What Our Profession Can Learn From Dentists

At least once a week, I have lunch with the chair of oral and maxillofacial surgery at our teaching hospital for the dental and medical schools. He has the dual degrees of MD and DDS. We share stories and pretty much compare notes about student and residency education. Naturally, I have picked this dentist’s brain and after much thought have come to the following conclusions.

I am convinced the dental model is the best one out there. Dentists have their own schools and are self-regulated. Their big advantage is that allopathic medicine has given up on teeth. Unfortunately, allopathic medicine has not given up on the foot so podiatry has more turf battles. Who shouted, “It’s an economic issue”? You bet it is. Oral and maxillofacial surgeons do have some turf battles, however, when they overlap with plastics and ear, nose and throat specialists.

Not all dental students want to be oral/maxillofacial surgeons. Dental students need to have manual dexterity no matter what they do. The surgical courses are required of all. However, students have to be aware of the number of dental residency slots available. Here’s an important stipulation: the clerks have evaluations during their oral and maxillofacial surgery (OMFS) rotation. If they lack surgical prowess, they do not get a good evaluation, which literally dooms their dental career.  

If we extrapolate the above to our profession, the yearly graduation of our 500 surgeons would be greatly reduced. The quality of our surgeons readily improves if this smaller number of graduates is doing more surgery with referrals by the large cadre of non-surgeons just like in dentistry.

What happens to everyone else’s education? I am not advocating truncating the three-year residency, just establishing two types: our version of OMFS that is currently in place (PMSR/RRA) and a new one dealing with every other part of foot and ankle care. Accordingly, both boards would remain. However, the surgical programs would be reduced and more than likely enhanced.

Around 1995, the Podiatric Education Enhancement Project began with all of our stakeholders to hash out the future of our education.¹ One initiative would have mimicked the dental model. The major stumbling block was the type of surgery the “general” podiatrist could do. Was it just a nail, a hammertoe or a simple bunion, whatever that is, or some other delineation whereby anything beyond the agreed scope would have to be referred to the “surgeon”?

Unfortunately, the Podiatric Education Enhancement Project never saw the light of day due to that major area of disagreement. Keep in mind this would have never been a retrospective or even concurrent change but, if put into place, would have been for a future graduating class under this rubric.

Consider this case scenario. A woman is having treatment for tinea pedis. She has developed a painful bunion and would like surgery. The first doctor then refers her to the surgeon who does the procedure and aftercare. When healed and ready to go, she goes back to the other physician for any other care (even orthoses) unless a surgical entity crops up again.

Oral and maxillofacial surgeons even have the capability to have a few residency slots in which one can also obtain an MD degree. The normal OMFS residency is four years while the MD/DDS residency is six years. During the second and third years of their residency, dentists are in their third and fourth years of medical school with an added burden of more tuition.Then it is back to OMFS residency for the fourth through sixth years of residency. Even though my OMFS chief and I have talked a lot about this, I am not convinced of its significance.

My dentist friend, for the life of him, can’t figure out why we have the Centralized Residency Interview Program (CRIP). “Shouldn’t residents come here to interview and see the place? If this was IBM with job openings, wouldn’t they have to come here?” Although I know our talking points (i.e. saves money, etc.), my commitment to CRIP is less today than it was a few years back. I happen to agree with him.

That is the proposal in a nutshell. I still can’t fathom preparing all of our students to be surgeons. It would be one thing if they were all maintaining surgical competence through the years but the numbers make this assumption suspect. If we tout ourselves as being the guardians of our nation’s lower extremities, the public deserves the most competent care.

Dr. Wallace is the Director of the Podiatry Service and the Medical Director of Ambulatory Care Services at University Hospital in Newark, N.J.

Reference
1. Curry L. Podiatric educational enhancement project. A project overview. J Am Podiatr Med Assoc. 1996;86(8):361-3.