Future of North American Oral and Maxillofacial Surgery
R. Bryan Bell, DDS, MD, FACS
Leon A. Assael, DMD
Shahrokh C. Bagheri, DMD, MD, FACS
Eric J. Dierks, DMD, MD, FACS
Leonard B. Kaban, DMD, MD, FACS
Roger A. Meyer, DDS, MD, FACS
Robert A. Ord, DDS, MD, FACS
M. Anthony Pogrel, DDS, MD, FACS
Contributors are Fellows of the AACMFS
Disclaimer: This article is for background information for the fellows of the AACMFS. The AACMFS does not take any responsibility for the facts or opinions expressed.
The modern version of the specialty of oral and maxillofacial surgery (OMS) in the United States emerged through the vision of early oral surgeons desiring to improve the specialty. Advances in scope and relevance were reflected in changing professional societies, as the American Society of Exodontists become the American Association of Exodontists and Oral Surgeons, followed by the American Association of Oral Surgeons, and finally the American Association of Oral and Maxillofacial Surgeons (AAOMS). Facilitating these changes were several milestone achievements, which include the establishment of the American Board of Oral (and Maxillofacial) Surgery following World War II, the decision on the part of AAOMS and CRET to mandate 3 year integrated hospital programs, the development of full time faculty training models, and the creation of dual degreed programs.
Controversy has existed throughout the specialty’s evolution. However, no issue in OMS has elicited more passionate opinions from dentists, physicians and lay people than that of training and scope of practice. Critics of the various training pathways throughout the world have derided them as being either too long or too short, depending upon the specific area of interest.(1-12) In the early 1980’s, visionary American Oral and Maxillofacial Surgeons on the American Association of Oral and Maxillofacial Surgeons Committee for Resident Education and Training (CRET) pushed to develop strong ties with the American College of Surgeons (ACS), advocated for advanced training programs and joint accreditation by Commission of Dental Accreditation (CODA) and Accreditation Council for Graduate Medical Education (ACGME), and fostered the development of dual degree programs for those residents interested in expanded scope practice. The effect of failure in the first initiative was recently manifested by the omission of oral and maxillofacial surgery from the ACS Committee on Trauma Resources for the Optimal Care of the Injured Patient,(13) and threatens the specialty’s position within the national health care debate. The later endeavor, however, was more successful, and recently the product of accredited fellowship training programs in “expanded scope” areas, such as head and neck oncologic surgery, microvascular reconstructive surgery and pediatric craniofacial surgery, has matured into a thriving minority within North American oral and maxillofacial surgery.(14-16) Just as the development of and training in orthognathic surgery contributed to the evolution of the U.S. specialty from oral surgery to one of oral and maxillofacial surgery in the late 1960’s and 1970’s, so too is advanced fellowship training having a transformative effect on the specialty today.
In 2010, the United States Congress passed and President Obama signed into law the Patient Protection and Affordable Care Act,(17) ushering in a new era of change and opportunity for American health care in general and Oral and Maxillofacial Surgery in particular. Coincidentally, North American Oral and Maxillofacial surgery finds itself precariously perched on a platform between two diverging professions-medicine and dentistry-as the quality, quantity, purpose, education, and training of the health professional workforce again becomes a major policy issue in the United States. Not since the “Great Society” legislation of the 1960’s has the American system of health care delivery been so greatly affected. While the ultimate impact of this law upon oral and maxillofacial surgeons is still unknown, it is clear that government and third party payers will increasingly influence the practice of major components of oral and maxillofacial surgery in the future.
In order to prepare for this reality, it is imperative that the academic and political leadership of our profession take a proactive approach in moving educators, practitioners, governmental agencies, professional societies, educational foundations, industry, insurers, and patients toward improving oral and maxillofacial health in the United States. It will be argued in this paper that to achieve this aim, a tripartite strategy of reform should be initiated that will fortify the three core areas of academic oral and maxillofacial surgery: patient care; education; and research.
The Nobel Laureate, Leszek Kolakowski, described as “infinite cornucopia” the concept that for “any given doctrine that one wants to believe, there is never a shortage of arguments by which one can support it”. Such it is with regards to the controversies surrounding patient care, education, advocacy, and research in oral and maxillofacial surgery. At issue are: the public health needs of our patients; an individual surgeon’s scope of practice, financial prosperity, and lifestyle; and the trainee’s desire or merit.
HISTORICAL PERSPECTIVE
The first dental school in the United States was the Baltimore College of Dentistry and the first university-based dental school was Harvard University School of Dental Medicine, established in 1867. Before then, an individual could become a dentist in two ways—graduate from medical school and apprentice to a MD dental surgeon, or by apprenticing to a non-MD dental surgeon, without previously obtaining an advanced degree. The dental degree and the formal separation of the professions came after dental schools were developed, but a dichotomy in the training of what were then termed “dental surgeons” continued throughout the 19th and early part of the 20th century, with some having medical degrees and no dental degree, some with a dental degree but no medical degree, and some with both degrees.
At the turn of the 19th century, a health care policy debate in the United States centered around the numerous proprietary medical and dental schools that existed at the time, which contained significant disparities in qualified faculty, staff, facilities, and curricula. The Carnegie Foundation for the Advancement of Teaching commissioned Abraham Flexner to report on the overall quality of health education, the results of which were published in 1010.(19) As a result of the so-called “Flexner Report”, many medical schools closed and quality standards were implemented and incentives provided that resulted in a significant expansion in the number of medical and dental schools housed within North American universities.
In 1926, William J. Gies authored the tenth of the series of reports supported by the Carnegie Foundation for the Advancement of Teaching.(20) This report focused on dental education and supported science-based health professional education that included basic sciences. Specifically, the report recommended that: dental education and science must be comparable to medical education in quality and support; dental educators must perform in teaching and research comparable to the best of a good university; the preparatory education/requirements for medicine and dentistry should be comparable, and: the training be provided in both a clinic-based as well as a hospital based environment.(20,21)
Thus a “special relationship” between medicine and dentistry was forged in which medicine abrogated oral health care to dentistry.(22) Implied in this paradigm of regionalized care was that dental schools would be part of the greatest universities housed within medical schools and that dentistry would be the anatomically based practice of medicine and surgery. Dentists would have full patient care responsibility within their scope of practice, could prescribe, supervise, be licensed, have hospital admitting privileges, and that the professions would have a common biomedical education.
The evolution of oral and maxillofacial surgery in the United States can be traced to when dentistry began to be formally integrated into United States hospitals with the appointment of Charles Wilson in 1872 to the medical staff of the Massachusetts General Hospital as Director of the Dental Clinic. Coinciding with the development of “hospital dentists” was the already established paradigm of medically qualified, and self-described “oral surgeons” such as Simon Hullihen and James Garretson. Garretson, in fact, persuaded the American Medical Association to establish a Section of Oral Surgery, which was formed in 1881, later becoming the Section of Stomatology.(18) In 1918, the American Society of Exodontists was founded by a group of dentally qualified, hospital based surgeons. By 1921, a separate group of medically qualified “oral surgeons” founded the American Association of Oral Surgeons, which in 1931 would become the American Society of Plastic and Reconstructive Surgeons, eventually resulting in the disbandment of the AMA’s section of stomatology in 1925. Also in 1921, the American Society of Exodontists changed their name to the American Society of Oral Surgeons and Exodontists, setting the stage for a century of competition between medically and dentally qualified “oral surgeons”. In 1946, the American Society of Oral Surgeons dropped the “Exodontist” qualifier from their name, and the following year, in 1947, the medically qualified group (most of whom also had dental degrees) formed the American Society of Maxillofacial Surgeons. As the dentally qualified version of “oral surgery” continued to expand their scope of practice in the areas of maxillofacial trauma, pathology and congenital and developmental facial deformities, members of the American Society of Maxillofacial Surgeons became increasingly tied to organized plastic surgery. Singly qualified plastic surgeons (MD-only) became trained in various aspects of maxillofacial surgery and increasingly outnumbered the dually trained (MD-DDS) oral surgeons of the past. In 1977, the American Association of Oral Surgeons changed their name to the American Association of Oral and Maxillofacial Surgeons, which appropriately reflected their member’s involvement in major maxillofacial surgery, particularly orthognathic surgery and trauma. Thus by the beginning of the 21st Century, the term “oral and maxillofacial surgeon” in North America typically applied to a specialist of dentistry that may or may not hold a medical degree, and the term “plastic surgeon” applied to a specialist of medicine that may practice components of oral and maxillofacial surgery but in only a few instances holds a dental degree. The resistance to the idea of oral surgery as a distinct medical specialty demonstrates that even 100 years ago the time was not yet ripe for the integration of dental science into medicine.
CURRENT STATE OF DENTAL EDUCATION
Currently dental education is being affected by declining federal and state funding for higher education, an unsustainable health care delivery/economic model, an antiquated dental curriculum, a strong private practice economy, and a crisis in faculty recruitment and retention Furthermore, the “special relationship” between medicine and dentistry has eroded close to the point of abandonment mostly due to the actions within organized dentistry and dental education that have separated dentistry from medicine. The decision by the American Dental Association to “opt out” of Medicare/Medicaid programs, as well as most medical insurance programs, in order to maintain a reasonable level of reimbursement has resulted in a much-celebrated economic model of health care delivery. But it has done so at the result of producing significant access to care issues that politicians are just now beginning to address. This political interest is evidence by actions of federal and state governments that have the authority to sanction so-called “mid-level providers” to care for underserved populations whose higher oral diseases rates and unmet oral care needs are well documented.(23) At the same time, dentistry has effectively removed itself from the health care debate, based its economy on a handful of remunerative procedures, and made itself vulnerable to the policy decisions of other health care agencies and professions.
A number of prominent dental educators have also bemoaned the deterioration of dental education in so much that it has not been responsive to shifting patient demographics and/or expectations, changing health system expectations, evolving interdisciplinary expertise, quality improvement, new scientific discoveries, and/or integration of emerging technologies.(23-28) More recently, the previously mentioned access to care issues have provided impetus for the rapid expansion in the number of U.S. dental schools, which are primarily being created as freestanding, for-profit schools housed outside of a university setting. These proprietary dental schools have largely abandoned the full-time faculty model of dental education, depend upon community-based practitioners to provide a clinical experience for their students, prioritize procedural or technical expertise over biomedical education, and provide little or no environment for scholarly activity or research. Furthermore, in an effort to minimize the need for non-clinical faculty, these new dental schools have severely limited their biomedical curricula to the point at which it is almost equivalent in clock hours to that of dental hygiene therapy programs in the United States and Europe: There is currently a 3.7 fold variation (from 478 to 1780 clock hours) in biomedical training among CODA-approved schools of dentistry. That such a disproportionate amount of time in dental school is still spent on the technical aspects of GV Black’s principles of operative dentistry, at the expense of basic science education, says as much about the state of dental education as it does about the risk that dentistry is devolving into a trade. That some of the most profound discoveries in oral health are today made outside of the dental school environment further describes the state of dental research.
Most worrisome for the preparation of oral and maxillofacial surgeons of the future, however, is the steady and continual erosion of the basic science curricula. How can we adequately prepare surgical residents for the complexities of patient care, let alone prepare them for medical and/or specialty board examinations, if the core sciences are minimized to the point of omission?
In addition to the myopic curriculum, dental education suffers from the same academic fragmentation that characterizes most universities: a disconnect between the clinical sciences, the basic sciences, and the various health care disciplines. Such “educational silos” prevent cross fertilization among students, residents, practitioners, clinical researchers and basic scientists. The fact that most dental schools have no access to the electronic medical record of their associated hospital or health center is at best a practical omission of economic necessity and at worst a statement regarding the considered relevance of dental services at our nation’s university health systems. It is certainly a gross disservice to the students and patients they serve.
ORAL AND MAXILLOFACIAL SURGERY TRAINING
So as dental education is at a crossroads, so too is oral and maxillofacial surgery training. (28) Since 1970, there have been two routes that lead to certification by the American Board of Oral and Maxillofacial Surgery: A four year certificate program, which includes one year of medical training on off-service rotations and 4 to 6 months of anesthesia; and a six year training program that integrates completion of a medical degree, 4-6 months of anesthesia, and 1-2 years of general surgery residency. The number of months spent on the oral and maxillofacial surgery (OMFS) service is typically 30-36 months in either program.
Currently there are a number of issues surrounding resident education that challenges both of the training models in oral and maxillofacial surgery. These include resident work hour restrictions, declining number of cases in core competencies, generational differences in attitudes towards “quality of life”, and demands for increases in anesthesia training, in addition to the same faculty retention and recruitment issues that face dental schools.
Resident work hour restrictions
It has been seven years since national implementation of 80-hour work week restrictions for medical residents. The Accreditation Council for Graduate Medical Education (ACGME) instituted these work hour restrictions in response to concerns about fatigued residents and medical errors. While OMFS resident training programs are accredited by the Council on Dental Accreditation (CODA), and are such not subject to the ACGME regulations, most hospital graduate medical education programs have expected compliance from all of their resident training programs, including oral and maxillofacial surgery.
A recent comprehensive review of published data related to resident work hour limitations in the United States suggests that the results of the ACGME guidelines are mixed.(29) Resident quality of life, as evidenced by decreased depression, decreased emotional exhaustion, less risk of motor vehicle crash, more time with family, and more time to read has clearly improved.(30,31) Less clear however, is the impact of work hour restrictions on operative volume and patient care. There are data that suggest that the quality and quantity of surgical cases has decreased during the last several years, especially in the context of major, emergency surgery.(32-38) In addition, several studies have documented surgical resident dissatisfaction with the work hour restrictions and echoed concerns over continuity of care.(39-42)
Declining number of cases
Despite little change in the overall number of matched OMFS resident positions in the United States annually, the number of cases available to train those residents in certain key areas of major maxillofacial surgery is declining or remains inadequate. This is particularly true in temporomandibular joint (TMJ) surgery, midfacial trauma, and cleft lip and palate. A review of data obtained from the AAOMS suggests that since 1991 there has been a decrease by approximately 70% in the number of TMJ cases available for resident training (Table 1). Furthermore, the number of midfacial fractures (Le Fort I, ZMC, NOE) during the same time period declined by approximately 20%. In the academic year of 2007-2008, there were only 359 NOE fractures available to train ALL of the senior OMFS residents in the country. If all 1372 Le Fort fractures available to train residents in 2007-2008 were evenly distributed amongst all OMFS training programs (which they are not), there would be fewer than 6 cases per chief resident–hardly enough to gain competence, let alone expertise.
These numbers are even more sobering when examining the number of cleft lip and palate cases-an historically important subspecialty interest for OMFS residents. 794 cleft palate cases and 269 cleft lip cases were available for resident training during 2007-2008. This means the average chief resident will see approximately 4 palates and just over 1 cleft lip-barely enough for familiarity.
Interestingly the two areas of greatest specialty growth during the last 20 years, as manifested by resident caseload, have been in the areas of dental implantology and benign and malignant pathology. Dental implant placement, not even in existence 20 years ago, is now the most common procedure reportedly performed in OMFS training programs, outnumbering mandibular fractures for the first time in 2007-2008. Coincidentally, the number of benign and malignant pathology cases has doubled since 1991-1992, with malignant disease outnumbering TMJ disorders for the first time in 2008. Orthognathic surgery numbers remain flat, but access to adequate numbers of cases for training at some institutions is limited by health policy decisions and economic realities. Trends in insurance coverage and low reimbursement in some parts of the country have caused many practioners to abandon orthognathic surgery, relegating it to a few high volume private practices and academic centers.(43)
These changes in resident case load, particularly highlighted by a soft midface trauma volumes, inadequate numbers of cleft cases, and a rising number of malignant cases is cause for American OMFS educators to reevaluate the priorities and mechanisms by which residents are evaluated and trained.
Faculty retention and recruitment
Editorials citing a “crisis” in faculty retention and recruitment began appearing the Journal of Oral and Maxillofacial Surgery in 1991.(44) Since then, at least a dozen articles and/or editorials have called for substantive action to assist academic programs in attracting and fostering the careers of budding academicians.(44-56) In 2002, the AAOMS and the Oral and Maxillofacial Surgery Foundation (OMSF) awarded the Faculty Educator Development Award (FEDA) to select junior full-time oral and maxillofacial surgery faculty. The purpose of the award was 3-fold: 1) encourage promising young oral and maxillofacial surgeons to choose a career in academia; 2) encourage promising junior faculty members who have been on faculty for up to 5 years to continue a career in academia; and 3) provide a financial incentive to dental schools and residency training programs to recruit and maintain faculty. Currently, the FEDA award is $130,000 ($40,000 to the awardee annually for 3 years and $10,000 to the institution). In return, the FEDA recipient is expected to stay in full-time academics for 6 years. To date, 33 individuals have received the FEDA, of which 4 have left academics prior to completion of their 6 year commitment.
Initially awarded based entirely on merit, the FEDA has evolved into an award based on financial need, not upon research development. While admirable in its purpose, there is reason to believe that the tax-liable FEDA may not be having its intended consequences. A recent survey of FEDA recipients cited dissatisfaction with the selection process and award disbursement, and was equivocal on whether or not the award was helpful in advancing careers.(51) The reason for this is multifactorial, but it may relate to frustration with individuals academic career as a whole: Academic departments are increasing cashstrapped, the clinical volume is flat, protected time for research is scarce, and funding for research projects is difficult to obtain.
Reinvigoration of academic OMFS departments will require much more that simply padding the salary of a few junior faculty–it will require re-thinking the current paradigm of providing “oral and maxillofacial surgical services” to a dental school and/or medical center. It will require the development of “oral health” centers that integrate dentistry with medicine into an economically viable oral health service, including the disciplines of oral and maxillofacial surgery, oral medicine, oral pathology, oral oncology. No longer is it enough for these subspecialties to exists within the ivory towers of university dental schools. Medical centers all over the United States are in need of oral health services, due to the disconnect between dentistry and public health systems, governmental and 3rd party insurance programs. It is possible that the oral and maxillofacial surgery training program of the future should be Medical Center based and affiliated primarily with hospitals and medical schools as well as dental schools.
Oral and maxillofacial surgery is a natural conduit between medicine and dentistry. The OMFS department of the future should establish clinical and research programs in oral cancer, cranio-maxillofacial trauma, and pediatric surgery, which will in turn provide relevance to the communities, hospitals and health systems they serve. Sound clinical programs are the driving force behind research and education and will in turn attract not only well-qualified applicants and faculty, but also non-clinical researchers. Reinventing the oral health service model by fostering the development of academic OMFS surgeons with advanced fellowship training in the areas of head and neck surgery, microvascular surgery, craniomaxillofacial trauma, pediatric cleft and craniofacial surgery will not be easy. However, support for focused, quality scientific research, specialized surgical training, and improvements in OMS resident education will reward the academician, the specialty, and the patients they serve.
Tiered Training
Despite a dichotomy in training (ie. medical degree), the scope of practice for U.S. oral and maxillofacial surgeons has generally been essentially the same, regardless of degree. While some differences have been noted between dual degree and single degree surgeons, it appears that more substantive differences in scope of practice are related to geographic location, years in practice, and academic involvement.(56) In years past, if an OMFS graduate wished to obtain training in any areas beyond that which was received in residency, then he or she was forced to seek it outside of the specialty, in either otolaryngology or plastic surgery. Recently, however, the development of a number of formally recognized and accredited advanced training fellowships within OMFS has significantly increased the opportunities available to those graduates of US oral and maxillofacial surgery programs wishing to expand their scope of practice.(14) The result has been the development of a de-facto tiered system of training within OMS that is based upon the trainee’s desire, merit, and quite often, degree.
Since there are currently fewer cases in which to train to proficiency, fewer hours in the day in which residents are available for training, fewer full-time faculty to provide training, and a clear lack of desire or financial feasibility on the part of many of the trainees to enter into complex maxillofacial surgery, why not concentrate training at centers or regions in a “tiered” manner, based upon the trainee’s desire and merit? This approach would be tailored to leave room for both pathways (single degree and dual degree), but also allow surgeons of the future to train to their level of their interest, while maintaining the manpower that is necessary to provide needed dental services to the public (figure 2).
In 2008, Laskin(56) presented a vision of the future of oral and maxillofacail surgery training that was based upon training to familiarity, competence and expertise. In his model, it is assumed that “core” OMS training should be achieved to expertise for all trainees in the areas of areas of oral medicine, dentoalveolar surgery and preprosthetic surgery/implantology (ie. oral surgery)(Figure 3). It is also assumed that all trainees are trained to competence in cranio-maxillofacial trauma, orthognathic surgery and TMJ surgery (ie. maxillofacial surgery. As evidenced in Figure 1, however, it is clear that not all training programs are equipped to achieve this goal. There are many reasons for this– including training program location, the presence or absence of a trauma center, and local politics–but regardless the goal should be the same: to train oral and maxillofacial surgeons to competence in the core areas of both oral AND maxillofacial surgery. Currently the dichotomy in training extends to the training programs themselves, not just whether or not a medical degree is offered as a part of the curriculum. A tiered system of training would allow for residents in the future to customize the location of their training to high volume centers based upon their desire and merit (Figure 4). Further fellowship training would be necessary in the subspecialty areas of head and neck oncology, microvascular surgery and pediatric cleft and craniofacial surgery.
Alternatively, a uniform pathway that incorporates a medical degree for all trainees would allow a similar amount of customization, and also remove the dichotomy or perceived dichotomy in training for the public and health care providers The disadvantage is that it may also be less attractive to some students due to the added length of time (2 years). In addition, a separate single degree specialty would likely emerge out of the transition, as has been the case in Great Britain, or a competing dental specialty (ie. periodontology) \would fill a real or perceived void left by a resultant manpower deficiency.
Either way, it is clear that OMFS education has not changed to reflect the evolving scope of practice defined by an increasing minority who has received fellowship training in head and neck oncology, microvascular surgery, or pediatric cleft and craniofacial surgery. The specialty of OMFS will increasingly be held to the same standard and expectation as colleagues in competing medical/surgical subspecialties.
We concluded therefore, that major educational reform of our training programs is necessary to address the issues outlined above. At issue is creating a continuum of training that focuses on allowing residents to train to their level of interest and competence, while utilizing optimal resources based upon regional politics and access to clinical material. Consideration should be given to having our fellowships and residencies accredited by the ACGME in order to alleviate concerns over the integration of dentistry into health education. . In addition, a dialogue should be held regarding creation of a separate subspecialty examining board, allied with or part of the American Board of Oral and Maxillofacial Surgery. Finally, a task force should investigate the feasibility of specialty recognition by the American Board of Medical Specialties for those surgeons who are medically qualified. In doing so the specialty will not distance itself from dentistry, but ford a much needed crossing between dentistry and medicine for the practice of core OMFS areas of dentoalveolar surgery, orthognathic surgery, etc., and also to establish a foundation for those medically qualified practitioners trained in and clearly practicing subspecialty areas that push the (real or perceived) boundaries of traditional dental practice acts.