772
LETTERS TO THE EDITOR
las which took place in 1972. Dr Tessier’s movie was very clear and explicit, and I am sure Dr Kaban, particularly because of his association with Dr Tessier in Boston, would agree about adding this citation to his bibliography. S. ANTHONYWOLFE, MD, FACS Miami, Florida DIVISION OF THE SPECIALTY To rhe E&or:-It is with interestthat I note the recent advertisementfor the American Board of Cosmetic Surgery in the January 1990 issue of Journal of Oral and
Maxiiiofacial Surgery: Although many of us are performing procedures that would qualify us for admittance into any subspecialty that can be deemed “cosmetic surgery,” The American Board of Cosmetic Surgery has taken upon itself to segmentalize our specialty into those who have obtained a dual MD-DDS degree and those who have not. I have read the protests of many oral and maxillofacial surgeons over the past few months in regard to the double degree situation and their expressed interest in maintaining a lack of duality within our specialty. It is obvious that this segmentalization has already occurred as recognized by the American Board of Cosmetic Surgery. I am afraid that what we are seeing is just the beginning of the further disjointing of our specialty; it is becoming a two-tiered specialty as has been feared by numerous members of our association. I would, therefore, hope that the powers that be within our organization (the members themselves) reconsider the proposed changes, for they have created a “can of worms” that has just been opened.
JOELS. TEE, DMD Brentwood, New York LOSING DENTOALVEOLAR SURGERY TO THE GENERAL DENTIST To rhe Editor:-The article on specialist-generalist relations in the last issue of the AAOMS Digest is overdue by about 20 years. I had personally approached the AAOMS people about this very thing at least 20 years ago and I was shrugged off. I also confronted AAOMS at that time about the concept of offering “how to” programs to the generalist, and the reaction was arrogant and smug. In this part of the world in today’s marketplace, prying patients away from the generalist is like pulling teeth. With the advocacy of the double-degree oral and maxillofacial surgeon, advanced training of the generalist in general practice residencies, and the continuation of “how to” programs offered to dentists by oral and maxillofacial surgeons, I see the demise of the dentoalveolar oral and maxillofacial surgeon in a very few years. ROBERTJ. BLUM, DMD Wayne, New Jersey THE PROPERWAY TO OBTAIN MEDICAL AND SURGICAL TRAINING
To the Editor:-Your editorial “A Second Look at the Double Degree” in the June 1989 issue was timely but, regrettably, stresses some of the lesser reasons for the program rather than the more substantial ones. The essential reason for advocacy of becoming medically qual-
ified was to remedy the medical education deficit of dental graduates. This is particularly important for oral and maxillofacial surgeons who cannot provide optimal patient care without sound basic medical knowledge and surgical skills. Our specialty has, indeed, broadened even without the four areas of future expansion you mentioned, although some of our colleagues do operate in those specific areas even now. McCallum’s article,’ in the same issue of the Journal as your editorial, lends support to this. He wrote, “My first question is whether our scope has changed? To this I would give a resounding yes.” In fact, if one overlooks the present burgeoning interest in cosmetic surgery, trauma, orthognathic, temporomandibular joint, and jaw reconstructive surgery, which constitute a significant portion of the present oral and maxillofacial surgeon’s work, are all complex procedures that demand knowledgeable pre- and postoperative care, as well as sophisticated surgical expertise. You posed the question of whether the present expanded training curriculum can provide the medical knowledge and core surgical training that oral and maxillofacial surgeons need. I would suggest that formal education, in the medical school context, is a more certain way of learning what we all declare to be necessary than an “apprentice” system integrated within a training program. Furthermore, all other surgical core specialties have recognized (and require) at least a year of basic surgical training. Despite that, our specialty assumes that if a resident spends 1 of 4 years rotating through various surgical departments, an equivalent surgical core will be acquired. In this litigious era, that seems particularly questionable. Being the responsible surgeon of record, for general surgery, requires medical licensure, and assuming responsibility is essential to the maturation of a surgeon in training. I agree with your last sentence, “The question of whether it is necessary for everyone in our specialty to have such training, however, still remains to be answered.” There are, however, a few suggestions I would make. One is that those who disagree with the double-degree concept be as tolerant of its advocates as they are of its adversaries. Time will, in fact, settle the issue and there is no need of confrontation. Secondly, the fear that our specialty will lose its identity as medically qualified members defect to “medicine” is not borne out by the record to date. A review of the San Francisco annual meeting program, with its numbers of presentations by double-degree colleagues, should hearten those who doubt their allegiance. WALTERGURALNICK,DMD Boston, Massachusetts
Reference 1. McCallum CA: The future of oral and maxillofacial surgery. J Oral Maxillofac Surg 1989 PROPERTRAINING FOR ORAL AND MAXILLOFACIAL SURGERY
To the E&or:-1 read with dismay the December editorial entitled “Maintaining the Unity of Oral and Maxillofacial Surgery” (48:1247, 1990). It implied that those residents finishing oral and maxillofacial surgery programs with a medical degree have somehow mysteriously expanded the scope of their training, and therefore the scope of their expected hospital credentials. As
773
LETTERS TO THE EDITOR
1
you well know, expanded realms of practice can only be legitimately gained through expanded training experiences, and the scope of training programs has changed little, if at all, over the last 20 years. In your plea to dually qualified oral surgeons to bring along the single-degree flocks to this expanded practice, you fail to recognize that those who are poorly trained, but additionally credentialed, are inappropriate tutors for those who are both poorly trained and inadequately credentialed. A weekend course or a mini-fellowship is hardly a substitute for residency training and board certification. Limited and poor training will lead to limited and poor results. Unfortunately, ultimately, individual situations in which poor-quality practice has been demonstrated will be argued in courts of law and perhaps at state legislatures. The profession of oral and maxillofacial surgery that I so vividly recall always prided itself on excellence of results, research, and patient care, and now steps way outside its boundaries for perceived pecuniary gains. The decision to try to expand the scope of practice to include procedures traditionally taught in plastic surgery residency is ill-conceived. The expectation that the responsibility for gaining this expansion rests with double-degree oral and maxillofacial surgeons is absurd. I would predict general disappointment and disillusionment with practice opportunities for those who are anticipating such expansion, and ultimately increased frustration. They will find the pot of gold at the end of this rainbow to be tilled with dissatisfaction in results, unhappy patients, subpoenas, and judgments. Perhaps this will lead to further divisivness within the ranks of organized oral and maxillofacial surgery. Perhaps those who are truly interested in the maintenance of excellance within their chosen profession will reject affiliations with nonrecognized specialty boards and other bogus organizations. Hopefully, those who truly seek recognition as legitimate practitioners of plastic surgery will gain that recognition in the old-fashioned way-earn it through legitimate residency training. The situation that you describe will unfortunately lead to misleading advertising, patient misinformation, and substandard health care, a sad degradation of the profession of oral and maxillofacial surgery. JONATHANS. JACOBS,DMD, MD
Norfolk, Virginia The editor replies:-1 read with dismay Dr Jacobs’ comments regarding my editorial. It is an excellent example of the “straw man” principle. To state that the scope of oral and maxillofacial surgery has not changed in the past 20 years is an indication of a total lack of familiarity with the literature. AU one needs to do is peruse the pages of our Journal to see the changes that have occurred in our specialty in such areas as orthognathic and TMJ surgery, reconstructive surgery, and management of facial trauma, to name but a few. The educational base has also increased in the last two decades. Thus, those residents finishing their programs, whether with a single or double degree, already have an expanded scope as well as the surgical background to expand it further. I do not share Dr Jacobs’ concern about the adequacy of the credentialling process or about residency training in oral and maxillofacial surgery. Credentialling depends on training, experience, and documented compe-
tency. Those who achieve such credentialling should certainly be able to practice well and to train others. TO imply that single-degree oral and maxillofacial surgeons are poorly trained also reflects a total unfamiliarity with current educational standards. Dr Jacobs’ comment that weekend courses or minifellowships are not substitutes for residency training is correct. However, an experienced surgeon does not need to complete residency to learn to do a new procedure. I am sure that even he did not perform every possible operation while in training, and is still able to adapt to new situations. Finally, Dr Jacobs raises the issue of specialty boundaries. I realize that he believes that plastic surgery has no boundaries, but that currently does not preclude other surgical specialists from doing plastic procedures in their particular field without being a board-certified plastic surgeon. Oral and maxillofacial surgeons were treating facial trauma and repairing clefts even before there was a specialty of plastic surgery, and it was the oral and maxillofacial surgeon who developed orthognathic surgery in this country. Clearly there is a difference of opinion about what can be considered traditional in the scope of plastic surgery. I share Dr Jacobs’ concern over divisiveness, and that was the point of the editorial. If those of us with our roots in dentistry, including Dr Jacobs, remember our heritage and remain loyal to it, our specialty will continue to be upgraded and not downgraded, as he seems to imply. DANIELM. LASKIN Richmond, Virginia DETERMINING THE FUTURE OF OUR SPECIALTY
To the Editor:-Ours is a learned society in the midst of changes that at once promise much, but also engender uncertainty and concern. We firmly believe that this specialty should endeavor to expand the learning opportunities of present and future members, and encourage the pursuit of broader academic interests. The assumption that the dual degree is synonymous with greater excellence or superior training is debatable, however, and if accepted as official association policy will usher in far-reaching changes regarding how we relate to our profession, our association, and ourselves. We feel most strongly that the issue of the dual degree and its effect on official association actions requires scrutiny and evaluation by the membership. We also feel strongly that the accreditation agency for oral and maxillofacial surgery training programs must remain exclusively the American Dental Association’s responsibility irrespective of the eventual degree obtained by graduates. Toward that end, we recommend that an open forum be convened at the New Orleans annual meeting where formal and informal debate can occur and the process culminate in the House of Delegates of the AAOMS determining the future course of our association. We further recommend that the format and speaker selections for this forum be by vote of the Board of Trustees of the AAOMS. BRIANALPERT DONALDCHASE RAYMONDFONSECA DANIELLEW PHILIPMALONEY
ROBERTA. OLSON LARRYPETERSON LELANDREEVE NORMANSHEPARD AL F. STEUNENBERG
LETTERS TO THE EDITOR
las which took place in 1972. Dr Tessier’s movie was very clear and explicit, and I am sure Dr Kaban, particularly because of his association with Dr Tessier in Boston, would agree about adding this citation to his bibliography. S. ANTHONYWOLFE, MD, FACS Miami, Florida DIVISION OF THE SPECIALTY To rhe E&or:-It is with interestthat I note the recent advertisementfor the American Board of Cosmetic Surgery in the January 1990 issue of Journal of Oral and
Maxiiiofacial Surgery: Although many of us are performing procedures that would qualify us for admittance into any subspecialty that can be deemed “cosmetic surgery,” The American Board of Cosmetic Surgery has taken upon itself to segmentalize our specialty into those who have obtained a dual MD-DDS degree and those who have not. I have read the protests of many oral and maxillofacial surgeons over the past few months in regard to the double degree situation and their expressed interest in maintaining a lack of duality within our specialty. It is obvious that this segmentalization has already occurred as recognized by the American Board of Cosmetic Surgery. I am afraid that what we are seeing is just the beginning of the further disjointing of our specialty; it is becoming a two-tiered specialty as has been feared by numerous members of our association. I would, therefore, hope that the powers that be within our organization (the members themselves) reconsider the proposed changes, for they have created a “can of worms” that has just been opened.
JOELS. TEE, DMD Brentwood, New York LOSING DENTOALVEOLAR SURGERY TO THE GENERAL DENTIST To rhe Editor:-The article on specialist-generalist relations in the last issue of the AAOMS Digest is overdue by about 20 years. I had personally approached the AAOMS people about this very thing at least 20 years ago and I was shrugged off. I also confronted AAOMS at that time about the concept of offering “how to” programs to the generalist, and the reaction was arrogant and smug. In this part of the world in today’s marketplace, prying patients away from the generalist is like pulling teeth. With the advocacy of the double-degree oral and maxillofacial surgeon, advanced training of the generalist in general practice residencies, and the continuation of “how to” programs offered to dentists by oral and maxillofacial surgeons, I see the demise of the dentoalveolar oral and maxillofacial surgeon in a very few years. ROBERTJ. BLUM, DMD Wayne, New Jersey THE PROPERWAY TO OBTAIN MEDICAL AND SURGICAL TRAINING
To the Editor:-Your editorial “A Second Look at the Double Degree” in the June 1989 issue was timely but, regrettably, stresses some of the lesser reasons for the program rather than the more substantial ones. The essential reason for advocacy of becoming medically qual-
ified was to remedy the medical education deficit of dental graduates. This is particularly important for oral and maxillofacial surgeons who cannot provide optimal patient care without sound basic medical knowledge and surgical skills. Our specialty has, indeed, broadened even without the four areas of future expansion you mentioned, although some of our colleagues do operate in those specific areas even now. McCallum’s article,’ in the same issue of the Journal as your editorial, lends support to this. He wrote, “My first question is whether our scope has changed? To this I would give a resounding yes.” In fact, if one overlooks the present burgeoning interest in cosmetic surgery, trauma, orthognathic, temporomandibular joint, and jaw reconstructive surgery, which constitute a significant portion of the present oral and maxillofacial surgeon’s work, are all complex procedures that demand knowledgeable pre- and postoperative care, as well as sophisticated surgical expertise. You posed the question of whether the present expanded training curriculum can provide the medical knowledge and core surgical training that oral and maxillofacial surgeons need. I would suggest that formal education, in the medical school context, is a more certain way of learning what we all declare to be necessary than an “apprentice” system integrated within a training program. Furthermore, all other surgical core specialties have recognized (and require) at least a year of basic surgical training. Despite that, our specialty assumes that if a resident spends 1 of 4 years rotating through various surgical departments, an equivalent surgical core will be acquired. In this litigious era, that seems particularly questionable. Being the responsible surgeon of record, for general surgery, requires medical licensure, and assuming responsibility is essential to the maturation of a surgeon in training. I agree with your last sentence, “The question of whether it is necessary for everyone in our specialty to have such training, however, still remains to be answered.” There are, however, a few suggestions I would make. One is that those who disagree with the double-degree concept be as tolerant of its advocates as they are of its adversaries. Time will, in fact, settle the issue and there is no need of confrontation. Secondly, the fear that our specialty will lose its identity as medically qualified members defect to “medicine” is not borne out by the record to date. A review of the San Francisco annual meeting program, with its numbers of presentations by double-degree colleagues, should hearten those who doubt their allegiance. WALTERGURALNICK,DMD Boston, Massachusetts
Reference 1. McCallum CA: The future of oral and maxillofacial surgery. J Oral Maxillofac Surg 1989 PROPERTRAINING FOR ORAL AND MAXILLOFACIAL SURGERY
To the E&or:-1 read with dismay the December editorial entitled “Maintaining the Unity of Oral and Maxillofacial Surgery” (48:1247, 1990). It implied that those residents finishing oral and maxillofacial surgery programs with a medical degree have somehow mysteriously expanded the scope of their training, and therefore the scope of their expected hospital credentials. As
773
LETTERS TO THE EDITOR
1
you well know, expanded realms of practice can only be legitimately gained through expanded training experiences, and the scope of training programs has changed little, if at all, over the last 20 years. In your plea to dually qualified oral surgeons to bring along the single-degree flocks to this expanded practice, you fail to recognize that those who are poorly trained, but additionally credentialed, are inappropriate tutors for those who are both poorly trained and inadequately credentialed. A weekend course or a mini-fellowship is hardly a substitute for residency training and board certification. Limited and poor training will lead to limited and poor results. Unfortunately, ultimately, individual situations in which poor-quality practice has been demonstrated will be argued in courts of law and perhaps at state legislatures. The profession of oral and maxillofacial surgery that I so vividly recall always prided itself on excellence of results, research, and patient care, and now steps way outside its boundaries for perceived pecuniary gains. The decision to try to expand the scope of practice to include procedures traditionally taught in plastic surgery residency is ill-conceived. The expectation that the responsibility for gaining this expansion rests with double-degree oral and maxillofacial surgeons is absurd. I would predict general disappointment and disillusionment with practice opportunities for those who are anticipating such expansion, and ultimately increased frustration. They will find the pot of gold at the end of this rainbow to be tilled with dissatisfaction in results, unhappy patients, subpoenas, and judgments. Perhaps this will lead to further divisivness within the ranks of organized oral and maxillofacial surgery. Perhaps those who are truly interested in the maintenance of excellance within their chosen profession will reject affiliations with nonrecognized specialty boards and other bogus organizations. Hopefully, those who truly seek recognition as legitimate practitioners of plastic surgery will gain that recognition in the old-fashioned way-earn it through legitimate residency training. The situation that you describe will unfortunately lead to misleading advertising, patient misinformation, and substandard health care, a sad degradation of the profession of oral and maxillofacial surgery. JONATHANS. JACOBS,DMD, MD
Norfolk, Virginia The editor replies:-1 read with dismay Dr Jacobs’ comments regarding my editorial. It is an excellent example of the “straw man” principle. To state that the scope of oral and maxillofacial surgery has not changed in the past 20 years is an indication of a total lack of familiarity with the literature. AU one needs to do is peruse the pages of our Journal to see the changes that have occurred in our specialty in such areas as orthognathic and TMJ surgery, reconstructive surgery, and management of facial trauma, to name but a few. The educational base has also increased in the last two decades. Thus, those residents finishing their programs, whether with a single or double degree, already have an expanded scope as well as the surgical background to expand it further. I do not share Dr Jacobs’ concern about the adequacy of the credentialling process or about residency training in oral and maxillofacial surgery. Credentialling depends on training, experience, and documented compe-
tency. Those who achieve such credentialling should certainly be able to practice well and to train others. TO imply that single-degree oral and maxillofacial surgeons are poorly trained also reflects a total unfamiliarity with current educational standards. Dr Jacobs’ comment that weekend courses or minifellowships are not substitutes for residency training is correct. However, an experienced surgeon does not need to complete residency to learn to do a new procedure. I am sure that even he did not perform every possible operation while in training, and is still able to adapt to new situations. Finally, Dr Jacobs raises the issue of specialty boundaries. I realize that he believes that plastic surgery has no boundaries, but that currently does not preclude other surgical specialists from doing plastic procedures in their particular field without being a board-certified plastic surgeon. Oral and maxillofacial surgeons were treating facial trauma and repairing clefts even before there was a specialty of plastic surgery, and it was the oral and maxillofacial surgeon who developed orthognathic surgery in this country. Clearly there is a difference of opinion about what can be considered traditional in the scope of plastic surgery. I share Dr Jacobs’ concern over divisiveness, and that was the point of the editorial. If those of us with our roots in dentistry, including Dr Jacobs, remember our heritage and remain loyal to it, our specialty will continue to be upgraded and not downgraded, as he seems to imply. DANIELM. LASKIN Richmond, Virginia DETERMINING THE FUTURE OF OUR SPECIALTY
To the Editor:-Ours is a learned society in the midst of changes that at once promise much, but also engender uncertainty and concern. We firmly believe that this specialty should endeavor to expand the learning opportunities of present and future members, and encourage the pursuit of broader academic interests. The assumption that the dual degree is synonymous with greater excellence or superior training is debatable, however, and if accepted as official association policy will usher in far-reaching changes regarding how we relate to our profession, our association, and ourselves. We feel most strongly that the issue of the dual degree and its effect on official association actions requires scrutiny and evaluation by the membership. We also feel strongly that the accreditation agency for oral and maxillofacial surgery training programs must remain exclusively the American Dental Association’s responsibility irrespective of the eventual degree obtained by graduates. Toward that end, we recommend that an open forum be convened at the New Orleans annual meeting where formal and informal debate can occur and the process culminate in the House of Delegates of the AAOMS determining the future course of our association. We further recommend that the format and speaker selections for this forum be by vote of the Board of Trustees of the AAOMS. BRIANALPERT DONALDCHASE RAYMONDFONSECA DANIELLEW PHILIPMALONEY
ROBERTA. OLSON LARRYPETERSON LELANDREEVE NORMANSHEPARD AL F. STEUNENBERG
