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The High Cost of Infrequent Events
EDITORIAL J Oral Maxillofac Surg 64:157, 2006
The High Cost of Infrequent Events What an evening it was, ignited by a thoughtful, serious inquiry from a leader of the specialty. “Why do you spend so much time training residents to do procedures they will never do in practice?” “Do you really think we should be training all of them to do that stuff?” Another prominent member of the practice community then chimed in, “Your resident (looking for an associateship) told me he had done 58 tracheostomies in his training. I replied that, fortunately, I haven’t had to do one in 25 years of practice!” Next, a wizened surgeon reached for his pipe and declared, “The residents need to understand that what makes them special is their ambulatory surgery capabilities. The needle goes in the arm and out comes the tooth.” I must admit that while I agree that our dentoalveolar core is the deserved, indivisible, heart of the specialty, I felt battered by their skepticism and contrarianism directed at the broad scope of contemporary oral and maxillofacial surgery training, and the lengthy, demanding program we require for specialty certification. I was also baffled at how the tables had seemingly been turned on a specialty that had spent decades achieving a scope and relevance that was the envy of other surgical disciplines. Had we been lulled by our own success? My self-doubt was augmented by the rarified OR schedule of the coming week that included patients being treated for a central giant cell lesion, nasal orbital trauma, tumor resection and fibula transfer, open condylar fracture, cleft, and osteotomy for skeletofacial deformity. The residents were sure to never leave the OR under that onslaught. Was I wasting their time? Worse, was I potentially hurting their future patients because their skills were doomed to remain unretained while their expectations would remain high? Or, would they eventually lose their sense of specialty identity to practice the full scope of oral and maxillofacial surgery? Were they destined to be frustrated by the realities of daily practice? Obsolescent. . .or complacent? I was reminded of a lecture to my class when I was a student, from a man of mythic stature, Francis Moore, then Surgeon in Chief of the Peter Bent Brigham Hospital. The first rare and demanding event of his career was during his residency in 1942 when the Cocoanut Grove Nightclub burned, killing nearly
500 people. His often futile treatment of the burn patients admitted to the Massachusetts General Hospital inspired a lifelong devotion to the metabolic aspects of surgical care, an undaunting aversion to undeserved death of patients, and a resulting intolerance for anything less than unwavering excellence in patient care. It was no surprise that in his lecture to us he railed against surgeons with insufficient experience to manage a clinical problem, the surgeon who would generate high costs, in life and limb, in the treatment of rare conditions. Curiously, in his lecture, “The High Cost of Infrequent Events,” he never mentioned his pioneering work with Joe Murray, culminating in the first kidney transplant. How did Dr Moore accommodate the tension created by clinical need, risk assessment, and a desire to make a difference for rare clinical problems? What is clear from my practice is that rare events seek us out whether we seek them or not. What makes us specialists is our ability to carry core diagnostic and clinical skills in oral and maxillofacial surgery toward successful treatment of the many rare and challenging problems that find their way into daily practice. For example, in this issue of JOMS, bone-grafted implants in clefts, sandwich alveolar osteotomies, tissue engineering of the mandible, restylane soft tissue reconstruction, mucormycosis, curvilinear craniofacial distraction osteogenesis, surgical expansion of the maxilla, and atrophic mandible fractures, are presented. Each of these problems will rarely present in daily practice. Yet, all require the special talents of oral and maxillofacial surgeons. Rare events, in the aggregate, occur commonly. By the next morning I had recovered from my self-doubting funk. As if to confirm my contention, a phone call from a fine surgeon in a small Montana city refreshed my spirits: “What are your thoughts on this patient with a recurrent central giant cell lesion?” he asked. “Would you recommend steroids, calcitonin, interferon, or bisphosphonates?” I nearly smiled through the phone. “It’s all in the Journal,” I replied, “I’ll send you some reprints.” LEON A. ASSAEL, DMD
© 2006 American Association of Oral and Maxillofacial Surgeons doi:10.1016/j.joms.2005.12.004
157
The High Cost of Infrequent Events What an evening it was, ignited by a thoughtful, serious inquiry from a leader of the specialty. “Why do you spend so much time training residents to do procedures they will never do in practice?” “Do you really think we should be training all of them to do that stuff?” Another prominent member of the practice community then chimed in, “Your resident (looking for an associateship) told me he had done 58 tracheostomies in his training. I replied that, fortunately, I haven’t had to do one in 25 years of practice!” Next, a wizened surgeon reached for his pipe and declared, “The residents need to understand that what makes them special is their ambulatory surgery capabilities. The needle goes in the arm and out comes the tooth.” I must admit that while I agree that our dentoalveolar core is the deserved, indivisible, heart of the specialty, I felt battered by their skepticism and contrarianism directed at the broad scope of contemporary oral and maxillofacial surgery training, and the lengthy, demanding program we require for specialty certification. I was also baffled at how the tables had seemingly been turned on a specialty that had spent decades achieving a scope and relevance that was the envy of other surgical disciplines. Had we been lulled by our own success? My self-doubt was augmented by the rarified OR schedule of the coming week that included patients being treated for a central giant cell lesion, nasal orbital trauma, tumor resection and fibula transfer, open condylar fracture, cleft, and osteotomy for skeletofacial deformity. The residents were sure to never leave the OR under that onslaught. Was I wasting their time? Worse, was I potentially hurting their future patients because their skills were doomed to remain unretained while their expectations would remain high? Or, would they eventually lose their sense of specialty identity to practice the full scope of oral and maxillofacial surgery? Were they destined to be frustrated by the realities of daily practice? Obsolescent. . .or complacent? I was reminded of a lecture to my class when I was a student, from a man of mythic stature, Francis Moore, then Surgeon in Chief of the Peter Bent Brigham Hospital. The first rare and demanding event of his career was during his residency in 1942 when the Cocoanut Grove Nightclub burned, killing nearly
500 people. His often futile treatment of the burn patients admitted to the Massachusetts General Hospital inspired a lifelong devotion to the metabolic aspects of surgical care, an undaunting aversion to undeserved death of patients, and a resulting intolerance for anything less than unwavering excellence in patient care. It was no surprise that in his lecture to us he railed against surgeons with insufficient experience to manage a clinical problem, the surgeon who would generate high costs, in life and limb, in the treatment of rare conditions. Curiously, in his lecture, “The High Cost of Infrequent Events,” he never mentioned his pioneering work with Joe Murray, culminating in the first kidney transplant. How did Dr Moore accommodate the tension created by clinical need, risk assessment, and a desire to make a difference for rare clinical problems? What is clear from my practice is that rare events seek us out whether we seek them or not. What makes us specialists is our ability to carry core diagnostic and clinical skills in oral and maxillofacial surgery toward successful treatment of the many rare and challenging problems that find their way into daily practice. For example, in this issue of JOMS, bone-grafted implants in clefts, sandwich alveolar osteotomies, tissue engineering of the mandible, restylane soft tissue reconstruction, mucormycosis, curvilinear craniofacial distraction osteogenesis, surgical expansion of the maxilla, and atrophic mandible fractures, are presented. Each of these problems will rarely present in daily practice. Yet, all require the special talents of oral and maxillofacial surgeons. Rare events, in the aggregate, occur commonly. By the next morning I had recovered from my self-doubting funk. As if to confirm my contention, a phone call from a fine surgeon in a small Montana city refreshed my spirits: “What are your thoughts on this patient with a recurrent central giant cell lesion?” he asked. “Would you recommend steroids, calcitonin, interferon, or bisphosphonates?” I nearly smiled through the phone. “It’s all in the Journal,” I replied, “I’ll send you some reprints.” LEON A. ASSAEL, DMD
© 2006 American Association of Oral and Maxillofacial Surgeons doi:10.1016/j.joms.2005.12.004
157