The Baby Boom created the current incarnation of oral and maxillofacial surgery, a specialty characterized by enormous economic, political, and clinical success. Today’s specialty (as well as all other dental and medical specialties) is a creature of the wants and needs of the Baby Boom generation. Proprietary office-based practice (more than 90% of Boomer OMS are self-employed), strong attention to the business of practice, hard work, a striving for broad clinical scope, and deferred rewards of time and money are characteristics of the Boomer oral and maxillofacial surgeon. As the Boomer generation ages and moves on, what will our specialty look like? What inevitable changes will occur? What actions can we take to promulgate our future success? To explore these questions, it is interesting to examine the current sociology/demographics of our specialty.
Boomers Moving On
During the height of the Baby Boom, dentistry and OMS were highly competitive careers. At the peak in 1975, 16,000 college students sought dental education with about 6,200 freshman dental school spots available. About 6 applicants were available for each of the 230 positions in our OMS residencies. Men filled nearly all of the OMS residency slots with just 2% going to under-represented minorities and 1% to women. The Boomers who entered OMS were focused on developing a meaningful career and philosophy of life while having greater economic success than their parents.
Baby Boomers have morphed into the last generation of sole household providers. They often have extended/multiple families. They are the sandwich generation, whose children remain financially dependent on them while their living parents require ever-greater care and resources. Boomers are an orthopedic surgeon’s and a cosmetic surgeon’s dreams come true as they strive to maintain their appearance and love of physical recreation. They are flat out opposed to aging. While they often seek early retirement, it is out of a desire to be an active retiree.
However, family obligations, insufficient planning, and poor interest rates continue to defer retirement plans for most Boomer surgeons indefinitely. The aging workforce of Baby Boomers and public need have driven the average age of practicing oral and maxillofacial surgeons ever higher. In spite of their persistence, Boomers must eventually move on and leave the specialty to succeeding generations. A majority of the oral and maxillofacial surgery workforce will likely retire before the end of the twenty teens.
Generation X, Moving Out
When Generation X applied to dental school our profession was perceived as senescent. Thus in 1989, there were just over 4,000 applications for 4,000 positions. Today there are about 300 applicants for our 180 OMS residency slots.
Gen X is also known as the missing Generation, the generation that didn’t show up, and the Baby Busters. Bowling leagues, community service clubs, professional organizations, and mainline religious organizations have all felt the brunt of Gen X’s failure to participate. American Dental Association membership has fallen from over 85% of dentists to 72%.
In oral and maxillofacial surgery, an entire generation has not shown up to be educators. Only 1 in 200 recent dental graduates has expressed an interest in being an educator. The few Gen Xers who have entered education have in large part left for private practice.
Our trainees have also fallen to the effects of life in Generation X. About 300 residents in oral and maxillofacial surgery have resigned during training in the past 10 years, fully 18% of the expected emerging workforce of 1,800 new surgeons in the past decade. That one 10-year effect is greater than all the surgeons in Washington, Oregon, Idaho, Montana, Wyoming, Nevada, and Utah combined. When they have completed their program they are less likely to take trauma call or seek fellowship for complex care such as tumor surgery. They refuse committee appointments, organization leadership positions, and even positions as JOMS reviewers. Here is a note I just wrote to one of the many Gen X OMS who have refused to accept occasional review of JOMS submissions:
“I was personally disappointed that you did not accept the opportunity to be a JOMS reviewer. In the future, if you change your mind, you might find it interesting to see what is happening in the cutting edge of the specialty. I never thought of it as an obligation to be a reviewer, just a privilege. Best wishes, and I do understand the pressures of academic surgery.”
He kindly replied to my note later in the day and explained he was leaving academics to enter private practice.
Millennials Moving Up
The first Millennials are just beginning OMS training. Millennials barely resemble Generation X. They are focused, hard working, economically driven, yet they are seeking balance in life. It has been said that they will work to live, not live to work. However, their lives are very structured around achievements. They are not prone to creating formal barriers such as those in current surgical specialty designations. While applications for orthodontics and pediatric dentistry have risen, most of the remaining specialties, including OMS, are seeing a sustained decline in applications. High stakes or unfair examination is not tolerated by Millennials, which has in part placed new pressure on the current live patient dental board examination. In medicine and dentistry, Millennial students are more diverse than Gen X students; there are now more female students and more first-generation-educated students. Millennial students are as prone to perform community service as Boomers, yet their student debt looms as a reason to defer social commitment.
Government Moving In
What are the inevitable changes for oral and maxillofacial surgery as the Boomers make their exit from the specialty and Gen X and Millennials succeed them in the coming decade? Certainly there will be fewer surgeons. They will be less focused on entrepreneurial success and more on lifestyle choices. They will work fewer hours and seek a less broad scope of practice. They will be less likely to care for the underserved. At some point we will see government moving in. Finally being forced to deal with the access to care issue, government will not cope well. Government’s propensity to interfere and over regulate, to punish success, to mandate but not fund, and to do it all incompetently might make it impossible for government to deal with this workforce issue effectively.
Marketplace Moving Forward
Name-brand dentistry and dental specialty offices are not an accident of the marketplace. Job-sharing, employment contracts that include the cost of education, spa dentistry, stock exchange multi-city dental practices, and aggressive lifestyle choices in practice are trends designed to meet the needs of Gen X and Millennials.
Surviving the Generational Tsunami
What can oral and maxillofacial surgery do to effect change to preserve the achievements of our specialty over the past 40 years? This is a generational tsunami of uncontrollable proportions.
We have an unsustainable OMS workforce.
We will not replace existing surgeons.
What was formerly 230 graduates per year is now 150 to 170 per year with 8,000 “slots” to fill in the next 30 years.
The occurrence of this tidal wave is inevitable. As with the recent tsunami that devastated the Pacific, we must seek higher ground, appeal to the better nature of our people, and finally seek a global assistance effort. Then we must rebuild. If we do not reinvent our surgical specialty while doing so, we will fail to recover.
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