editoriaal van prof. Schoenaers voor Belgian News OMFS

Editorial RBSSOMFS  November 2014

Shaping the next generation of Oro-Maxillo-Facial Surgeons and the Specialty A vision for the near future:

Survival of the fittest is the concept described in the “Origin of species” by Charles Darwin. The specialty which renders itself most flexible and adaptive to the upcoming changes within the social environment and the needs of care in the oro-facial and head and neck region, is the one, to most likely gain impact and therefore expand (or survive). Hence comes the basic question: can we predict the future and how should the current generation of oro-maxillofacial surgeons ideally conceive their specialty and outline a successful future for the OMFS specialist.

The outgoing CEO of the Vlerick Business School, Marc Buelens,  a psychologist by profession and trainer of top managers for 40 years, on his retirement gave an in depth interview in an authoritative weekly, in which he verbalized his insights and guiding thoughts for a promising enterprise. His most important ideas are summed up in his book: “Bye , bye management”. Some of the most decisive topics have to do with the influence of the European dimension, and the globalization of each enterprise (environmental factors !). Another major theme is that managers have to be careful with everything that is monofocal in this ever changing world: the certainties and hence, the predictability, of the past no longer exist. We continuously have to probe the future and act with anticipation. In a context of a SWOT analysis (Strengths, Weaknesses, Opportunities and Threats ) one should move on from problems, and invest in opportunities: look forward and further develop successful options. In this endeavor a managing authority should be as ambitious as in climbing Mount Everest: “climb high, sleep low”, but always come back to basecamp. If one is blinded by the top and looses contact with reality, the outcome can be disastrous.

The key is to develop a vision and, for the actual leaders, to foster junior members of the Society with some visionary talents, besides their daily professional commitment and clinical output.

Ed Barlow, a self-proclaimed “futurologist”,was hired by the IAOMS 10 years ago, to shape the bi-annual convention of OMFS delegates at the headquarters in Oackbrook, Chicago. Several areas of the OMFS specialty were highlighted and contrasted with presumable future issues, within and outside the Association. Each of those meetings was conducted interactively with the attending delegates: setting the actual scenery, indicating the trends and developments worldwide (based upon extended but focused internet searches), and finally asking the representatives for their constructive ideas on these matters. At the same time a fundamental concern was expressed by Barlow about the average age of the delegates, as he considered them too old to gather all necessary information applicable to the future generation’s field of practice. After collecting the different viewpoints and concerns brought forward by the representatives of all the participating nations, Barlow merged their suggestions and IAOMS issued reports advising on necessary changes for particular fields within the specialty. Then the IAOMS implemented a whole wave of transformations anticipating on the future with the objective of  safeguarding OMFS worldwide: change of the structures of the representative bodies, recruitment of global representation (from then on from ALL nations of the world) and rejuvenation of the national representatives and of IAOMS staff members (actively inviting younger generations and trainees). Furthermore, they advocated feminization in organizational bodies, as well as in the specialty. A major concern was how to define the future (entry) level for basic education for trainees, theoretical knowledge and clinical skills of the OMFS specialist.  The trend towards super-specialization lead to the installment of SIG’s (“Special Interest Groups”).

The IAOMS took it upon itself to upgrade educational programs for OMFS care-workers of all ages all over the world, by harmonization, teaching, certification and recertification, by investing in ICT technology and interconnectivity and in this process E-learning and many exchange programs were implemented. In all this they make good use of the pool of knowledge and clinical expertise residing in the elderly OMFS specialists.

The IAOMS improved standards of care worldwide (but adapted to local societies) providing educational grants, stimulating collaborative efforts between research- and training centers and providing its community with monthly, weekly and daily updates - via e-messaging - on developments in the collateral dental, as well as medical professional worlds, in the same process adapting itself to the educational transformations .

Also in our country of over 11 million Belgians, we, the Royal Belgian Scientific Society of OMFS, have to invest, not merely in education , in scientific research and development (“R&D”):

but also in a VISION.

First and foremost, the specialty should comply to the needs and the expectations of the consumers of our care: so once again an extrinsic factor is fundamental - society as a whole and the individual patient’s needs and expectations precede over our traditional self-image and -perception. In essence, we derive our assignment and value from our ability to serve our community’s needs. Our population is aging and there is an increase in esthetical awareness - these trends need to be valued.

As a hybrid specialty we are exposed to a tremendous amount of opportunities, as our services are requested both by the dental community as well as neighboring medical specialties. New technologies are always on the verge: imaging techniques, navigational surgery, implants, minimal invasive and endoscopic techniques and robot surgery are to be explored and developed, also in our specialty. At the same time we have to permanently keep up awareness of imminent profile changes which will ensue in these collateral specialties.

Without losing our core identity as dento-medical OMF surgeons, we have to develop (super) specializations – with knowledge, skills and networking. Not all OMFS colleagues have to specialize to the same degree: second and tertiary referrals within our specialty should be encouraged. Multi-headed associations and collaborative multi-disciplinary care programs should provide a strong foundation for such super specialist care, allowing a number of OMF surgeons to narrow their focus. In the same context, other OMF surgeons should support this advanced care by refraining from providing care for the same pathology, not only to the benefit of the patients, but also to allow OMFS colleagues to establish a super specialised level of care. The aptitude to limit one’s universal aspirations within the confines of the OMFS specialty is a condition sine qua non in this context. In this respect some areas within OMFS will have to be regulated. If we are not willing to accept this principle we will delay and depreciate the profile and competitiveness of our specialty. For example: OMFS in head and neck oncology; and OMFS in cleft and craniofacial anomalies.

The scope of OMFS is extremely wide with a huge variety of treatment modalities. Fortunately, innovative diagnostics and treatment modalities are steadily introduced in each of the sectors of OMFS.  Ongoing development of surgical and non-surgical treatment options and diversification will probably persuade surgeons to focus on some areas within our specialty. Most probably, one’s interests will be directed towards one or a few of the following fields: prosthetic oral rehabilitation (pre-prosthetic and implant surgery), orthognathic surgery (orthodontic surgical correction of dento-facial deformities), dento-alveolar surgery, pain- and nerve disturbances and TMJ related dysfunctions, oral pathology and iatrogenic disease, care for medically compromised patients, saliva and salivary gland pathology (sialo-endoscopy and salivary gland surgery), facial esthetics,  etc. Even though these special interest groups undoubtedly are developing within OMFS, and have their own scientific forums, they are, for now, not threatened by the imminent burden of a regulatory body. However, the development of these specialty “subdivisions”, contains a risk of disintegration of the common body of OMFS. Hopefully we are lucid enough as a minor medical specialty in Belgium to have the common sense to adhere to the principle of  “United we stand”, in line with the logo of our hybrid country:  “Eendracht maakt macht / L’union fait la force”. In too many countries this subspecialty drift is masked by a generation conflict. A conflict, in which young would-be pioneers tend to sacrifice the integrity of the existing specialty, as a whole, to their own search of “founder father-ship”, e.g. some esthetic- and maxillofacial surgeons will deny the need for a dental education to be part of their training.  This trend has been observed in many other countries: Poland, France, Turkey, and much to the dismay of the national guardians of the mainstream specialty and of the umbrella professional organizations.  Unfortunately, this threat also exists in Belgium.

A self-respecting professional organization, as the RBSSMFS, cultivates appreciation towards its peers and its founders, previous generations of professors, researchers, diplomats and emeriti and older practitioners, both from private practices, as from university settings. Identification of ‘who we are’ resides in the past and is a major constituent of what we want to be:  “Those who don’t remember the past are condemned to repeat it” (William Rendu-Osler), or simply refer to the related sentences in the timeless oath of Hippocrates.

We, at the Belgian society, do appreciate the presence of our peers at the scientific and professional meetings, as highly valued councilors of our Society. Their presence reminds us of the past times in which our society prevailed and sprouted to what is has become. Their presence illustrates in many aspects the wide scope of practice, but also the liaison to many foreign OMFS centers of excellence. They allow identification processes to occur in the mid-level residents in training (“in their professional puberty”) and challenge them to do better than them in the future. We have to welcome them with respect and esteem at our semesterial  activities and value their protective advice in dubious situations. Their access to the meetings has to be facilitated by all means.  Beyond 65, talented OMFS specialists still have a lot to contribute to the Association and our society, be it often in an indirect way.

The future is in the hands of the youth. In Belgium we are blessed with high level primary and secondary school systems, of which many also provide a high level of philosophical awareness. The economical situation of the recent past has also provided a protective environment, not available in many other countries. Novices recruited from medical- as well as dental school, in a competitive setting, warrant a high quality intake of future residents. Selection at the onset (by triage), the access examination and the lucidity of the coordinating trainers, have provided our profession with highly motivated novices.  Differences have been stated though, with respect to different Belgian regions, between the sexes and primary recruitment (from medical or from dental schools).

Belgium, as a hybrid nation, is a federal state, which comprises of 4 communities: the Flemish speaking (6 mil), Walloon speaking (4 mil),  the German speaking (80.000) and Brussels Capital. Planning of manpower is impeded by discoordination between these regions. Also in the BRSSOMFS the manpower planning according to the number of inhabitants is unequal and the numbers of recruitment are disproportional to the regions’ proportions - this may also apply to the first and second generation of immigrants. Variety in population may be a hassle, but many societies prove that this diversity may be turned into an opportunity and a major source of positive evolution. In all cases the principle of “equal opportunity” should be respected.

Due to divergence, mainly in the medical educational and specialty training scene, between the Walloon and Flemish regions, elementary principles have recently not been equally applied: the access examination (toelatings proef / examen d’admission) is not applied at the same level of undergraduate training in both regions and recruitment of dentists and MDs is not performed according to similar numerical indices. This will affect the manpower planning in the distinct regions. The section of OMFS at UEMS has preferentially proposed a 1/120.000 OMFS specialty programming, whereas in Belgium this is outnumbered in general to locally 1/ 40.000 or less. Fortunately, the OMFS training has as an intake requirement that stipulates that he or she is also holder of a dental diploma: this warrants referrals from the dental colleagues, predominantly, as well as from the MD’s. Nevertheless the manpower consideration deserves attention nowadays, where all regional clinics employ dually qualified OMFS surgeons within their walls. If numbers increase further, the inherent boundaries of professional activity with only dental surgery specialists will be blurred and out-of-hospital OMFS  practices will blossom. And this will depreciate the OMFS profile.  If, on the contrary, the rather high number of OMFS specialists is enabled and stimulated to sub-specialize, (by means of positive or negative reinforcement) than this higher density of OMFS specialists is the ultimate key to quality enhancement and upgrading of the standards within the specialty. Also adherence to the university careers (clinical, educational, research) and governmental assignments may be a positive outcome of this imminent super-saturation of OMFS care providers. In this respect attention also needs to be reserved for disproportional intake of candidates between these national regions, which may cause outspoken imbalances in OMFS manpower.

Equal opportunities for an M.D. (medical doctor) and for a D.D.S (dental  surgeon) should prevent polarisation of entry into the double qualification: the access of medical doctors to the specialty in Belgium has previously always been predominant. Rather seldom a dental surgeon would envision a full medical education and would then subsequently apply for a prolonged clinical residency training, which might then last a full 5 year term (according to Belgian law), leading to the registration as a “Stomatologist”. Since the separation of the Dental school from the Medical school in 1978, dentists were no longer recruited from medical candidate years, but would start, de novo, in the dental training curriculum. The recruitment of dental surgeons turned into a positive one. Since then, the opposite pathway into the double qualification, starting with a dentistry diploma, through medical school and subsequent OMFS clinical training became a fact. 

However, the acquisition of a registration in OMFS is not equal in both of the main regions , Walloon and Flemish. In the Flemish region the one who starts out with an MD diploma is enabled to obtain the university DDS diploma in three years, and subsequently over a 2 year trajectory the degree of Stomatologist and  after 4 years of training the OMFS registration is achieved. The DDS first candidate would, after 5 years of dentistry, be facing a 5 year long MD education, and faces a similar period of 10 years in combined medical and dental school, before entering residency of four years.  So equal opportunities for both MD-first and DDS-first candidates was installed. No salary for any of both undergraduate master degrees is available. In order to fully apply equal opportunities, one contingency specialist place is provided per 80 students (per annual cohort), provided that each of them fulfills the possession of a second master’s degree in due time, with a satisfactory score. In the French-speaking region, influx into the OMFS training is still preferentially via MD-first qualification. The dental education is partly incorporated in the clinical training period and a subliminal salary is provided to the MD during his time in dental school. The opposite entry, starting as a dentist-first is much less likely to occur in the French speaking region.

We should try and harmonize access criteria to and financing during preparative master education for OMFS. We believe that equal opportunities for MD and DDS in all regions of the Belgian territory have to be installed. It has to be recognized that several dentists-first colleagues are eminent specialists in OMFS and have earned credits for this. We also observed that the candidates from dental school, are traditionally the best of their year, where OMFS candidates recruited from medical school most often have less outstanding curriculum vitae’s. The eagerness of dentally qualified distinguished students, who apply in multifold of the maximum vacancies, is also a warranty of never falling behind in plausible candidates for specialization, even in years in which  not  one single MD student would consider a training path in OMFS. Dental-surgeons-first seemingly are also better embedded in the dental professional body, incite easier referrals and clearly illustrate the major difference between the professional level of OMFS and any other dental surgical specialty.

Equal opportunities and sexes: we state that female OMFS surgeons are increasingly installed in the country. In a period of about 20 years, their proportional numbers in the specialty have doubled from < 20 % to > 40 %. This figure is low compared to the female proportionality in the recently (2014):  recognized medical specialists group : 70%. This feminization should be considered a positive trend, as females have a high reputability in basic care provision, especially in the fields of pediatric oral surgery. With regard to female patient treatment, they have  a specific role to play and compensate for a previous deficit of female OMF surgeons. On the other hand, it is to be noted that a female professional career does not equally cover care provision when compared to a man’s professional track record. Pregnancies and other priorities are major determining factors. Although very welcome in the field, manpower calculations, both during their training period as well as in their professional setting, have to be modified accordingly: in order to achieve  job fulfillment a compensatory quotient of activity should be introduced for female specialists. It is evident that the OMFS specialty allows for well planned working schedules, which are compatible with other, mainly parental, duties. Questionable is whether attractiveness of this long lasting specialty for females should be raised by allowing periodic part-time education schemes.

OMFS specialist have an important role to assume in the planning of complex pathologies, as is common in care programs. Having close ties with both the medical and dental specialties an OMF Surgeon would be the ideal coordinating  specialist. And also in litigation our colleagues should invest more time and effort due to their inherent and unique expertise.

Also in Belgium we have to stimulate exchange programs and support translational research.

Semantics will stay an important issue :  A harmonized vertical stratification  of  professional titles in all countries ultimately has to enable integration between the several surgical specialties that are  active in the dento-oro-cranio-maxillofacial region. The name giving within the scope of DOCMFS needs to be based on a verifiable education and a licensed competence.

The youth needs to be embraced by the RBSSOMFS  and the thresholds for them being part of the professional community should be kept low.  All trainees ideally should be junior members  of continental  and global societies starting at the onset of their training. OMFS trainees must be encouraged to nurture their own resident’s Society: with a leadership, a structure , an aim and with representation in the professional peer societies. This environment should foster future professional  diplomats.

Now after the question: What can the specialty do for each of the OMFS specialists, comes de second part of the interactive commitment: What can each of the specialists do for the specialty (with reference to John Kennedy’s saying).

All of the before mentioned themes have to be carried by involved and committed member specialists. Membership is a first prerequisite! Assuming duties in the workforce is a subsequent investment that is necessary. Many of our peers in Belgium, have delivered their best efforts in order to create and sustain the Belgian scientific and professional societies as they are. They have taught, educated, and represented their colleagues at the European and at the international forums. Many duties need to be supported: several positions in the Belgian scientific association, in the professional trade-union like societies as well as in  the educational programs (universities and affiliated training centers) need to be manned. Such jobs are :  the secretary and the vice secretary, the treasurer, the past president, the president and the president-elect, members of the executive committee (“bestuurscomité” of “comité directeur”), representative at the Belgian specialist organization (VBS /GBS), representative at the UEMS (Union of European medical specialists) section of OMFS and higher, representative at the European Scientific Society (EACMFS), representative at the International Association of Oral and Maxillofacial Surgery (IAOMS), representative for the residents in training (at the Belgian, European and International  levels), member of the commission of recognition of OMFS specialists, but also assignments at the university and in training centers (professor and assisting professorship, clinical and research staff member positions) and expert activities in litigation.

Our major current concern is that most specialists in those functions are aging, and that we have no prospect of many (if any) others taking the standing invitations to follow-up and possibly improve the existing role models. Progressively also, we observe an obvious Dutch-speaking preponderance in the assumption of duties and there is a strikingly low involvement of female specialists.

So we urgently need more, preferably young, people that want to invest in these professional aspirations in general. Particularly we need French-(and German-) speaking colleagues in the team, and we wonder when finally female colleagues claim their share of the chairs.

We need to recruit dynamic people with vision in our OMFS specialty

Who?

Do not look to others, but to the one you meet daily in the mirror. YOU try and YOU reply to this call of duty.

As an outgoing president of the society, I want to express my sincerest appreciation for all those who encircled me with their constructive support for the bettering and the representation of our Royal Belgian Scientific Society during the past 2 years and the 4 past scientific meetings.

My greatest appreciation goes to our secretary Edmond Lahy.

I have the honor to announce a historical ‘first’ in the RBSSOMFS: Professor Isabelle Loeb takes over the presidential duties. This opens a new age where a lady president stands by  “Yes We Can”.

Modern management of the eighties did steal its innovational ideology essentially from religion: the concepts Vision, Mission and Values all stem indeed originally from religion. I hope that Professor Loeb can go one step further then the Churches. That she may succeed in convincing many more lady professionals to join her in carrying our professional endeavors, proportional to their increasing presence in the clinical arena.

By he outgoing President 2012-2014 Joseph Schoenaers, Professor of OMFS at the KU/UZ Leuven