My opinion: If you never get comfortable with ambulatory anesthesia during residency, you never will in practice. Also, being great at trauma has nothing to do with orthognathics and vice versa. You need both. Finally, I could learn Head and Neck surgery in a fellowship but I can't learn dentoalveolar surgery in one.
PS "If you can do a neck dissection, you can take out #17." I beg to differ.
Gary "couldn't agree with this sentiment more" Ruska.
There are, generally speaking, surgical and technical skills that are broadly applicable to a wide range of procedures and those nuanced techniques that separate the men from the boys when it comes to specific procedures.
There is a great deal of painting with broad strokes on these boards when it comes to surgical skill, and it seems that many people err on the side of "doing bigger operations makes you a better surgeon...FOR EVERYTHING." This is, of course, not true.
Doing big OMFS procedures (bimaxillary procedures, panfacial trauma, head and neck, major craniofacial operations, etc.) makes you better at doing those procedures and operating for long periods of time. The skill transfer from these procedures to placing implants and doing routine dentoalveolar surgery are no more than basic surgical skills (flap design, incisions, dissection technique, hemostasis and suturing). The nuances of removing third molars or placing implants are far more complex than a cursory glance would suggest.
There are a few reasons for this, but the most important, in GR's opinion, is the "complexity paradox". This paradox is simple - the easier the procedure, the more careful you have to be because a complication or unfavorable outcome can be disastrous. For example, if a patient with ragining head and neck cancer undergoes a complicated neck dissection, with notable respiratory issues and requires prolonged ventilatory support, this can, in many or instances, be said to be related to the patient's disease and the relatively poor prognosis. While it is a significant event, it is, by no means, a rare one in this context.
Now, an otherwise healthy patient who walks into the office for third molar extraction and has a complication, even though it may be a clinically less substantial event, may end up being a bigger problem because its a "simple procedure."
The take home point is this - one needs to do big procedures frequently to justify continually performing procedures of this magnitude, where the potential for disastrous complications is high. One also needs to do a large volume of "small procedures" because a) the complications are relatively infrequent and the practitioner will only generate an adequate database of complications if enough procedures are done (the old adage that "if you haven't seen a dental implant complication, you simply haven't placed enough implants") and b) complications in otherwise healthy patients having elective or semi-elective procedures can be as devastating as the more serious clinical complications.
There comes a point in everyone's career trajectory where they need to decide what kind of practitioner they want to be. Unfortunately, due to the ever narrowing focus of sub-specialties, it seems that this is occurring earlier and earlier in career paths. Thus, it is the case that 3rd and 4th year dental students, operating with imperfect and incomplete information, need to choose programs based on specific foci of interest.
GR would make the following suggestions:
1. It is as important to know what you dislike as it is to know what you like.
2. Operations are cool. Anyone who wants to be a surgeon will agree. But, before you go to a program that does a ton of cancer, craniofacial or other "big procedures", spend some time in the associated clinics. This is where the real thinking and planning occurs. If you don't like this setting, no amount of operating can make up for it. Medicine is moving in a direction where surgical therapy is becoming less and less invasive. In the future, the operating will not be the most challenging aspect of the care of these patients.
3. With rare exceptions, anyone who wants to do head and neck oncology, craniofacial surgery or major facial esthetic surgery will need to do a fellowship. If you're not sure about these areas, go to a program that will offer you exposure, which is sufficient to help you decide whether to pursue additional training.
4. There are few implant/dentoalveolar fellowships. Learn these things well, as well as ambulatory anesthesia and benign path. This is how you will pay your bills, unless you belong to the group of <5% of oral surgeons.
