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Why Don't I Want to Pursue Academic Oral and Maxillofacial Surgery?

2024; Elsevier BV; Volume: 82; Issue: 3 Linguagem: Inglês

10.1016/j.joms.2023.12.012

1531-5053

Benjamin Palla,

Innovations in Medical Education

"Can one of the chief residents interview applicants with Dr Miloro today?" Despite the regret of not wearing a bowtie, I was ecstatic. During the next 2 days, I listened to Dr Miloro ask each applicant, "What is your plan after completing residency?" The answer was consistently, "Private practice performing implant and dentoalveolar surgery." Then the predictable follow-up question, "If so, why waste your time training in full-scope oral and maxillofacial surgery? Why pursue 4-6 years of training if you are not going to use everything that you are trained to do?" After enough interviewees, I felt this interrogation was being directed at me—and perhaps it was. I began residency eager to pursue a career in academic oral surgery, and, at that time, I was sincere in that commitment. I told my wife that I wanted to apply for a fellowship and that she should prepare for the long haul. I remained involved with research, now with 24 publications. Yet, come this June, I will join the majority of the OMS profession in an office-based, narrow-scope, private practice. So, as the cross-examination proceeded in front of me this year, I asked myself the question, "Why don't I want to pursue a career in academic oral surgery?" With such an overwhelming percentage of residents leaving the academic environment after graduation, the reason must extend beyond a simple personal one. What is the shared rationalization among oral and maxillofacial surgery (OMS) graduates for this decision? Why do we sacrifice the time, energy, and money in a broad scope residency, if these skills will not be part of our future practice? My initial thought was to compare OMS to other surgical specialties. What is the benefit of head and neck training to an otolaryngology resident who will focus on 'tubes and tonsils'? Why do plastic surgery residents spend years performing facial reconstruction for a career spent tightening 'butts and boobs'? I don't think oral and maxillofacial surgeon is any different, with most focusing on 'teeth and titanium.' Consider our own exposure to head and neck oncology. By training 'one-level-of-depth-greater' than we plan to practice, an appropriately trained oral and maxillofacial surgeon can determine what to ask, where to biopsy, when to refer, and how to monitor or manage these patients postoperatively. In a simplistic comparison, this broad scope residency is our high-altitude training before the marathon. "The life of the surgeon is in the dealing of complications," Dr Constantinus Politis told me. One must be trained for that next level of care. Separate arguments, however, crossed my mind. Which surgeon actually spends more of their time operating, and which surgeon deals more with paperwork and hospital bureaucracy? Which career choice offers more free time for self, partners, and family? A greater choice of where to live? Which has a better work-life balance and a healthier lifestyle? Which career offers you the most control? Even from a utilitarian view, which surgeon promotes the greatest good for the community? A single 12-hour oncologic resection requires significant costs and resources including multiple surgeons, prosthodontists, intensive care unit (ICU) nursing, wound care, nutrition, therapy, possible complications, and revision surgery, with a 5-year survival rate of 50%. Consider that these same resources could aid hundreds of other patients with lower costs, commitments, and complications. However, to simplify this argument and identify why I believe most graduates chose a narrow-scope, office-based, private practice, "it's all about the money." It is a strong departure from the idealism many applicants enter the medical field with. However, I believe this reason is honest and frank. Also, it is not just a financial decision that leads graduates into the private sector; it also dictates the narrow scope. Despite some variations that may exist, most academic salaries fall in the $250,000-$500,000 (the salary of many state-employed surgeons is public). A first-year salary in the private market may start as low as $250,000; however, there is significant growth opportunity and a higher ceiling. Many oral and maxillofacial surgeons target $1,000,000 or more per year following partnership. It is also common for first-year graduates willing to work for a dental service organization to earn $500,000-$750,000 the first year. This is a categorical difference. This contrast in salaries has always existed. Its growing influence, however, is perhaps related to the disproportionate growth in educational debt. Despite research suggesting an average debt load of recent OMS graduates to be $400,000 - $450,000,1Jones J.P. Ellis E. Trends associated with debt loads among oral and maxillofacial surgery chief residents.Oral Surg Oral Med Oral Pathol Oral Radiol. 2019; 128: 590-596Abstract Full Text Full Text PDF Scopus (3) Google Scholar I feel many older surgeons neglect the influence this should play in career selection. With 6-7% interest rates, however, the average resident accrues an additional $2,000 per month in interest alone. Paying off student debt is often incomprehensible for a recent graduate and overwhelming. The same survey showed 24% of current graduates have over $500,000 in educational debt. Economic influence is also a large factor in determining the scope of OMS practice. Dentoalveolar surgery has a low overhead cost and a high reimbursement. Trigeminal nerve repair has a high overhead cost and low reimbursement. Look no further than the practice of orthognathic surgery in private practice and the ebb and flow that has occurred with changing insurance coverage. When reimbursement allows, OMS has proven before it is not just capable, but actually eager to expand its scope. Without any financial considerations, would more OMS graduates remain in academics, or at least pursue a job with broader scope? I would say, yes. In Maslow's Hierarchy of Needs, financial stability comprises the second level. Despite this economic argument, however, I do think a more meaningful one exists. One thing that private practice can offer to a greater ability than an academic position is the opportunity to create something. Although all surgeons can reflect themselves in their work, as a private practice surgeon, you have the ability to build a practice. The surgeon is reflected in that practice; in their choice of the office layout, staff, décor, materials, scheduling, website, and educational pamphlets. I think a vital part of human nature, on a basic level, is this act of taking an internal idea, and being able to express it. I acknowledge this may not be the reasoning for many surgeons, vis-à-vis the dental service organization. However, for residents who sucked the marrow out of opportunities during residency, private practice can be a new challenge. Of course, this is all the opinion of a resident who has yet to practice. In 5-10 years, I am equally interested in observing how this view may change. And finally, new rule, the academic oral and maxillofacial surgeon is not the only life-long learner. Do not forget that many nonacademicians engage with American Association of Oral and Maxillofacial Surgeons (AAOMS) and other national and international organizations, JOMS, and local dental societies and study groups. Many office-based practices are utilizing intraoral scanners, 3D printers, implant guides, virtual surgical planning, and custom plates. To further identify the practice patterns, however, I agree with Dr Miloro's editorial2Miloro M. Why do you want to be an oral and maxillofacial surgeon.J Oral Maxillofac Surg. 2024; 82: 261-262Google Scholar and our previous publication in this journal3Palla B. Callahan N. Miloro M. One survey to rule them all.J Oral Maxillofac Surg. 2021; 79: 282-285Abstract Full Text Full Text PDF Scopus (5) Google Scholar that more information is needed. For this, the Resident Organization of the American Association of Oral and Maxillofacial Surgeons (ROAAOMS) should heed the call for a yearly survey. ROAAOMS can provide important evidence few others could obtain without a significant response bias. What would influence more graduates to pursue academics? Is it purely financial, or how do certain programs create environments that seem to grow academicians4Roudnitsky E. Hooker K.J. Darisi R.D. Peacock Z.S. Krishnan D.G. Influence of residency training program on pursuit of academic career and academic productivity among oral and maxillofacial surgeons.J Oral Maxillofac Surg. 2022; 80: 380-385Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar? So, what is an honorable pursuit in a career choice? On a basic level, a provider must practice safely within the AAOMS Parameters of Care.5Parameters of care.J Oral Maxillofac Surg. 2023; 81: E2-E12Google Scholar With our broad scope training, I think it is important to offer at least one unique practice to our community; cosmetics, temporomandibular joint, nerve repair? As a practitioner advances, they can give back more, begin to mentor other students or surgeons. At the highest level, one can innovate and provide unique contributions to the field. Perhaps, this is what the academic oral surgeon represents. Many academic oral surgeons have dedicated, and in many ways sacrificed, a component of their lives for an academic career. Their legacy resides in their research and scholarly activity, service, teaching, and also in the lives of the surgeons they have trained. For the rest of us outside of academics, we each must determine what type of legacy we wish to leave behind. The author wishes to acknowledge Dr. Michael Miloro for his guidance in revising this article.