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The Allurement of Specialization*
THE ALLUREMENT OF SPECIALIZATION* By ABRAM HOFFM AN, D.D .S., F.A.C.D., Buffalo, N ew York
HIS presentation, “T he Allure ment of Specialization” is prompted by the rapidly increasing number o f specialties in the healing arts and the still more rapidly increasing number of specialists. T he subject suggests three principal thoughts. ( a) Are all these special lines of endeavor justified? (b ) W hat is it that attracts one to these special lines? (c) Are those taking up the special lines properly qualified for such practice? At the present time, it is quite gen erally conceded that dentistry is part and parcel of the great healing art and should be studied and practiced as such. T h e day of the purely “ artisan” dentist is passing, and the time is not far dis tant when the dentist must, from necessity, have a broader medical train ing coupled with his handicraft, espe cially so if he elects to practice one of the specialties involving mechanical procedures wherein the biologic, chem ical, physiologic or pathologic principles predominate or even play an important part. I t is impossible, mentally and physi cally, for the dentist to have a com plete working knowledge o f all branches of dentistry; neither can he give, in full measure, the variety and
T
*Read before the Section on O rthodontia a n d P eriodontia a t the Sixty-Seventh A nnual Session o f the Am erican D ental Association, L ouisville, K y., Sept. 24, 1925. Jour. A . D . A D e c e m b e r , 1926
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quality of service that is demanded in this age. T he public is willing to pay for superior service, and the dentist must be prepared to give a commensu rate service. T he relationship of den tistry to general health is assuming such a commanding position that no part of the science can be neglected nor under estimated. The specialist has come to stay. T he superior service rendered by those who early devoted themselves to the various branches o f the healing arts has been accepted in such a manner that, from necessity, the former “ unit,” medicine, has been divided and subdivided in accord with the demand for service. More recently, dentistry, which for many years was frowned on as a spe cialty of medicine, is also breaking up into numerous specialties, the first dis tinct and recognized branch being orthodontia. I t is to this specialty that the substance o f this paper is directed. Assuming that specialization is justi fied and that there is a place in the dental field for the six or eight “odontias” that have developed within our midst, what is it that attracts one to give up a general practice and enter on limited practice? This question has been asked of a half dozen or more well known special ists, and the following phrases seem to epitomize their opinions: Interest in a special field and the desire to do the best possible w ork in th at field.
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Realization th a t concentration in one field w ill yield the best results. A desire to get better fees. A desire to advance the sum to ta l o f know ledge in dentistry. A realization o f the need by m any indi viduals, f o r services o f a specialist. T h e a llu rin g advertisem ents o f appliance m anufacturers. T h e belief th at specialization offers a field o f “ easier w o rk .” A feelin g th at one’s desires, train in g , equip m ent, clientele, etc., cannot at the same time lend themselves to a successful general practice and the conduct o f a special line. A desire to serve.
W ithout a doubt, men have entered the field of specialization with the high est ideals, but it may be said with just as much assurance that too many take up their work with a lack o f the real sincerity and purpose which should sur round a professional man. T here seems to be some peculiar fascination about being classed as a specialist, and this is undoubtedly an allurement which draws many inade quately prepared persons into the special field, to say nothing o f the magnetic power of the supposedly large fees. I t is commonly asserted that far too many men are led into the field of orthodontia because of the alluring advertisements of the appliance manu facturer and the inference that this specialty offers an easy road to success. But what an awakening follow s!— the blasted hope and shattered pride of the pseudo-orthodontist who has tried to break into the fold via the crude ready made appliance or even by the “ efficient, precision” apparatus, which is supposed to be the last word in its class. A few dismal failures, perhaps some irrepa rable damage, and someone is the target for severe criticism. It isn’t the pseudo orthodontist alone; for the science and
art of orthodontia come in for a good share as well. It is to be regretted that these mis leading advertisements are allowed in our professional periodicals. Perhaps, we cannot avoid them in all o f our journals, but we can cause their exclu sion from our own journals, and, along with this, we can make an earnest plea for better censorship or their exclusion from the trade journals. Assuming that there is a definite demand for the specialist, and recogniz ing from the rapidly increasing number of specialists that there is an ample attraction for individuals to take up the special lines of practice, what should be the basis upon which one might properly declare himself to the public as being entitled to the confidence, the emoluments and the other rewards which are usually accorded the spe cialist? Many o f them offer pitfalls of the most serious nature to the uninitiated. There is no short-cut nor easy road to success by the specialization route. I make no plea for exclusion, exclu siveness nor anything of the sort in the practice of orthodontia. I have long been an advocate o f the general prac titioners’ carrying on this type o f prac tice so that the vast number of children in need of the service may have relief. But I do make an earnest plea for a more conscientious study before under taking treatment. The Century Dictionary defines a specialist as “ a person who devotes him self to a particular branch of a pro fession, science, or art; one who has a special knowledge of some particular subject.” Stedman’s Medical Diction ary says that he is “ one who devotes himself to the study of a particular
Hoffman— The Allurement of Specialization science or to the study and treatment of a particular group o f diseases.” Taken in the abstract, it appears that most specialists are “within the law,” but is it not a fact that fa r too many are first declaring themselves specialists and then devoting themselves to acquiring the special knowledge and skill that their clientele has a right to expect? I t is too frequently a case of “ the cart before the horse.” I am not unm indful of the fact that there are many men in the specialties today who entered on their work in this very manner, but they have paid the price. T he possessor o f a dental degree has every legal right to follow any of our specialties. Has he a moral right to do so without adequate preparation? T he helplessness of our patients and the absolute confidence with which they place themselves in our care make a righteous demand for the best service we have in us, and anything short of this is a breach o f professionalism. T he motive of the specialist should, first of all, be service, and until a man acquires this point of view, he is not entitled to the rewards of the highest idealism in professional life. At the present time, when dental edu cational standards are undergoing so many changes, and with a condition bordering on chaos, it is almost like carrying coals to New Castle to add any fuel to the fire. Still, we are all work ing for the honor and advancement of a noble profession, which less than 100 years ago was refused admission to the realm of medicine; but because of the wisdom and foresight of such men as Hayden and Harris, and the persistence of the strong men who have carried on the early ideals, we now enjoy the privilege of being in a highly regarded profession, which must, and will, in the
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near future, be on the same plane as the recognized specialties o f general medicine; for dentistry is just as prop erly a form of health service as any specialty of medicine and particularly those having a connection with the oral structures. T herefore, it behooves us to carry on, building better and better, as did those who have gone before us. It seems almost satirical fo r one who has had no specific training as a special ist, other than twenty and more years of experience in orthodontia to offer suggestions as to the qualifications for one’s announcing himself as a specialist. Perhaps that very status justifies one in taking the initiative. I t is quite generally admitted that undergraduate orthodontic instruction in the dental school has fallen short of the ideals of those in charge. This may have been due to the mode of teaching. Undergraduate instruction in a specialty should, at its best, only serve to stimulate to further effort and study after graduation. A somewhat liberal experience in teaching this sub ject convinced me of two things: first, that the average dental student has but little interest in orthodontics, and, sec ondly, that as some orthodontic instruc tion must be given, the course should be divided into two parts, a required and an elective course. All students should take the required or lecture course (including technics), and those few, for the percentage is small, who desire a further knowledge should be given the elective course, with proper credit for carrying on simple cases and witnessing the demonstration treatment of the more complicated cases in the clinic. This at once relieves the teacher of all students disinterested in the practical work, but at the same time gives the student all the necessary basic
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The Journal of the American Dental Association
instruction which should properly be included in the curriculum and which may rightfully be expected from the school. I feel that until something more definite is offered, the prospective spe cialist should, on graduation, serve at least a three-year preceptorship in the office of an orthodontist whose practice is of such proportions as to enable study, investigation and treatment by the be ginner. Under proper conditions and tutelage, this should afford a better preparation for specialization than the short postgraduate courses now being offered. T h e short postgraduate courses that have been in vogue for the past twentyfive years have served their purpose well. Students and instructors have been carefully chosen, and the instruc tion has been a sincere effort to prepare the students for specialization; and thus they have helped to supply the con stantly increasing demand for ortho dontists. Many of the graduates of these schools properly occupy positions of prominence in our profession, and, again, many of them have used the schools solely as a stepping stone. T he form er are the ones who have had an inherent desire fo r advancement and service; the latter have had a false con ception of the science and art with an “allurement” that is not conducive to the highest type o f professionalism. I shall not attempt to discuss at any length the evolutionary or revolutionary changes now taking place in dental edu cational circles. I t remains a fact that much of the teaching is passé, and I believe that after the smoke has cleared away, all instruction, undergraduate and postgraduate, will be where it properly belongs— in the university dental schools. Such a plan will elimi
nate much superfluous study and loss of time. I t will further result in sys tematic, graded instruction, so that a student, on graduation, may proclaim to the public, by his collegiate degree, what his position or status in the pro fession is or should be. Several of our universities are already establishing graduate courses with a suitable degree on completion of the course. This is assuredly a step in the right direction. I t has long been my belief that one entering on a specialty should precede such a step with several years’ experi ence in general practice. This un doubtedly has been a proper precaution in the past, but such loss of time may be just as properly avoided with the instruction that will result from coor dinated teaching throughout the pre dental, dental and postgraduate courses. T he sincerity with which the leaders in the dental profession are working lends wholesome confidence in the fu ture of our profession, and it should be a great comfort and satisfaction to feel that the American Dental Association, through its committees on education, the Dental Educational Council of America and the American Association o f Dental Schools, will undoubtedly soon arrive at a standard of preparation which will qualify men for specializa tion. W ith such betterment, dentistry will be placed upon a still higher plane in the healing arts and in public esteem. 381 Linw ood Avenue. DISCUSSION A lbert W . Crosby, N e w H aven, Conn.: I shall confine m yself to a discussion o f the question: “ A re those tak in g up the special lines properly qualified f o r such practice?” “ I am convinced that one o f the pressing necessities o f our times is a generation o f dabblers to correct astigm atism and sterility
Hoffman— The Allurement of Specialization o f the specialists,” comments G lenn F ran k .1 “T h ere is, o f course,” he continues, “ the m ore accurate w ord ‘polym ath’ w hich means a person o f m uch varied learning, one ac quainted w ith various subjects o f study.” As an illustration o f such v irility , he hopes we m ay “ recapture the spirit of L eonardo da Vinci in tw entieth century education, politics, and business. L eonardo da Vinci was the apostle o f all-ro u n d expresson rather than specialized expression. He was a sculp tor, an artist, a poet, an epigram m atist, an engineer, a statesm an, a soldier, and a musi cian. T r u ly enough, he was not equally successful in an objective o r critical sense in a ll these fields; but quite as certainly he owed his surpassing excellence in one o r tw o o f them to the fact th at he tried them a ll.” In our own times, the late F . H opkinson Smith is an exam ple o f broad attainm ents. He had an enviable reputation as an artist, author, and engineer. Please do not think I am a d vocating the train in g o f a m an to be a Ja c k -o f-a ll-tra d e s; rath er, I am speaking in the sense w hich Jo h n H ays H am m ond used w hen asked w h a t w ould he have him study w hom he wished to educate f o r engi neering. H e said, “A nything but engineer in g .” A specialty should be b u ilt like a pyram id— the broader the base, the h igher the apex. T h e reason dentistry today is not quite on the level o f m edicine is because the younger science has n o t yet been able to fu rn ish as m any men o f culture and educa tion as has the m edical profession. I differ fro m D r. H offm an in th at I am strongly in fa v o r o f a professional m an tak in g up gen eral practice fo r a term o f years before he lim its his practice to a specialty. A specialty should be an evolution o f experience. P ro fessor K ellar o f Y ale cites an instance to the po in t:2 An em inent nerve specialist w ho be came such by a n a tu ra l process o f develop m ent out o f general practice, once rem arked th a t i f he had his w ay every doctor should begin by engaging fo r a w hile in unspecial ized activities. H e enforced the contention by an incident out o f his experience. A b rillian t young specialist had stru g g led in 1. F ra n k , G le n n : C ult o f the Dabblers, C entury M agazine, Ja n u a ry , 1923. 2. K ellar, A. G .: G eneral Practice, Yale Rev., October, 1923.
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vain w ith w hat he had diagnosed as a case o f nerves and had finally called in the older colleague. T h e patient was a boy about 12 years old. T h e veteran listened to the pros and cons th a t were vexing the specialist, and w ithout com m ent told the boy to take off his shirt. “ T h ere was as p re tty a line o f nodules around th at child’s sternum as you w ould ever see,” he reminisced, “ absolutely unm is takable. D o n ’t you know w hat is the m atter w ith him ,” I asked. “ No, I don’t.” “ W ell, it’s rickets” said I. “See those lum ps?” “ Yes, but w hat o f it? ” he asked. “ W ell,” said I, “ I guess you have never been in general p ra c tice, have you? I f you had, those same lum ps w ould be shouting rickets at y o u .” A nd the old doctor w ent on to tell how o ften a n a rro w specialist could be fooled when an old fashioned fam ily doctor w ould at once recognize the handiw ork o f one o f his fa m il iar foes. T h e man who told the story was no enemy o f the specialist and specialization. He was him self a specialist. H e was m erely an advocate o f breadth. As we turn the pages o f the dental jou rn als, we find them filled w ith advertisem ents o f schools and socalled colleges w hich advertise to fit a m an f o r a specialty in a few weeks or a t m ost a year, w ith possibly a supplem ental postg rad uate course. I t means the admission o f battalions o f ill-qualified men to positions o f responsibility. T h ey rem ind one o f A ris totle’s definition o f a sophist— “ One who makes money out o f the appearance o f k n o w l edge w ithout the reality.” T h e ir graduates come fo rth to fleece the public, arrayed in a w ardrobe o f disguises, i f not wolves in sheep’s clothing, to their own ultim ate dis satisfaction. It is not the quickness o f our a rriv in g , but, as Goethe says, the quality o f our striving. T h e perfection o f fine f r u it depends som ew hat on the duration o f its grow th. Charles R . Jackson, India n a fo lis, Ind.: If D r. H offm an had chosen as his subject, “ T h e Illusions o f Specialization,” discussion w ould have been m uch sim plified. Personally, I am alm ost tw enty years fro m its allurem ent and about tw enty m inutes fro m some o f its illusions. In the practice o f dentistry, today, there is no question about the need f o r some specialists. Ju s t how m any divisions there should be, only tim e and experience w ill de-
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The Journal of the American Dental Association
term ine, but the opinion seems to be gro w in g that there are too m any varieties o f special ists in the lim ited field covered by the science o f dentistry. W hatever m ay have been the actuating m otives inducing these men to spe cialize, it w ould be interesting to get their opinions a fte r five o r m ore years o f practice. W hether these new er specialties are to con tinue w ill depend on the experience o f those now specializing. T h e specialty o f orth o dontia is lo n g past this experim ental stage and is firm ly established as a necessity. Bet ter facilities should be provided fo r dentists w ishing to specialize in this branch. W hile we realize that dental teaching is now in the evolutionary stage, the plain statem ent o f a few facts m ay, I believe, c la rify ra th e r than m uddle the situation. U ndergraduate ortho dontic instruction, as carried on today, is w o efully deficient and discouraging. T his, combined w ith the n a tu ra l indifference o f the average dental student to things orth o dontic, produces grad u ate dentists whose know ledge o f orthodontics is practically nil. T h e really serious p a rt is th at the m ajority do not know th a t they do not know . Ig n o rance is only dangerous when we are not conscious o f our ignorance. A t one tim e, I believed the general p ractitioner could and should correct malocclusions, but experience has tau g h t me that, w ithout m ore instruction and experience than th at attained in under graduate institutions, it is exceedingly rare th a t one is fo u n d who doesn’t do more harm than good. Y et we cannot blam e the gen eral practitioner. O ur present teaching does n o t q u a lify a dentist in orthodontics but still leaves the impression in his m ind th at he is qualified. H e has a diplom a, the possession o f which implies, at least, th at he is com petent to do all kinds o f dental w ork. D r. Bunkum assures him th ro u g h advertisem ents th a t “ straightening teeth” is simple— just put on an appliance, w atch it w ork and collect a b ig fee. T h e result is a trip le reaction— against the patient, the dentist and the practice o f orthodontia. I believe th at under grad u ate instruction „hould be m uch better or m uch worse. I t should L; thorough enough t® q u a lify the dentist to treat m al occlusions in telligently o r should be lim ited to didactic instruction so he w ill realize his deficiencies and not undertake cases w ithout study and preparation. In our postgraduate schools, we need not so much quantity p ro
duction as quality production. A fe w weeks instruction, how ever intensive, is not suffi cient to tu rn out pro p erly qualified special ists. I t is to be regretted th a t any school should stoop to m isrepresentation to induce patronage. A c ircular letter recently issued contained the fo llo w in g : “ We assure you that towns w ith a population o f 10,000 w ith a d jacent comm unities are p roviding am ple sources fo r very flattering orthodontic prac tices, and w here there is room fo r one there is room fo r an o th er.” Such a statem ent is so m anifestly absurd as to need no comm ent. H ow ever, we have high hopes fo r the qual ity o f our fu tu re specialists. W hen our university schools have perfected plans f o r postgraduate w ork covering a considerable period o f tim e we m ay then be proud o f the recruits to o u r ranks. I am sorry to say that, in m y opinion, the g reat influx o f specialists at the present tim e is the result o f the a llu re m ent o f the a lm ig h ty d ollar and th a t there is a g reat aw akening in store fo r the m ajo rity o f them . T h ere seems to be a very e rro neous idea o f the w ork, responsibilities and rew ards o f the orthodontic specialist a t least. A fte r all, the general p ractitioner is the im portan t m em ber o f the dental fam ily , and the only allurem ent o f the specialties, in the final analysis, is the satisfaction gained fro m d oing som ething in which one is p articu larly interested o r fo r which one has a special aptitude. Frederick S. S tillw ell, Cincinnati, Ohio: O rthodontia is the most exacting science den tistry can offer. I believe th at m any young men are draw n to this specialty by erroneous ideas as to large fees and are not shown the actual relation to tim e spent and money received. W h at can be done? As I see it, it is p a rtly the fa u lt o f the colleges. T h ey give too m uch train in g in m echanics; and the conception o f the mechanism o f the m outh and the developm ent or possibilities f o r lack o f developm ent are not presented as they should be. I believe every general prac titioner should consult frequently concerning children in his care w ith an orthodontist, and leave the question o f correction entirely to the la tte r’s judgm ent. Is it not reasonable to assume th at one who is a specialist and h ighly developed in one a rt is in a position to give better ju d g m en t and service than one w ho m ust keep up a semblance o f technic in m any branches? I f we can g et the general p ra c
Hoffman— The Allurement of Specialization titioner to sh ift the responsibility entirely onto the orthodontist as to e arly o r delayed treatm ent, we have done a g re at deal.
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into a credit to his specialty. O thers w ill fa ll by the wayside. Some o f the best men th at we have in o u r specialty today never even had a short course. T w o o f your speakers here H. F . H o ffm a n , D enver, C olo.: W e can today never have been allied w ith any o f the never get aw ay fro m the allurem ents o f so-called short course schools. T h e plan th at orthodontia, but w hat we m ust do, unless is being tried in several universities, th a t is, these allurem ents are to be the death o f our the one and the tw o year plans, are still on specialty, is to devise some m eans by which trial. W e do not know w hat they w ill p ro the practitioner o f a specialty, especially duce; but we know this: they w ill not orthodontia, shall be required to keep produce enough orthodontists; yet I do be him self prepared f o r the advance o f his lieve th a t they are going to produce a quality profession. O ur specialty occupies a unique o f m an th a t is m uch to be desired. T h ey position. W e have no legal requirem ents ex should give us teachers o f orthodontists and cept being licensed f o r the practice o f den I hope some good research men, which a short tistry, and we have absolutely no orthodontic course never could produce, but m ight educational standard o f qualifications. Ju st stim ulate. As f a r as D r. H offm an’s rem arks before I le f t home, a representative o f the about h av in g some standard or some periodical departm ent o f com m unity organization o f our exam ination w hereby we can see w hether they state university said to m e : “ W e are consider are keeping up in the specialty o f orthodontia, such as they are thin k in g o f applying in ing seriously a m ovem ent to require periodical reexam ination o f professional m en,” re fe rrin g C olorado to medicine and dentistry, th a t is possibly chim erical. It could not be done in especially in his conversation to physicians a dem ocratic fo rm o f governm ent under the and dentists. Teachers, as he said, are now present day civilization. So let’s fo rg e t that. required in m ost states to keep abreast o f the W e can only stim ulate a m an to advance. It advancem ent o f their profession. T h is, it is the individual effort o f the leading men in seems to me, m ight offer some solution to our the specialty, p a rticu la rly in Am erica and problem . I t w ill be a lo n g tim e before we C anada (a n d a fe w a b ro a d ), th a t has placed can be placed on any real leg a l fo o tin g re the specialty on the high plane w here it is q u irin g a definite standing, and i f we cannot today. I t is no reflection on these men th at do th at, we should do som ething else. T his nearly a ll o f them are graduates o f short w ould have to be a volu n tary m ovem ent in course schools. I t was m erely the only m ethod our ranks, and I believe it m ig h t be worked th at was presented a t th a t time. T h e short out to o u r advantage. course has its evils and they are decided evils. W . C. Fisher, N e w Y o rk C ity . D r. H off It has its advantages. I w ill say th a t they are m an’s paper could be discussed indefinitely; not so g reat as they looked a t one tim e to be, there are so m any branches to it th a t the dis but the people need orthodontists ju st as they cussers have gone off a t a tangent. I feel need dentists. T h e public has been educated very m uch as I im agine a law yer feels when in the benefits o f o rthodontia and orthodontic tak in g a case. I could take any side o f this treatm ent. T h e y have seen a sufficient num question and argue f o r or against it. I have ber o f children g re atly im proved in every had some experience in orthodontic education little com m unity, and we know th at when a and have been an earnest student o f it, yet I m an sees th at his little g irl is developing a do n o t believe, a fte r nineteen years, th a t we severe deform ity, he is goin g to seek service, have, o r w ill achieve, any one ideal m ethod too. I f you a re dissatisfied w ith present con o f producing orthodontists. Y ou w ill hear ditions, let us do as D r. W augh is try in g to criticism s o f short courses and a g re at deal do, as they are doing in Illinois, in the U n i in fa v o r o f the long course, and ju stly so. versity o f P ennsylvania and other schools. I believe th at we are goin g to produce orth o L et us see i f we cannot devise some w ay dontists tom orrow ju st as we produced them whereby we can supply a stim ulus to these yesterday— th ro u g h individual effort, purely graduates to come out and take up the plan and simply. I t has produced the g re at special th at D r. A bell has spoken o f, o r any plan th a t ists in m edicine f o r the past fifty years and it w ill develop the orthodontist. w ill produce them in dentistry. One m an can F rank M . Casto, C leveland, O h io : One o f take a short course a n d get enough stimulus the speakers stated th a t the allurem ent o f and sufficient know ledge therein to develop
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The Journal of the American Dental Association
specialization is still w ith u s; one rem arked th at the delusions are also still w ith us, and there m ay be some tru th in both. T h e dis cussion has resolved itself som ew hat into the question o f p relim in ary education or quali fication fo r those w ho desire to enter a special field o f practice. T h is subject has been dis cussed pro and con fo r, lo, these m any years, and opinions are alm ost as varied as there are opinions. Some believe th a t substantially more instruction in o rthodontia should be given to the undergraduate student in the dental schools. Others believe th at only the fu n d a m ental principles can be tau g h t. M ost o f the difficulty, I believe, lies in the fa c t th a t there never has been a real concerted effort on the p a rt o f the orthodontists to prescribe and es tablish a balanced, standardized course o f study. D ental educators recognize the ne cessity f o r teaching orthodontics, but they are sim ply gro p in g in the d a rk in reg ard to how it shall be tau g h t and the content o f the course. T h e orthodontists w ill have to as sume these responsibilities, and u n til they make good on the proposition, n o th in g different can be expected. T h e problem is becom ing m ore complex and m ore difficult o f solution. T h e requirem ents in a ll departm ents have a d vanced so ra p id ly th a t the curriculum is a l ready overloaded. A t present, in a ll good schools, the fo u r-y ear course o f study com pre hends fro m 4-,800 to 5,000 hours, an average o f approxim ately 1,250 hours per year, or about thirty-nine hours per w eek du rin g the th irty -tw o weeks o f instruction. A bout 100 hours are a llo tted to didactic and technic in struction in orthodontics. T h e num ber o f hours in clinical instruction varies w idely in different schools. I t is quite obvious, under the present circumstances, th a t it is possible to teach only a lim ited am ount o f orthodontics. T h is is also true in other special branches. A dean o f one o f our best dental schools had a vision. He thought he had a m ethod whereby the problem o f rendering efficient instruction in special branches could be solved. He pre sented the proposition to his fa cu lty , which briefly was as fo llo w s: T h ere m ust be a m inim um num ber o f hours in each subject that w ould meet the requirem ents fo r general
qualification, and which was less than the num bers o f hours now in vogue, in which case a m axim um num ber o f hours w ould be available to those students who were p a rticu la rly interested in some special subject, such as orthodontia, exodontia, prosthetics, and who developed some unusual ability or skill alo n g certain lines, i. e., a student could, therefore, take the m inim um num ber o f hours on one subject and the m axim um num ber o f hours in an o th er and still meet a ll o f the re quirem ents. H e requested the members o f the fa c u lty to consider this m atter c arefully and re p o rt back to him . T h e result was th a t every m an reported as a m inim um require m ent m ore hours than he previously had and a m axim um requirem ent f a r in excess o f any possible adjustm ent. T h e total num ber o f m inim um hours exceeded the present scheduled num ber by a bout 1,000, m aking a to ta l o f approxim ately 6,000, w hile the m axim um was m ore than 8,000. T h e fu tility o f such an a r rangem ent is im m ediately evident. I sim ply call yo u r attention to this incident to illustrate the u tter hopelessness o f attem pting to give enough instruction to the undergraduate to q u a lify him f o r special practice. I should be derelict in m y duty i f I did not correct the statem ent m ade by one o f the speakers in re g a rd to the unlim ited stress placed on mechanics in the dental schools today a t the expense o f the biologic sciences and didactic instruction. T h e curriculum in m ost schools presents a w ell-balanced course o f study. W ith the induction o f the preprofessional year, a ll o f the courses in the fundam ental sciences were advanced and enlarged, and the prerequisites were adhered to m ore con scientiously, and, as a result, the present-day dental student is receiving a fine education. T h e first tw o years is devoted m ostly to the study o f the basic sciences, in which extensive lab o rato ry instruction is given. A consider able am ount o f tim e is given to didactic instruction th ro u g h o u t the fo u r years. Cer tainly, the technic courses are as extensive as tim e w ill perm it, and a large am ount o f tim e is allotted to p ractical clinical instruction. It could not be otherw ise if a well balanced product is the goal.
HIS presentation, “T he Allure ment of Specialization” is prompted by the rapidly increasing number o f specialties in the healing arts and the still more rapidly increasing number of specialists. T he subject suggests three principal thoughts. ( a) Are all these special lines of endeavor justified? (b ) W hat is it that attracts one to these special lines? (c) Are those taking up the special lines properly qualified for such practice? At the present time, it is quite gen erally conceded that dentistry is part and parcel of the great healing art and should be studied and practiced as such. T h e day of the purely “ artisan” dentist is passing, and the time is not far dis tant when the dentist must, from necessity, have a broader medical train ing coupled with his handicraft, espe cially so if he elects to practice one of the specialties involving mechanical procedures wherein the biologic, chem ical, physiologic or pathologic principles predominate or even play an important part. I t is impossible, mentally and physi cally, for the dentist to have a com plete working knowledge o f all branches of dentistry; neither can he give, in full measure, the variety and
T
*Read before the Section on O rthodontia a n d P eriodontia a t the Sixty-Seventh A nnual Session o f the Am erican D ental Association, L ouisville, K y., Sept. 24, 1925. Jour. A . D . A D e c e m b e r , 1926
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quality of service that is demanded in this age. T he public is willing to pay for superior service, and the dentist must be prepared to give a commensu rate service. T he relationship of den tistry to general health is assuming such a commanding position that no part of the science can be neglected nor under estimated. The specialist has come to stay. T he superior service rendered by those who early devoted themselves to the various branches o f the healing arts has been accepted in such a manner that, from necessity, the former “ unit,” medicine, has been divided and subdivided in accord with the demand for service. More recently, dentistry, which for many years was frowned on as a spe cialty of medicine, is also breaking up into numerous specialties, the first dis tinct and recognized branch being orthodontia. I t is to this specialty that the substance o f this paper is directed. Assuming that specialization is justi fied and that there is a place in the dental field for the six or eight “odontias” that have developed within our midst, what is it that attracts one to give up a general practice and enter on limited practice? This question has been asked of a half dozen or more well known special ists, and the following phrases seem to epitomize their opinions: Interest in a special field and the desire to do the best possible w ork in th at field.
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Realization th a t concentration in one field w ill yield the best results. A desire to get better fees. A desire to advance the sum to ta l o f know ledge in dentistry. A realization o f the need by m any indi viduals, f o r services o f a specialist. T h e a llu rin g advertisem ents o f appliance m anufacturers. T h e belief th at specialization offers a field o f “ easier w o rk .” A feelin g th at one’s desires, train in g , equip m ent, clientele, etc., cannot at the same time lend themselves to a successful general practice and the conduct o f a special line. A desire to serve.
W ithout a doubt, men have entered the field of specialization with the high est ideals, but it may be said with just as much assurance that too many take up their work with a lack o f the real sincerity and purpose which should sur round a professional man. T here seems to be some peculiar fascination about being classed as a specialist, and this is undoubtedly an allurement which draws many inade quately prepared persons into the special field, to say nothing o f the magnetic power of the supposedly large fees. I t is commonly asserted that far too many men are led into the field of orthodontia because of the alluring advertisements of the appliance manu facturer and the inference that this specialty offers an easy road to success. But what an awakening follow s!— the blasted hope and shattered pride of the pseudo-orthodontist who has tried to break into the fold via the crude ready made appliance or even by the “ efficient, precision” apparatus, which is supposed to be the last word in its class. A few dismal failures, perhaps some irrepa rable damage, and someone is the target for severe criticism. It isn’t the pseudo orthodontist alone; for the science and
art of orthodontia come in for a good share as well. It is to be regretted that these mis leading advertisements are allowed in our professional periodicals. Perhaps, we cannot avoid them in all o f our journals, but we can cause their exclu sion from our own journals, and, along with this, we can make an earnest plea for better censorship or their exclusion from the trade journals. Assuming that there is a definite demand for the specialist, and recogniz ing from the rapidly increasing number of specialists that there is an ample attraction for individuals to take up the special lines of practice, what should be the basis upon which one might properly declare himself to the public as being entitled to the confidence, the emoluments and the other rewards which are usually accorded the spe cialist? Many o f them offer pitfalls of the most serious nature to the uninitiated. There is no short-cut nor easy road to success by the specialization route. I make no plea for exclusion, exclu siveness nor anything of the sort in the practice of orthodontia. I have long been an advocate o f the general prac titioners’ carrying on this type o f prac tice so that the vast number of children in need of the service may have relief. But I do make an earnest plea for a more conscientious study before under taking treatment. The Century Dictionary defines a specialist as “ a person who devotes him self to a particular branch of a pro fession, science, or art; one who has a special knowledge of some particular subject.” Stedman’s Medical Diction ary says that he is “ one who devotes himself to the study of a particular
Hoffman— The Allurement of Specialization science or to the study and treatment of a particular group o f diseases.” Taken in the abstract, it appears that most specialists are “within the law,” but is it not a fact that fa r too many are first declaring themselves specialists and then devoting themselves to acquiring the special knowledge and skill that their clientele has a right to expect? I t is too frequently a case of “ the cart before the horse.” I am not unm indful of the fact that there are many men in the specialties today who entered on their work in this very manner, but they have paid the price. T he possessor o f a dental degree has every legal right to follow any of our specialties. Has he a moral right to do so without adequate preparation? T he helplessness of our patients and the absolute confidence with which they place themselves in our care make a righteous demand for the best service we have in us, and anything short of this is a breach o f professionalism. T he motive of the specialist should, first of all, be service, and until a man acquires this point of view, he is not entitled to the rewards of the highest idealism in professional life. At the present time, when dental edu cational standards are undergoing so many changes, and with a condition bordering on chaos, it is almost like carrying coals to New Castle to add any fuel to the fire. Still, we are all work ing for the honor and advancement of a noble profession, which less than 100 years ago was refused admission to the realm of medicine; but because of the wisdom and foresight of such men as Hayden and Harris, and the persistence of the strong men who have carried on the early ideals, we now enjoy the privilege of being in a highly regarded profession, which must, and will, in the
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near future, be on the same plane as the recognized specialties o f general medicine; for dentistry is just as prop erly a form of health service as any specialty of medicine and particularly those having a connection with the oral structures. T herefore, it behooves us to carry on, building better and better, as did those who have gone before us. It seems almost satirical fo r one who has had no specific training as a special ist, other than twenty and more years of experience in orthodontia to offer suggestions as to the qualifications for one’s announcing himself as a specialist. Perhaps that very status justifies one in taking the initiative. I t is quite generally admitted that undergraduate orthodontic instruction in the dental school has fallen short of the ideals of those in charge. This may have been due to the mode of teaching. Undergraduate instruction in a specialty should, at its best, only serve to stimulate to further effort and study after graduation. A somewhat liberal experience in teaching this sub ject convinced me of two things: first, that the average dental student has but little interest in orthodontics, and, sec ondly, that as some orthodontic instruc tion must be given, the course should be divided into two parts, a required and an elective course. All students should take the required or lecture course (including technics), and those few, for the percentage is small, who desire a further knowledge should be given the elective course, with proper credit for carrying on simple cases and witnessing the demonstration treatment of the more complicated cases in the clinic. This at once relieves the teacher of all students disinterested in the practical work, but at the same time gives the student all the necessary basic
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The Journal of the American Dental Association
instruction which should properly be included in the curriculum and which may rightfully be expected from the school. I feel that until something more definite is offered, the prospective spe cialist should, on graduation, serve at least a three-year preceptorship in the office of an orthodontist whose practice is of such proportions as to enable study, investigation and treatment by the be ginner. Under proper conditions and tutelage, this should afford a better preparation for specialization than the short postgraduate courses now being offered. T h e short postgraduate courses that have been in vogue for the past twentyfive years have served their purpose well. Students and instructors have been carefully chosen, and the instruc tion has been a sincere effort to prepare the students for specialization; and thus they have helped to supply the con stantly increasing demand for ortho dontists. Many of the graduates of these schools properly occupy positions of prominence in our profession, and, again, many of them have used the schools solely as a stepping stone. T he form er are the ones who have had an inherent desire fo r advancement and service; the latter have had a false con ception of the science and art with an “allurement” that is not conducive to the highest type o f professionalism. I shall not attempt to discuss at any length the evolutionary or revolutionary changes now taking place in dental edu cational circles. I t remains a fact that much of the teaching is passé, and I believe that after the smoke has cleared away, all instruction, undergraduate and postgraduate, will be where it properly belongs— in the university dental schools. Such a plan will elimi
nate much superfluous study and loss of time. I t will further result in sys tematic, graded instruction, so that a student, on graduation, may proclaim to the public, by his collegiate degree, what his position or status in the pro fession is or should be. Several of our universities are already establishing graduate courses with a suitable degree on completion of the course. This is assuredly a step in the right direction. I t has long been my belief that one entering on a specialty should precede such a step with several years’ experi ence in general practice. This un doubtedly has been a proper precaution in the past, but such loss of time may be just as properly avoided with the instruction that will result from coor dinated teaching throughout the pre dental, dental and postgraduate courses. T he sincerity with which the leaders in the dental profession are working lends wholesome confidence in the fu ture of our profession, and it should be a great comfort and satisfaction to feel that the American Dental Association, through its committees on education, the Dental Educational Council of America and the American Association o f Dental Schools, will undoubtedly soon arrive at a standard of preparation which will qualify men for specializa tion. W ith such betterment, dentistry will be placed upon a still higher plane in the healing arts and in public esteem. 381 Linw ood Avenue. DISCUSSION A lbert W . Crosby, N e w H aven, Conn.: I shall confine m yself to a discussion o f the question: “ A re those tak in g up the special lines properly qualified f o r such practice?” “ I am convinced that one o f the pressing necessities o f our times is a generation o f dabblers to correct astigm atism and sterility
Hoffman— The Allurement of Specialization o f the specialists,” comments G lenn F ran k .1 “T h ere is, o f course,” he continues, “ the m ore accurate w ord ‘polym ath’ w hich means a person o f m uch varied learning, one ac quainted w ith various subjects o f study.” As an illustration o f such v irility , he hopes we m ay “ recapture the spirit of L eonardo da Vinci in tw entieth century education, politics, and business. L eonardo da Vinci was the apostle o f all-ro u n d expresson rather than specialized expression. He was a sculp tor, an artist, a poet, an epigram m atist, an engineer, a statesm an, a soldier, and a musi cian. T r u ly enough, he was not equally successful in an objective o r critical sense in a ll these fields; but quite as certainly he owed his surpassing excellence in one o r tw o o f them to the fact th at he tried them a ll.” In our own times, the late F . H opkinson Smith is an exam ple o f broad attainm ents. He had an enviable reputation as an artist, author, and engineer. Please do not think I am a d vocating the train in g o f a m an to be a Ja c k -o f-a ll-tra d e s; rath er, I am speaking in the sense w hich Jo h n H ays H am m ond used w hen asked w h a t w ould he have him study w hom he wished to educate f o r engi neering. H e said, “A nything but engineer in g .” A specialty should be b u ilt like a pyram id— the broader the base, the h igher the apex. T h e reason dentistry today is not quite on the level o f m edicine is because the younger science has n o t yet been able to fu rn ish as m any men o f culture and educa tion as has the m edical profession. I differ fro m D r. H offm an in th at I am strongly in fa v o r o f a professional m an tak in g up gen eral practice fo r a term o f years before he lim its his practice to a specialty. A specialty should be an evolution o f experience. P ro fessor K ellar o f Y ale cites an instance to the po in t:2 An em inent nerve specialist w ho be came such by a n a tu ra l process o f develop m ent out o f general practice, once rem arked th a t i f he had his w ay every doctor should begin by engaging fo r a w hile in unspecial ized activities. H e enforced the contention by an incident out o f his experience. A b rillian t young specialist had stru g g led in 1. F ra n k , G le n n : C ult o f the Dabblers, C entury M agazine, Ja n u a ry , 1923. 2. K ellar, A. G .: G eneral Practice, Yale Rev., October, 1923.
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vain w ith w hat he had diagnosed as a case o f nerves and had finally called in the older colleague. T h e patient was a boy about 12 years old. T h e veteran listened to the pros and cons th a t were vexing the specialist, and w ithout com m ent told the boy to take off his shirt. “ T h ere was as p re tty a line o f nodules around th at child’s sternum as you w ould ever see,” he reminisced, “ absolutely unm is takable. D o n ’t you know w hat is the m atter w ith him ,” I asked. “ No, I don’t.” “ W ell, it’s rickets” said I. “See those lum ps?” “ Yes, but w hat o f it? ” he asked. “ W ell,” said I, “ I guess you have never been in general p ra c tice, have you? I f you had, those same lum ps w ould be shouting rickets at y o u .” A nd the old doctor w ent on to tell how o ften a n a rro w specialist could be fooled when an old fashioned fam ily doctor w ould at once recognize the handiw ork o f one o f his fa m il iar foes. T h e man who told the story was no enemy o f the specialist and specialization. He was him self a specialist. H e was m erely an advocate o f breadth. As we turn the pages o f the dental jou rn als, we find them filled w ith advertisem ents o f schools and socalled colleges w hich advertise to fit a m an f o r a specialty in a few weeks or a t m ost a year, w ith possibly a supplem ental postg rad uate course. I t means the admission o f battalions o f ill-qualified men to positions o f responsibility. T h ey rem ind one o f A ris totle’s definition o f a sophist— “ One who makes money out o f the appearance o f k n o w l edge w ithout the reality.” T h e ir graduates come fo rth to fleece the public, arrayed in a w ardrobe o f disguises, i f not wolves in sheep’s clothing, to their own ultim ate dis satisfaction. It is not the quickness o f our a rriv in g , but, as Goethe says, the quality o f our striving. T h e perfection o f fine f r u it depends som ew hat on the duration o f its grow th. Charles R . Jackson, India n a fo lis, Ind.: If D r. H offm an had chosen as his subject, “ T h e Illusions o f Specialization,” discussion w ould have been m uch sim plified. Personally, I am alm ost tw enty years fro m its allurem ent and about tw enty m inutes fro m some o f its illusions. In the practice o f dentistry, today, there is no question about the need f o r some specialists. Ju s t how m any divisions there should be, only tim e and experience w ill de-
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The Journal of the American Dental Association
term ine, but the opinion seems to be gro w in g that there are too m any varieties o f special ists in the lim ited field covered by the science o f dentistry. W hatever m ay have been the actuating m otives inducing these men to spe cialize, it w ould be interesting to get their opinions a fte r five o r m ore years o f practice. W hether these new er specialties are to con tinue w ill depend on the experience o f those now specializing. T h e specialty o f orth o dontia is lo n g past this experim ental stage and is firm ly established as a necessity. Bet ter facilities should be provided fo r dentists w ishing to specialize in this branch. W hile we realize that dental teaching is now in the evolutionary stage, the plain statem ent o f a few facts m ay, I believe, c la rify ra th e r than m uddle the situation. U ndergraduate ortho dontic instruction, as carried on today, is w o efully deficient and discouraging. T his, combined w ith the n a tu ra l indifference o f the average dental student to things orth o dontic, produces grad u ate dentists whose know ledge o f orthodontics is practically nil. T h e really serious p a rt is th at the m ajority do not know th a t they do not know . Ig n o rance is only dangerous when we are not conscious o f our ignorance. A t one tim e, I believed the general p ractitioner could and should correct malocclusions, but experience has tau g h t me that, w ithout m ore instruction and experience than th at attained in under graduate institutions, it is exceedingly rare th a t one is fo u n d who doesn’t do more harm than good. Y et we cannot blam e the gen eral practitioner. O ur present teaching does n o t q u a lify a dentist in orthodontics but still leaves the impression in his m ind th at he is qualified. H e has a diplom a, the possession o f which implies, at least, th at he is com petent to do all kinds o f dental w ork. D r. Bunkum assures him th ro u g h advertisem ents th a t “ straightening teeth” is simple— just put on an appliance, w atch it w ork and collect a b ig fee. T h e result is a trip le reaction— against the patient, the dentist and the practice o f orthodontia. I believe th at under grad u ate instruction „hould be m uch better or m uch worse. I t should L; thorough enough t® q u a lify the dentist to treat m al occlusions in telligently o r should be lim ited to didactic instruction so he w ill realize his deficiencies and not undertake cases w ithout study and preparation. In our postgraduate schools, we need not so much quantity p ro
duction as quality production. A fe w weeks instruction, how ever intensive, is not suffi cient to tu rn out pro p erly qualified special ists. I t is to be regretted th a t any school should stoop to m isrepresentation to induce patronage. A c ircular letter recently issued contained the fo llo w in g : “ We assure you that towns w ith a population o f 10,000 w ith a d jacent comm unities are p roviding am ple sources fo r very flattering orthodontic prac tices, and w here there is room fo r one there is room fo r an o th er.” Such a statem ent is so m anifestly absurd as to need no comm ent. H ow ever, we have high hopes fo r the qual ity o f our fu tu re specialists. W hen our university schools have perfected plans f o r postgraduate w ork covering a considerable period o f tim e we m ay then be proud o f the recruits to o u r ranks. I am sorry to say that, in m y opinion, the g reat influx o f specialists at the present tim e is the result o f the a llu re m ent o f the a lm ig h ty d ollar and th a t there is a g reat aw akening in store fo r the m ajo rity o f them . T h ere seems to be a very e rro neous idea o f the w ork, responsibilities and rew ards o f the orthodontic specialist a t least. A fte r all, the general p ractitioner is the im portan t m em ber o f the dental fam ily , and the only allurem ent o f the specialties, in the final analysis, is the satisfaction gained fro m d oing som ething in which one is p articu larly interested o r fo r which one has a special aptitude. Frederick S. S tillw ell, Cincinnati, Ohio: O rthodontia is the most exacting science den tistry can offer. I believe th at m any young men are draw n to this specialty by erroneous ideas as to large fees and are not shown the actual relation to tim e spent and money received. W h at can be done? As I see it, it is p a rtly the fa u lt o f the colleges. T h ey give too m uch train in g in m echanics; and the conception o f the mechanism o f the m outh and the developm ent or possibilities f o r lack o f developm ent are not presented as they should be. I believe every general prac titioner should consult frequently concerning children in his care w ith an orthodontist, and leave the question o f correction entirely to the la tte r’s judgm ent. Is it not reasonable to assume th at one who is a specialist and h ighly developed in one a rt is in a position to give better ju d g m en t and service than one w ho m ust keep up a semblance o f technic in m any branches? I f we can g et the general p ra c
Hoffman— The Allurement of Specialization titioner to sh ift the responsibility entirely onto the orthodontist as to e arly o r delayed treatm ent, we have done a g re at deal.
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into a credit to his specialty. O thers w ill fa ll by the wayside. Some o f the best men th at we have in o u r specialty today never even had a short course. T w o o f your speakers here H. F . H o ffm a n , D enver, C olo.: W e can today never have been allied w ith any o f the never get aw ay fro m the allurem ents o f so-called short course schools. T h e plan th at orthodontia, but w hat we m ust do, unless is being tried in several universities, th a t is, these allurem ents are to be the death o f our the one and the tw o year plans, are still on specialty, is to devise some m eans by which trial. W e do not know w hat they w ill p ro the practitioner o f a specialty, especially duce; but we know this: they w ill not orthodontia, shall be required to keep produce enough orthodontists; yet I do be him self prepared f o r the advance o f his lieve th a t they are going to produce a quality profession. O ur specialty occupies a unique o f m an th a t is m uch to be desired. T h ey position. W e have no legal requirem ents ex should give us teachers o f orthodontists and cept being licensed f o r the practice o f den I hope some good research men, which a short tistry, and we have absolutely no orthodontic course never could produce, but m ight educational standard o f qualifications. Ju st stim ulate. As f a r as D r. H offm an’s rem arks before I le f t home, a representative o f the about h av in g some standard or some periodical departm ent o f com m unity organization o f our exam ination w hereby we can see w hether they state university said to m e : “ W e are consider are keeping up in the specialty o f orthodontia, such as they are thin k in g o f applying in ing seriously a m ovem ent to require periodical reexam ination o f professional m en,” re fe rrin g C olorado to medicine and dentistry, th a t is possibly chim erical. It could not be done in especially in his conversation to physicians a dem ocratic fo rm o f governm ent under the and dentists. Teachers, as he said, are now present day civilization. So let’s fo rg e t that. required in m ost states to keep abreast o f the W e can only stim ulate a m an to advance. It advancem ent o f their profession. T h is, it is the individual effort o f the leading men in seems to me, m ight offer some solution to our the specialty, p a rticu la rly in Am erica and problem . I t w ill be a lo n g tim e before we C anada (a n d a fe w a b ro a d ), th a t has placed can be placed on any real leg a l fo o tin g re the specialty on the high plane w here it is q u irin g a definite standing, and i f we cannot today. I t is no reflection on these men th at do th at, we should do som ething else. T his nearly a ll o f them are graduates o f short w ould have to be a volu n tary m ovem ent in course schools. I t was m erely the only m ethod our ranks, and I believe it m ig h t be worked th at was presented a t th a t time. T h e short out to o u r advantage. course has its evils and they are decided evils. W . C. Fisher, N e w Y o rk C ity . D r. H off It has its advantages. I w ill say th a t they are m an’s paper could be discussed indefinitely; not so g reat as they looked a t one tim e to be, there are so m any branches to it th a t the dis but the people need orthodontists ju st as they cussers have gone off a t a tangent. I feel need dentists. T h e public has been educated very m uch as I im agine a law yer feels when in the benefits o f o rthodontia and orthodontic tak in g a case. I could take any side o f this treatm ent. T h e y have seen a sufficient num question and argue f o r or against it. I have ber o f children g re atly im proved in every had some experience in orthodontic education little com m unity, and we know th at when a and have been an earnest student o f it, yet I m an sees th at his little g irl is developing a do n o t believe, a fte r nineteen years, th a t we severe deform ity, he is goin g to seek service, have, o r w ill achieve, any one ideal m ethod too. I f you a re dissatisfied w ith present con o f producing orthodontists. Y ou w ill hear ditions, let us do as D r. W augh is try in g to criticism s o f short courses and a g re at deal do, as they are doing in Illinois, in the U n i in fa v o r o f the long course, and ju stly so. versity o f P ennsylvania and other schools. I believe th at we are goin g to produce orth o L et us see i f we cannot devise some w ay dontists tom orrow ju st as we produced them whereby we can supply a stim ulus to these yesterday— th ro u g h individual effort, purely graduates to come out and take up the plan and simply. I t has produced the g re at special th at D r. A bell has spoken o f, o r any plan th a t ists in m edicine f o r the past fifty years and it w ill develop the orthodontist. w ill produce them in dentistry. One m an can F rank M . Casto, C leveland, O h io : One o f take a short course a n d get enough stimulus the speakers stated th a t the allurem ent o f and sufficient know ledge therein to develop
1802
The Journal of the American Dental Association
specialization is still w ith u s; one rem arked th at the delusions are also still w ith us, and there m ay be some tru th in both. T h e dis cussion has resolved itself som ew hat into the question o f p relim in ary education or quali fication fo r those w ho desire to enter a special field o f practice. T h is subject has been dis cussed pro and con fo r, lo, these m any years, and opinions are alm ost as varied as there are opinions. Some believe th a t substantially more instruction in o rthodontia should be given to the undergraduate student in the dental schools. Others believe th at only the fu n d a m ental principles can be tau g h t. M ost o f the difficulty, I believe, lies in the fa c t th a t there never has been a real concerted effort on the p a rt o f the orthodontists to prescribe and es tablish a balanced, standardized course o f study. D ental educators recognize the ne cessity f o r teaching orthodontics, but they are sim ply gro p in g in the d a rk in reg ard to how it shall be tau g h t and the content o f the course. T h e orthodontists w ill have to as sume these responsibilities, and u n til they make good on the proposition, n o th in g different can be expected. T h e problem is becom ing m ore complex and m ore difficult o f solution. T h e requirem ents in a ll departm ents have a d vanced so ra p id ly th a t the curriculum is a l ready overloaded. A t present, in a ll good schools, the fo u r-y ear course o f study com pre hends fro m 4-,800 to 5,000 hours, an average o f approxim ately 1,250 hours per year, or about thirty-nine hours per w eek du rin g the th irty -tw o weeks o f instruction. A bout 100 hours are a llo tted to didactic and technic in struction in orthodontics. T h e num ber o f hours in clinical instruction varies w idely in different schools. I t is quite obvious, under the present circumstances, th a t it is possible to teach only a lim ited am ount o f orthodontics. T h is is also true in other special branches. A dean o f one o f our best dental schools had a vision. He thought he had a m ethod whereby the problem o f rendering efficient instruction in special branches could be solved. He pre sented the proposition to his fa cu lty , which briefly was as fo llo w s: T h ere m ust be a m inim um num ber o f hours in each subject that w ould meet the requirem ents fo r general
qualification, and which was less than the num bers o f hours now in vogue, in which case a m axim um num ber o f hours w ould be available to those students who were p a rticu la rly interested in some special subject, such as orthodontia, exodontia, prosthetics, and who developed some unusual ability or skill alo n g certain lines, i. e., a student could, therefore, take the m inim um num ber o f hours on one subject and the m axim um num ber o f hours in an o th er and still meet a ll o f the re quirem ents. H e requested the members o f the fa c u lty to consider this m atter c arefully and re p o rt back to him . T h e result was th a t every m an reported as a m inim um require m ent m ore hours than he previously had and a m axim um requirem ent f a r in excess o f any possible adjustm ent. T h e total num ber o f m inim um hours exceeded the present scheduled num ber by a bout 1,000, m aking a to ta l o f approxim ately 6,000, w hile the m axim um was m ore than 8,000. T h e fu tility o f such an a r rangem ent is im m ediately evident. I sim ply call yo u r attention to this incident to illustrate the u tter hopelessness o f attem pting to give enough instruction to the undergraduate to q u a lify him f o r special practice. I should be derelict in m y duty i f I did not correct the statem ent m ade by one o f the speakers in re g a rd to the unlim ited stress placed on mechanics in the dental schools today a t the expense o f the biologic sciences and didactic instruction. T h e curriculum in m ost schools presents a w ell-balanced course o f study. W ith the induction o f the preprofessional year, a ll o f the courses in the fundam ental sciences were advanced and enlarged, and the prerequisites were adhered to m ore con scientiously, and, as a result, the present-day dental student is receiving a fine education. T h e first tw o years is devoted m ostly to the study o f the basic sciences, in which extensive lab o rato ry instruction is given. A consider able am ount o f tim e is given to didactic instruction th ro u g h o u t the fo u r years. Cer tainly, the technic courses are as extensive as tim e w ill perm it, and a large am ount o f tim e is allotted to p ractical clinical instruction. It could not be otherw ise if a well balanced product is the goal.