Infinite cornucopia: The future of education and training in oral and maxillofacial surgery

Abstract

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 and the care of their patients. Advances in scope and relevance were reflected in changing professional societies, as the American Society of Exodontists became 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 its Committee on Resident Education and Training (CRET) to mandate 3-year integrated hospital programs, the development of full-time faculty training models, the creation of dual-degreed programs, and the fostering of accredited fellowship programs in head and neck oncologic surgery, reconstructive microvascular surgery, pediatric craniofacial surgery, and cosmetic surgery. Despite these successes, a number of issues currently surrounding OMS resident education must be settled if the specialty is to be well prepared for a changing health care environment and if the public need for hospital-based OMS services is to be met. The most important of these, in my opinion, is overcoming a serious dichotomy in major maxillofacial surgery experience and volume among United States training programs. It has been almost a decade since national implementation of 80-hour workweek 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 OMS resident training programs are accredited by the Council on Dental Accreditation (CODA), and as such are 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. While the effect of these work hour restrictions on patient care and resident education continues to be hotly debated, one thing is for sure and that is resident surgeons leave training programs with less experience and fewer cases.1Bilimoria K.Y. Chung J.W. Hedges L.V. Dahlke A.R. et al.National cluster-randomized trial of duty hour flexibility in surgical training.N Engl J Med. 2016; 374: 713-727Crossref PubMed Scopus (276) Google Scholar Despite little change in the overall number of matched OMS 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, particularly in the areas of maxillofacial trauma, temporomandibular joint (TMJ) disorders, and cleft lip and palate. A review of data obtained from the AAOMS2American Association of Oral and Maxillofacial Surgeons, 2011.Google Scholar suggests that since 1991, there has been a decrease by approximately 70% in the number of TMJ cases available for resident training. This is not surprising, given the changes in treatment paradigms that have occurred since the 1980s, which favor nonsurgical intervention. Nevertheless, open TMJ surgery still has a role to play, and it is increasingly worrisome that fewer and fewer residents are being trained adequately in this important aspect of OMS practice. Even more concerning, however, are the trends in craniomaxillofacial trauma surgery related to declining numbers of operative facial injuries, resident work hour restrictions and program-related limitations. For example, the number of midfacial fractures being reported by programs since 1991 has declined by approximately 20%. While this number may seem modest compared with declines in TMJ surgery, when taken in the context of the individual resident surgeon and the type of injury, the data are more sobering. In the academic year of 2007-2008, there were only 359 naso-orbital-ethmoidal (NOE) fractures reportedly available to train ALL of the senior OMS residents in the country. If all 1,372 Le Fort fractures available to train residents in 2007-2008 were evenly distributed amongst all OMS training programs (which they are not), there would be fewer than six cases per chief resident–hardly enough to gain competence, let alone expertise. Cleft lip and palate is perhaps the most challenging area in which to gain experience and is a historically important subspecialty interest for OMS residents; 794 cleft palate cases and 269 cleft lip cases were reportedly available for resident training during 2007-2008. This means the average chief resident will see approximately four palates and just over one 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 25 years ago, is now the most common procedure reportedly performed in OMS training programs, outnumbering mandibular fractures for the first time in 2007–2008. Ironically, as the number of office-based procedures has outpaced the number of hospital-based procedures overall, the number of benign and malignant pathology cases has doubled since 1991–1992, with malignant diseases outnumbering TMJ disorders for the first time in 2008. This finding likely corresponds with the rise in the number of OMS programs offering head and neck cancer services.3Clark PK, Markiewicz MR, Bell RB, Dierks EJ. Trends and attitudes regarding head and neck oncologic surgery: a survey of United States oral and maxillofacial surgery programs. J Oral Maxillofac Surg. 2012;70:717-729.Google Scholar 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 practitioners to abandon orthognathic surgery, relegating it to a few high-volume private practices and academic centers. These changes in resident caseload, particularly highlighted by the soft midface trauma volumes, the inadequate numbers of cleft cases and TMJ surgery, and the rising number of malignant cases is cause for OMS educators in the United States to re-evaluate the priorities and mechanisms by which residents are evaluated and trained. Since 1970 there have been two routes that lead to certification by the American Board of Oral and Maxillofacial Surgery (ABOMS): A 4-year certificate program, which includes 1 year of medical training on off-service rotations and 4 to 6 months of anesthesia; and a 6-year training program that integrates completion of a medical degree, 4 to 6 months of anesthesia, and 1 to 2 years of general surgery residency. The number of months spent on the oral and maxillofacial surgery (OMFS) service is typically 30 to 36 months in either program. Despite a dichotomy in training (i.e., medical degree), the scope of practice for US 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, fellowship training and academic involvement. In years past, if an OMS 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 OMS has significantly increased the opportunities available to those graduates of US oral and maxillofacial surgery programs wishing to expand their scope of practice. 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. In 2008, Laskin4Laskin DM. The past, present, and future of oral and maxillofacial surgery. J Oral Maxill6ofac Surg 2008;66:1037-1040.Google Scholar presented a vision of the future of OMS training that was based on training to achieve familiarity, competence, and expertise. In his model, it is assumed that “core” OMS training should develop expertise in all trainees in the areas of areas of oral medicine, dentoalveolar surgery, and preprosthetic surgery/implantology (i.e., oral surgery). It is also assumed that all trainees are trained to achieve competence in craniomaxillofacial trauma, orthognathic surgery, and TMJ surgery (i.e., maxillofacial surgery). It is clear, however, that not all training programs are equipped to achieve this goal. Even though training standards exist, these standards are so broad that even programs with very limited scope of training will meet accreditation standards by reporting a narrow set of hospital-based procedures that are not representative of the scope of practice required of modern OMS. We are kidding ourselves if we say that the training of a resident who managed a few dozen isolated mandible fractures at a community hospital is equivalent to that of one whose training occurred at a designated level 1 trauma center and involved the full spectrum of craniomaxillofacial trauma, airway management, and penetrating neck injuries. Likewise, if a resident has never been exposed to head and neck oncologic surgery or microvascular surgery, then achieving even familiarity would be difficult. Furthermore, if there are only so many NOE fractures and cancer cases available with which to train residents, should such cases be operated on by the surgeons of the future who will never see them again after training? There are many reasons for the training dichotomy that exists today--including training program location, the presence or absence of a trauma center, limited head and neck surgery experience, and local politics--but regardless, the goal should be the same: to train oral and maxillofacial surgeons to competence in the core areas of the specialty that they will eventually practice. Because 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 would also allow surgeons of the future to train to the level of their interest, while maintaining the manpower that is necessary to provide needed OMS services to the public. 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. Further fellowship training would be necessary in the subspecialty areas of head and neck oncology, microvascular surgery and pediatric cleft and craniofacial surgery. 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, medical center resources and access to clinical material. Yes, it would require two ABOMS certificates---one in oral surgery and another in maxillofacial surgery---but such subspecialization may be necessary in the future. It is time for a hard look at the product that we are turning out when we define what it is to be a graduate of an OMS program. If OMS accrediting bodies are to legitimately offer to the public a product that is trained to competence in maxillofacial trauma, for example, then training programs in the future might, in fact, look more like training consortiums, defined and identified by accrediting bodies or the AAOMS’s CRET. Indeed, this might necessitate a resident’s relocation to different cities or states during their training to have access to adequate clinical material, as is currently the norm in the United Kingdom, or even for interdisciplinary cooperative groups to share experiences in those overlapping areas of interest, such as trauma. But it will also allow for those trainees with no interest in hospital-based surgery to leave training earlier and in less debt. 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 OMS education and training. It is time for our specialty's leaders and CRET to once again push the specialty forward through difficult actions that set objective standards for major hospital-based maxillofacial surgery and consider radical changes in educational tracts and certification. Programs or departments that cannot provide that training must be matched with those that can. This will undoubtably lead to uneasy partnerships between academic and community-based health systems, and subspecialty departments, as well as a lot of angst as things get sorted out. But, it will take years to achieve, so the sooner we get started, the better.