Fellowships: The Third Wave

The First Wave: Hospital-Based Training 

Oral surgery became the first (and still the only) dental specialty to wholly enter the hospital with the inauguration of the 3-year hospital-based residency in 1967. By 1988, 4-year residencies were required to further expand our presence among the surgical house staff. By casting its lot with hospitals, rather than in dental schools, our specialty committed itself to the care of the sick and injured in a capacity that could only be achieved in the hospital environment. As essential surgeons in level-one trauma, treatment of head and neck tumors, and infection, oral and maxillofacial surgeons became essential members of the inpatient team. OMS was also now well-positioned to develop new elective surgical endeavors such as orthognathic surgery, major preprosthetic surgery, and temporomandibular joint surgery. Those new surgical technologies rapidly developed in the 1970s precisely because of our ability to develop those surgical procedures in hospitals. More than oral and maxillofacial surgery's service in war and perhaps even more than our dental training, our presence in hospitals continues to guide the progress of our specialty today. Oral surgeons emerged from the first wave with the change in the name of our Journal and our specialty in 1978 with the change of both to “Oral and Maxillofacial Surgery” when then AAOMS President Terry Slaughter led the specialty toward appropriate recognition of its scope of care in the hospital. Oral and maxillofacial surgery rode the first wave, and uses the power of that surge to this day.

The Second Wave: Integration With Medical and Surgical Education 

The first wave, hospital-based training, made riding the second wave possible. Integrating OMS education with the vast resources of medical surgical education propelled the specialty beyond the imagination of its early leaders. In 1972, Mort Goldberg recognized that by becoming part of the department of surgery, access to the full scope of surgical education was possible. Hartford Hospital inaugurated a 4-year residency in the department of surgery that included a full year of general surgery. At Harvard, Walter Guralnick courageously fostered the notion that the best means toward recognition of medical surgical expertise was to have recognized and verifiable medical surgical education. He combined the residency with a program leading to the MD and concomitant general and oral and maxillofacial surgical education. Leon Eisenbud integrated oral surgery education at Long Island Jewish Hospital with the hospital dental service bringing in comprehensive dental specialty education into the hospital environment. Thus programs such as general practice dentistry, pediatric dentistry, geriatric dentistry, oral medicine, and oral pathology as well as OMS were integrated into hospital medical surgical education in the academic health center. It helped that the then director of graduate medical education at Long Island Jewish Hospital was a dentist, Jim Mulvihill. In that environment, OMS became an integral part of comprehensive graduate dental education.

In Journal of Oral Surgery 1972 and 1973, Eisenbud,1 Goldberg,2 and Guralnick3 joined the great debate over the best means to integrate OMS education with medical surgical education. Reading these papers can help the contemporary reader understand the effective but very different ways the second wave was to be ridden. The Great Debate over OMS education integration with medical surgical education remains. Oral and maxillofacial surgery has persisted with 2 basic pathways of education in 4 and 6-year programs and 2 main directions of practice, major hospital-based surgery, and office-based practice. The second wave, while having great impact, remains a choppy and unfocused wave to this day.

The Third Wave: Fellowship Training 

Fellowships are the contemporary mechanism that surgical specialties use to advance the art and science of their disciplines without casting off those components of their specialty. Herein is a lesson for oral and maxillofacial surgery. While general surgery completely cast off orthopedics and neurosurgery decades ago, it recognized the unintended and undesirable consequences of separate disciplines. Additionally, general surgery recognizes that techniques developed by other disciplines such as cardiac catheterization and gastrointestinal endoscopy create inherent challenges to maintaining their preeminence in the care of patients with surgical problems. General surgery's contemporary means of nurturing disciplines that have undergone enormous advances and promoting yet further advances is through the uses of fellowship training. Today, general surgery relies upon oncology, trauma, minimally invasive surgery, vascular, and transplant fellowships among others to develop disease-based approach to care while maintaining those endeavors within the rubric of general surgery.

Oral and maxillofacial surgery is similarly challenged. Our specialty compromised its dental school-based surgical education when it became hospital-based. Sadly, many dental schools and dental students now identify dentistry's surgeons as periodontists and see OMS as a medical/surgical-based discipline. Additionally, other disciplines are developing techniques that surpass the effectiveness of OMS methods of treating the same clinical problem, eg, mini-implant orthodontics to treat open bite. Development and fostering of fellowships is necessary to the future success of OMS.

Tumor fellowships provide the best early example of how these programs can propel our specialty. While clearly still only a small impact on our specialty's workforce, fellowship graduates are having an outsized effect on the practice of oral and maxillofacial surgery in a variety of environments across the nation. Bryan Bell recently showed a nice Powerpoint map of the US demonstrating the effect of Eric Dierks/Bryce Potter's fellowship at Emanuel Hospital Portland and Bob Ord's fellowship at Maryland, among newer ones. Fourteen academic health centers are now transformed by the graduates of these programs. OMS involvement in tumor surgery is well-positioned to accelerate.

A lesson for OMS is that for those disciplines in which fellowships are not created, other specialties will ride that wave. Particular concerns are that we have no accredited fellowships in implant surgery or orthognathic surgery, though other disciplines do have such fellowships. OMS needs to strategically look at fellowships and their impact and develop a plan to foster new programs of the highest quality.

To ride the third wave, you always had to look over your shoulder, paddle like crazy, grab the rails of the board, and spring to your feet. After a moment of unbalanced uncertainty, the joy that followed remains the stuff of dreams, impossible to describe. If you missed the third wave with the sun low on the horizon, you would be left to wonder if there would be enough time to wait for the next set. Let us look forward to this generation of surgeons riding this third wave, the fellowship wave.