director, OMS University of Nebraska, Lincoln, NE, 2018 24. Personal communication: Joseph Piecuch, DMD, MD, Simsbury, CT, 2018 25. Personal communication: Peter D. Waite, DDS, MD, Chair, Department of OMS University of Alabama, Birmingham, AB, 2018 26. American Association of Oral and Maxillofacial Surgeons Data, 2014-2018. Available at: aaoms.org. Accessed June 4, 2018 27. Asch DA, Nicholson S, Vujicic M: Are we in a medical education bubble market? N Engl J Med 369:1973, 2013 28. Centers for Medicare and Medicaid Services. CMS Office of the Actuary Releases 2017 National Health Expenditures. Available at: https://www.cms.gov/newsroom/press-releases/cms-officeactuary-releases-2017-national-health-expenditures 29. Centers for Medicare and Medicaid Services. CMS Office of the Actuary Releases 2018-2027 Projections of National Health Expenditures. Available at: https://www.cms.gov/newsroom/ press-releases/cms-office-actuary-releases-2018-2027-projections-national-health-expenditures