Yet Another Turf Battle; MD v. DDS

Finally M3 said:

http://story.news.yahoo.com/news?tm...chicagotrib/oralsurgeonswanttocutinonfaceneck

Hopefully this doesn't bring MacGyver out of the woodwork.

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Too late! Did you think my turf war radar was malfunctioning or something? Shame on you!

As for the article, 3 words come to mind:

BLATANT MONEY GRAB!

What about the oral surgeons who also have medical degrees? This is actually a trick question. As an oral & maxillofacial surgery resident who has completed both dental school and medical school, I feel like I have a valid opinion on this whole mess. I train alongside non-MD OMFS residents who are equally (and maybe more) capable as far as surgical skills and patient management. Which rotation in medical school did you learn to do facial osteotomies and blephs? I just held the sticks when I was in med school, even though I was driving the scalpel the year before as an OMFS intern. My point is that you really learn your specialty in your residency, not in medical or dental school.

I am always amused by the extent of knowledge people presume to have about dental school and oral & maxillofacial surgery training when they have experienced neither. I don't mean to sound insulting, but most of the other medical residents I work with are just uninformed. Probably because they have no exposure to our training and what we do.

I'm not sure what to make of the previous comment that "systemic complications" are better treated by an MD. Oral surgeons admit, operate, and treat patients the same as the other surgical specialties. If there's a bleeding diathesis, we deal with it appropriately. "Multiple underlying medical conditions" are addressed in our pre-operative workup the same as we did when I was on general surgery. By the way, this is all true for MD and non-MD oral surgeons.

As for the "BLATANT MONEY GRAB," this is the same reason the plastics guys want to keep us out. We all want a job, don't we?

This is a pissing-match as old as time and doesn't need to be re-hashed. In my opinion, the guy who should be doing cosmetic surgery (or any type) is the one who makes it a primary focus of their practice, not just a weekend hobby. I'm really not trying to irritate anyone, I'm only trying to make us all more informed. I'll sit down now and let MacGyver rant and rave.

toofache32 said:

As for the "BLATANT MONEY GRAB," this is the same reason the plastics guys want to keep us out. We all want a job, don't we?

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What kind of ****ed up logic is that? Are you trying to claim that oral surgeons (MD and non MD alike) have trouble finding jobs?

Blatant money grab is the PERFECT descriptor for this. This isnt about finding a job, its about increasing revenue and either switching your practice or expanding it into non-reconstructive cosmetic procedures. I suppose you are going to sit there and tell me that its pure coincidence that plastic cosmetic surg is one of the most lucrative specialties with very little insurance hassles?



There is absolutely no reason to change the status quo. Everybody who wants to find a plastic surgeon for this kind of crap can easily do so. The dentists who say this is about "increasing patient access" are lying thru their teeth. This is all about the $$$ and nothing more.

Oral surgeons already have their own practices, dont have any trouble finding jobs, and yet they want to expand into territory that another specialty has control over.

I'll tell you what. When you let the dental assistants get a shortcut to a DDS/DMD, then we'll give you a shortcut to plastic surg. After all, allowing dental hygienists do regular dentistry would increase patient access wouldnt it?

What a bunch of hypocrites.

MacGyver said:

I'll tell you what. When you let the dental assistants get a shortcut to a DDS/DMD, then we'll give you a shortcut to plastic surg. After all, allowing dental hygienists do regular dentistry would increase patient access wouldnt it?

What a bunch of hypocrites.

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A couple of points:

1) dental assistants and dental hygienists are NOT one and the same. One requires a degree and licensure, the other doesn't.

2) We're more than happy to allow hygienists to do regular dentistry... if they pass all of our licensure exams first. It seems that what is always forgotten in this topic is that those oral surgeons who obtain the MD degree have passed the EXACT same exams as their other MD counterparts. Are you saying the USMLE steps as well as all MD licensure exams, are a hoax?

My thought is that if somebody can pass the exam and do well enough to match with a HIGHLY coveted residency/specialty--then who am I to say they aren't qualified?

So yeah, I don't have a problem with hygienists doing dental work. They just need to take NBDE I, then be admitted to a dental school, then take NBDE II, and then take a regional licensure exam.

By the way, my last post only deals with those who hold the dual degree (DDS/MD or DMD/MD). I have quite different feelings about those oral surgeons who don't have the MD degree. They, I believe, have no business stepping out into the cosmetic world.

It has nothing to do with education, but everything to do with scope of pratice. Those dual-degree oral surgeons are licensed MDs just like every other allopathic physician.

Still, the funny thing about all of this is that oral surgeons, plastics, and ENTs rotate trauma call at most places. So depending on the given night, you may get any one of the three remodeling your face.

I don't understand this argument at all.

Why should somebody (even one as rabid as MacGyver) care whether an Oral Surgeon (who has an MD) expand into surgeries of the head and neck? As I understand it, most oral surgeons educated today hold the DDS and the MD, and therefore would presumably comply with what I gather is MacGyver's primary theme - that only medical doctors should practice medicine.

My understanding is that Oral Surgeons are perhaps the MOST (at least, as equally) qualified practitioners of reconstructive surgery of the face on the planet, no? If I want a nose job, eye lift, face lift, etc., it seems to me that I would go to a plastic surgeon. However, if I've had my face bashed in with a baseball bat, i think I want an oral surgeon. And it seems to me that the oral surgeon has the "foundation" necessary to expand comfortably into the aesthetic/reconstructive side of plastics, no? Surely somebody who can repair a oral anomoly (such as a severe cleft pallate - say one where the mouth and nose presents as a single "oraface") would have NO trouble with (and should be trusted with) rhinoplasty.

Judd

As opposed to what Mcgyver may say, this is a financially based issue and nothing else. How come we dont talk about OMFS's doing leforte's, open reductions, deep lacerations/major facial trauma, congenital craniofacial corrective procedures (clefts), resections & reconstructive procedures (oncolgic) etc? because, none of the abovementioned procedures are elective or "cash" procedures, yet all of the abovementioned are way more invasive and require a lot more expertise. I just finished an OMFS rotation through school and after watching these guys do all these procedures, I feel rhinos, blephs, genios and lifts are relatively cake for them. Also, if OMFS and ENT's have the ability, expertise and training to do these procedures to suppliment their income I say good for them.... why leave all the money minting "cash" procedures to the plastics people?
Now a days after finishing the 6yr OMFS/MD program, most of the people interested in plastics do the AAOMS accredited 1yr craniofacial plastics fellowship which trains them for any facial cosmetic procedure that needs to be done. Not that I need a nosejob, but if I ever did, I would prefer a surgeon who has limited his/her practice to the face.

If you have an MD and complete a fellowship for facial go ahead, but if you don't then stick to teeth.

What the pho's comment makes no sense to me and I don't understand the basis of his comment.

toofache32 said:

What the pho's comment makes no sense to me and I don't understand the basis of his comment.

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What I'm tryin to say is those DDS/DMD who do a OMFS res and get a MD can go ahead and do facial plastics, but the DDS/DMD who don't get a md better stick to the oral cavity.

There is no difference in surgical training between a single or dual degree OMFS. What the pho statement about singel degree OMFS sticking with the oral cavity makes no sense when they do as much surgical reconstruction, plastics as dual degree OMFS during their residency. If one (OMFS) wants to dedicate their practice to full time plastics than I think they should seek further training via a fellowship after residency. The main difference between a single degree and dual degree OMFS performing a rhinoplasty, given they have the same surgical training, is a political one.

I am also curious to know the reasons behind Gavin's and the Pho's statements. If single and dual degree OMS's receive the same surgical training, then why should one not be able to utilize it?

The medical degree is peripheral to our training, and to our specialty. Some residencies put med school at the beginning of residency, and some put it at the end. That's why it is irrelevant to our scope of practice.

As far as "sticking to teeth" and "the oral cavity", What the pho needs to become better informed about what we do, then make comments after he knows what he is talking about. This link can probably explain it better than I can:

http://www.aaoms.org/home/home_template.asp?content_type_id=466&entity_id=126

I would have to agree that whether one is single or dual degree is irrelevant when it comes to doing elective cosmetic surgery. It should be based upon one's degree of comfort and proficiency to do cosmetic surgery. With the MD, one doesn't have to justify doing cosmetics as much as the single degree guys, which is based primarily on the fact that they are able to practice under medical license. BUT single degree surgeons are equally competent, if not more. Out here in cali, most OMFS programs are six years, including mine. But all the DDS/MD OMFS in my school say that there are no differences between the two types in training, 6 yrs is 2 additional for 3rd and 4th year of medical school.

I agree with the observation that the argument distinguishing b/w single degree & dual-degree oral surgeons is a pretty trivial distinction. I'm a little puzzled by the focus on that with some of the politicing over this issue except for the fact I guess its easier to prohibit legislatively against those without an MD degree.

I think what needs to be recognized in this discussion is the relative paucity of training of oral surgeons compared to the standards traditionally set for plastic and aesthetic surgery. Of the six years of training to become a duel degree oral surgeon, 2 of those are as a medical student with signifigant blocks of the remaining time doing core curriculum in anesthesia, denistry & oral hygene, and functioning in large part as a junior resident. If you think that this is adequate preparation to dive into aesthetic surgery I think you need to reexamine things. Oral Surgery is an interesting background from which to go on and pursue further training as a plastic surgeon, and I think that's what should be endorsed by its professional organization (fat chance)

As a society, I think we need to come to some consensus about what are the minimum standards someone needs to achieve to be allowed to perform these operations safely with acceptable morbidity & results. Remember there's no great public health issue that need's to be addressed by minting another set of providers chasing cosmetic surgery patients and the last thing we need is to set the bar lower with dentists performing a pretty ambitious land grab in this area

What the pho said:

What I'm tryin to say is those DDS/DMD who do a OMFS res and get a MD can go ahead and do facial plastics, but the DDS/DMD who don't get a md better stick to the oral cavity.

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Bingo. I couldn't agree with you more.

River13 said:

I am also curious to know the reasons behind Gavin's and the Pho's statements. If single and dual degree OMS's receive the same surgical training, then why should one not be able to utilize it?

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I understand that differences in education are minimal, but my response comes from the "it's easier to legislate things that way" area. I'm a firm believer in letting x do his job and letting y do his job.

I think what needs to be recognized in this discussion is the relative paucity of training of oral surgeons compared to the standards traditionally set for plastic and aesthetic surgery. Of the six years of training to become a duel degree oral surgeon, 2 of those are as a medical student with signifigant blocks of the remaining time doing core curriculum in anesthesia, denistry & oral hygene, and functioning in large part as a junior resident. If you think that this is adequate preparation to dive into aesthetic surgery I think you need to reexamine things. Oral Surgery is an interesting background from which to go on and pursue further training as a plastic surgeon, and I think that's what should be endorsed by its professional organization (fat chance)

This statement comes from someone with more paucity of information on the specialty. Your reference to significant blocks of time doing dentistry and oral hygiene highlights your ignorance on the subject. This is the reason why we constantly get patients referred to our clinic for cleanings, fillings and denture fabrication from our medical counterparts in the hospital. I think the numbers of procedures done by a particulary resident as primary surgeon is a better measure of competance than anything else. Frankly your post is a joke.

omsres said:

This statement comes from someone with more paucity of information on the specialty. Your reference to significant blocks of time doing dentistry and oral hygiene highlights your ignorance on the subject. This is the reason why we constantly get patients referred to our clinic for cleanings, fillings and denture fabrication from our medical counterparts in the hospital. I think the numbers of procedures done by a particulary resident as primary surgeon is a better measure of competance than anything else. Frankly your post is a joke.

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Ok then please correct me. Of your clinical program what specifically is the amount of time you spend as the SENIOR operative surgeon doing aesthetic or craniofacial surgery outside of of extractions, oral care , wisdom teeth, and dental related procedures. I've seen what it is first hand @ a really good program with a few AO celebrities on staff & its a conservative amount. I'm not degrading the training pathway for Oral Surgery, I'm just pointing out that there are real and substancial differences in the background of a new group of providers compared to the traditional Plastic Surgeon.

I'll state on the record that I have tremendous respect for what oral surgeons can do. They understand dental mechanics and orthognathics better then I ever will & I ask advice on mandibular and occlusion issues all the time from their chief residents (who incidentally were medical students under me years ago). However, to parlay that dental background to aesthetics is a pretty big reach as a lot of the building blocks for treatment, analysis, and technique are pretty far from their background.

OMSRES beat me to this post. Dental Hygiene? You can't be serious. An OMFS doing dental hygiene is like a colorectal surgeon wiping someone's a**. As for your OMFS exposure...I interviewed at Louisville and have to say that those are some of the nicest guys around. They have great trauma & orthognathics training, but they are definately deficient on cosmetics, especially compared to many other programs. You're right that Kushner and Alpert are big dudes at AO/ASIF, but that's not really relevant to cosmetics, as we all know. I'm afraid you might not be getting an accurate representation of what many other programs do. All programs in all specialties have weaknesses, as we all remember learning during interviews. Ironically, my program's weakness is the low amount of wisdom teeth. The plastics program here does fewer head & neck flaps/reconstructions (according to my junior-level Plastics buddy) because the ENT guys have the market.

As for the time we spend on anesthesia and med school...that's when we really do much of our reading and learning the literature (at least at my program) and STILL do OMFS during med school. In other words, our "junior" years are spent with our minds on OMFS, not gall bladders and pus like our plastics PGY1-3s (at least here).

DrOliver raises a very good question. As for how much time we operate as the SENIOR resident...we spend the same amount as every other surgical specialty as chief...one year (I think this is what you're asking). We definately spend more time doing facial cosmetics than the Plastics guys down the hall (who only do a 3 month rotation their cheif year, which is divided among the whole body). We also spend 3 months of our chief year with our craniofacial faculty, although he fills in gaps with cosmetic cases also. Not to mention the cases where the chief is already operating another case, and the junior resident gets to be the "senior" on a new case, but I'm sure the Plastics guys experience this also.

I haven't figured out the "quote" button, so I'll cut & paste: "However, to parlay that dental background to aesthetics is a pretty big reach as a lot of the building blocks for treatment, analysis, and technique are pretty far from their background."

ALL dentistry is cosmetic and we are all trained to have an eye for the aesthetic component of everything we do. Even the lady who wants a gold tooth up front is making a cosmetic request. Dentists are trained from day#1 that "form and function" are what the patient notices ("form" being how it looks). As for analysis, this is the core of orthognathic treatment planning, and we logically extend it into aesthetic cases. OMFS literature has hovered around this topic since the many publications by William H. Bell in the 1960s. As for technique, we read the same literature as you do and use the same instruments.

I, like DrOliver, also want to go on the record that I admire the extremely broad scope that plastic surgeons practice. It may be the broadest of all surgical specialties. I would definately go to a plastic surgeon if my wife or mistress wanted a breast aug. Just kidding about the mistress. But for the face, I would prefer someone who limits their practice to the face. It's the same reason I take my Volvo to a guy who works on Volvos "all day & every day" instead of a guy who works on all models. BTW, this includes ENT, Plastics, or OMFS guys who limit their practice to the face.

Our training gives us 26 months of senior operator experience. The rest is divided as 15 months of junior level resident, 18 months in medical school, 4 months anesthesia, and 6 months general surgery, 1 month usmle study and 2 months ER intern. The hospital where I train doesn't have a PRS residency so there may be more cases than the norm. I don't have exact numbers infront of me but I can estimate between 5 and 10 major facial esthetic case per month. Procedures including noses, facelifts, blephs, brows, platysmaplasty, liposuction. We also do a fair amount of minor things like botox, chemical peels, scar revisions, dermabrasion, etc. The rest of the time we do head and neck cancer and other pathology, tracheotomies, orthognathic, implants(dental not breast), trauma, facial reconstruction with bone grafts, lefort III distraction, cranial vault reshaping, CL/P all stages. Yeah and thirds, infections, routine extractions blah, blah. Our main two faculty have both done H/N cancer fellowships, and one also has done a craniofacial fellowship. We do a lot of the above cases each year so I think our chiefs finish with ample experience and #s of cases.

I'm sorry, but the way you're portraying things at your training programs it seems that your Oral Surgery training is an afterthought to learning cosmetic surgery. I have a hard time believing that the oral surgery training at the several programs I've seen is that much different then the norm, and none of them approach what you're describing. If your experience is as in depth as what you say it sounds like you're getting some good exposure.

toofache32 - I meant no disrepect with the oral hygeine comment. I was referring to extractions & the like. As for senior operative experience, for me personally I would pretty much have done about 5 years of that b/w General & Plastic surgery. The point I'm trying to convey is that the difference b/w OMFS & Plastic Surgery or ENT is a lot of clinical & peri-operative experience. It makes no sense to me to sit and argue that you can train someone competently as a surgeon with 1.5-2.5 of training from ground zero especially as facial aesthetics is somewhat an aside from traditional oral surgery curriculum. So much of the building blocks of peri-operative/post-operative care, catastrophic events, and reoperative surgery takes years to accumulate in a slow and often painful process. This is aside from the technical aspects of surgery which go along parallel with this. Talk to people who've done the OMFS-PRS route about what the difference is in the training, a number of them have testified in some of the legislative debates around the country on this issue

from somebody who is on the other side of the ether screen --- I feel that on the whole, especially from a technical point of view, the OMFS guys are pretty darn good at reconstructing faces (and having taken care of OMFS faces and Plastic Faces in the SICU - their aesthetics are pretty comparable).

From my point of view, the big difference lies in patient management... I feel that the Plastics guys are a lot more comfortable dealing with complicated wound (especially chronic) management, and have a better feel for patient management on the floors. But then again, most of this argument revolves around cosmetics - and those tend to be elective on healthy people

Shouldn't this topic have come up sooner when dermatologists started doing "cosmetic surgery"? I know dermatologists as well as ophthos who do blephs...

"I'm sorry, but the way you're portraying things at your training programs it seems that your Oral Surgery training is an afterthought to learning cosmetic surgery."

--Herein lies one of the many misconceptions of the OMS training...programs expect you to be an expert at dentoalveolar surgery BEFORE you start the residency...residencies actually sift through candidates for this expertise in interviews. Dental school is the place to learn how to take out teeth, not an oral surgery residency. Impacted third molar experience is the main thing to be gained there.

--Not all residencies are the same in any specialty of medicine. This obviously goes for OMS as well. Alpert and Kushner are great surgeons without question, but it is also common knowledge nationally that neither has much interest in cosmetic or craniofacial surgery. Having graduated from U of L dental school, I know firsthand that their residency is what many would call a bread and butter OMS program. As with all surgical specialties, the interest of the primary attendings guides the surgeries taught at that residency. Because of this I chose a residency that has attendings who have interest in cosmetic/craniofacial/cancer surgery. Lefort III osteotomies haven't been done there for years, while other residencies are full of them. I know also that the OMS dept. at U of L has recently brought on an OMS who just finished Jeff Posnick's craniofacial fellowship in Maryland, so look for the training at U of L to become more well rounded as well.

DrOliver--I have no hard feelings about the dental hygiene comment. Reading my post again, it was a little strong and I apologize, because I am really not like that. While I'm at it, I'll say thanks for keeping discussions civil and logical (incontrast to MAcGyver).

I would be curious to know your pathway into PRS. 3 years General Surg (integrated)? 5 years General Surg? I'm trying to understand your 5 years of senior experience. That sounds pretty impressive, but does that your Gen Surg years? When I was on Gen Surg we always consulted the Face Service (OMFS, PRS, ENT) and rarely got experience above the neck. I'm not clear on how you can go 5 years without having a more senior person (i.e., chief) on service. I'm guessing it may be similar to my program where we have one chief who operates the case of his choice, then several junior residents who get to be "seniors" on the remaining cases going on at the same time.

toofache,

we essentially were the operative surgeon on just about every case we did from pgy 3-5 years of general surgery (1500 procedures on my ACGME log, not including the cases I logged as teaching resident) and I'm the operative surgeon for the overwhelming majority of the cases I did my PGY 6 year in Plastics (550 cases and counting).

It's coming from that kind of experience that I'm always taken aback when many of the abbreviated tracks into something (be it integrated plastics, facial plastic surgery, Oral surgeons who want to do aesthetic, the proposed fast tracks for CTVS & vascular, or what have you) think that you can lop off large blocks of senior level experience & patient care, replace it with junior level roations, and expect to end up with products that are similar in quality. I can rarely resist the urge to chime in with that whenever any of these topics pop up in the surgery board.

Again, I think OMFS is a great background to do plastic surgery but I think there's a big gap experience wise in a lot of ways and that you're better served (if you're interested in cosmetic surgery) by going on to do plastic surgery training, if for no other reason then that it's a lot of fun. I can't help but think that there's going to be some increased medical liability issues with a lot of the specialties with aesthetics & you're better off in those circumstances having the gold-standard pedigree when you get dragged into court.