Training the Future: Protecting the Scope and Diversity of Oral and Maxillofacial Surgery

What a Grand Time it Was 

It was a time of excitement and progress. In our generation, oral and maxillofacial surgery leapt from its seminal days of predominantly office-based dentoalveolar surgery and anesthesia practice to a surgical specialty with a scope and diversity that is the envy of our colleagues. Trauma, surgical oncology, craniofacial anomalies, orthognathic surgery, implant reconstruction, and office-based anesthesia, among others, as presented in JOMS, reveal a specialty that has created its own meaningful identity.

These advances were created to a great extent in our academic programs (see “From the Teaching Centers,” a renewed JOMS section that highlights our specialty’s accomplishments in our training programs) and our programs’ trainees benefited from every new technique and technologic innovation. Our graduates were given the chance to learn and subsequently they chose to practice the broad scope of the specialty. Most did so and the rewards for those surgeons practicing today are enormous. In the contemporary full scope practice of oral and maxillofacial surgery, every patient is unique. The skills we bring to bear in daily practice are so diverse that boredom is impossible. The positive impact we have on our communities and the health of our citizens makes us proud to be known as oral and maxillofacial surgeons.

A certainty of the passage of time is that we now must pass this legacy of greatness on to a new generation of oral and maxillofacial surgeons. How are they receiving this precious gift?

Would that the Past Is Prologue 

It began as a quiet voice from other programs, other specialties, other faculties… not ours. First we pitied the programs and the regions affected. Then with each meeting of the AAOMS Faculty Section the news spread and all were facing the sea change. Our residents, our institutions, and our faculty were not the same.

Programs began cutting their positions while others combined or closed. While a balance among 4- and 6-year programs has been obtained, there is a net loss in positions at a time when population growth, persistent pathology, affluence, and technologic advances have increased the demand for our services (Fig 1). Funding for faculty was lost and many full professors, as well as young faculty, left for private practice. Some of our greatest teachers retired, never to be replaced.

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Figure 1. While a sustained balance has been achieved among 4- and 6-year programs, there is a net loss in positions.

New dental schools opened without residencies in oral and maxillofacial surgery, while other programs fled the foibles of the dental school environment for the relative safety of the hospital. Dental students did not learn of our specialty. As a result, the new generation of dental graduates are not as interested in what we are offering. Applications to our residencies are now dropping (Fig 2).

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Figure 2. Applications have dropped by more than a third.

Attrition of residents began to grow with most surgical émigrés choosing general dental practice. Of 153 reported resignations from 50 programs in 10 years, 28 returned to general dentistry. Retained residents often have less grand aspirations for surgical practice than their predecessors. Prestigious fellowships are not filling their positions. Graduates armed with high-quality and high-volume training are electing to practice in communities and environments where but a small part of their skills is needed. Some decide to work part time in office-only or multispecialty “retail” settings. Others decide not to work at all for extended periods after residency.

For those existing practices seeking new graduates as associates and potential partners, a simple, but perverse, formula seems to have emerged: offer short work hours, high income, real estate support, abundant recreational opportunity with extended vacations, location in a wealthy community, and no hospital call. While this scenario may seem to be overstated for effect, it is a refrain too often heard today to be ignored.

This new landscape has adversely affected the demographics of practice. Rural and inner city surgeons retire and are not replaced. For example, in Oregon only the rare surgeon will practice in communities with substantial unmet clinical needs. In the 70,000 square miles of Oregon east of the Cascade Mountains (three quarters of the state), just 7 oral and maxillofacial surgeons practice, and all but 2 of these are in the recreational hub of Bend/Redmond, OR. Fifty-six of the 74 surgeons in the state practice in the desirable, mostly suburban Willamette Valley. Left unchecked, the practice of oral and maxillofacial surgery will be left to ambulatory office-based practice in affluent communities that bear little resemblance to the depth and scope of training obtained or the community needs to be met.

Strategies 

In the coming months, JOMS will focus on strategies to address the problems identified in “Training the Future.” As a teaser common to the popular press, here are some highlights that might inspire some optimism as we address this existential problem.