Australian Dental Journal

Transcription

1 Australian Dental Journal The official journal of the Australian Dental Association Australian Dental Journal 2018; 63:(1 Suppl): S4 S10 doi: /adj Extractions to reconstruction: The Development of Oral & Maxillofacial Surgery in Australian and New Zealand AN Goss,* R Linn *The University of Adelaide, Adelaide, South Australia,Australia. Emeritus Professor of Oral & Maxillofacial Surgery, Emeritus Consultant Surgeon, The Royal Adelaide Hospital, Adelaide, South Australia,Australia. Historical Consultants Pty Ltd, Cherry Gardens, South Australia, Australia. Department of History, School of Humanities, Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia. ABSTRACT Oral and Maxillofacial Surgery developed initially from Dentistry as exodontia. It then expanded into the surgical management of jaw disorders. As the specialty evolved, it came into increasing conflict with related surgical disciplines. In the 1960s and 1970s these external criticisms were well-founded as training in oral surgery was individual, solely University-based and highly variable. In the 1980s the speciality developed a plan which involved hospital-based surgical training, a mandatory high level college surgical examination and detailed workforce and training studies. These were progressively implemented over the next twenty years with a dual degree (medicine and dentistry) and a final fellowship (FRACDS (OMS)). This resulted in accreditation by the Australian Medical Council and the Australian Dental Council and recognition as a Principal Surgical Speciality by the Commonwealth Department of Health. This development was monitored by published workforce studies over three decades that are important yardsticks to inform the credentialing of dental specialists. Keywords: Accreditation, Australia, education, History, New Zealand, surgery. Abbreviations and acronyms: ADC = Australian Dental Council; AHPRA = Australian Health Practitioner Regulation Agency; AMC = Australian Medical Council; ANZAOMS = Australian & New Zealand Association of Oral & Maxillofacial Surgeons; ANZSOS = Australian & New Zealand Society of Oral Surgeons (former name of ANZAOMS); Dual Degree = Registerable Medical & Dental degrees; FRACDS(OMS) = Fellow of the Royal Australasian College of Dental Surgeons in Oral & Maxillofacial Surgery.; IAOMS = International Association of Oral & Maxillofacial Surgeons; NZDC = New Zealand Dental Council; NZMC = New Zealand Medical Council; OMFS = Incorrect term. Maxillofacial is one word; OMS = Oral & Maxillofacial Surgery; RACDS = Royal Australasian College of Dental Surgeons; RACS = Royal Australasian College of Surgeons.. Accepted for publication October Oral & Maxillofacial Surgery (OMS) developed out of surgical Dentistry to its current position as the formally recognised surgical speciality in both medicine and dentistry. The international definition of OMS is the surgical speciality that includes the diagnosis, surgical and related treatment of a wide spectrum of disease, injuries, defects and aesthetics of the mouth, teeth, jaws, face and head and neck. 1 The speciality has achieved this high standard of recognition by never losing sight of the fact its core goal is the delivery of high quality care to our community and patients. At times there has been opposition by related health disciplines and governing bodies. This development has been explored in detail in a recent book. 2 The archival records for that book are currently lodged in the National Library of Australia in Canberra. In this paper, we explore some of the key milestones in the development of OMS highlighting the important S4 points and acknowledging the contribution of key individuals. As George Santayana said, Those who cannot learn from history are doomed to repeat it. BEGINNINGS TO 1950 OMS did not begin in Australia and New Zealand but started in continental Europe by general surgeons with an interest in the face and mouth. This was often of necessity from war injuries, there being no shortage of such wounds from close combat and trench warfare. In parallel with the United States of America the development of academic Dentistry brought with it the skills of oral pathology and exodontia. The need for these skills came into focus from the mass casualties of the First World War. 1 In the United Kingdom the need to develop dedicated Maxillofacial Surgery Units was soon realised.

2 Extractions to reconstruction New Zealanders had a major impact with Gillies, McIndoe, Mowlen and Pickerill, the Dean of the Otago Dental School all having major roles 3,4 (Fig. 1). These Maxillofacial Surgery Units required teams of dedicated Medical, Dental and Nursing staff working together. In 1916 William Kelsey Fry, a founder of British Oral Surgery in a letter to Harold Gillies, a founder of British Plastic Surgery defined their respective roles as I ll take the hard tissues (teeth and bones) and you take the soft. Wise words. In the interwar years much of Dentistry was directed at the management of pain, pathology and surgery. These were major topics at the eighth Australian Dental Congress held in Adelaide in 1933 (Fig. 2). The need to maintain partnerships between the Dental and Medical professions was promoted. The importance of a healthy mouth to the health of the community was also emphasised. 2 During the Second World War there was again a need for Maxillofacial Surgery Units and many young surgeons from Australia & New Zealand, who later went on to hold key roles in the development of Dental Schools, obtained their early surgical experiences in this environment (Fig. 3). FORMING A SPECIALIST ASSOCIATION In the 1950s and 1960s there were extensive discussions between the few practising specialists about the need to form a speciality society. The concept was vigorously pursued by Everett Magnus and Frank Helmore from New South Wales. At the fifteenth Australian Dental Congress held Adelaide in 1959 the first National planning meeting was held in Buck Lindsay s rooms. Plans to develop a constitution and elect officers for an Australian Society of Oral Surgeons were developed. At the next ADA congress in Perth, Gil Henderson was appointed first President and Ted Adler, first Honorary Secretary of the newly formed Australia & New Zealand Society of Oral Surgeons (Fig. 4). The object of the Society was the study and advancement of Oral Surgery and its furtherance as a distinct Dental Specialty. Coinciding with this development, the ADA was in negotiation with the RACS to establish a Faculty of Dental Surgery similar to that which had been established by the United Kingdom colleges. Unfortunately, after several attempts, this development was firmly rejected by the RACS. In 1965 the Australian College of Dental Surgeons, soon to become the RACDS, was formed. A SPECIALITY ESTABLISHED In the 1970s ANZSOS, soon to become ANZAOMS, progressively developed a number of key and frequently inter current themes which involved much of its energies and resources over the next two decades. These were education and accreditation, federal health authorities, Medicare and organizational interactions. These will be discussed sequentially although it must be noted that they were usually intertwined. Fortunately during this period the speciality had a number of strong leaders and surgeons (Fig. 5). EDUCATION AND ACCREDITATION High level education and training has always been a key goal of ANZAOMS. In the post war period speciality training in Oral Surgery was University based and highly individual. There was no standardization. This was illustrated in the 1970s when analysing twenty-two consecutive applicants for full membership of ANZAOMS showed there were 19 different combinations of masters and fellowship qualifications and the training period varied from 1 to 22 years! There was clearly a need for a National Standard Curriculum involving Hospitals, Universities and Colleges with a high standard exit qualification. The first attempt at this was implemented by ANZAOMS in Adelaide with a University Masters degree with a minimum of three years Hospital based experience and on completion, the new Diploma in Oral Surgery of the RACDS. This was implemented with strong support of all parties. The Fig. 1 Pickerill s Maxillofacial Team. Hocken Library, University Of Otago. Fig. 2 Attendees at the eighth Dental Congress. Adelaide S5

3 A Goss and R Linn Fig. 3 Professor Amies (Melbourne), Arnott (Sydney), Lumb (Queensland), Walsh (NZ). Fig. 4 Founders of ANZAOMS. Everett Magnus (NSW), Frank Helmore (NSW), Buck Lindsay (SA), Gil Henderson (WA), Ted Adler (WA). Fig. 5 Early Leaders. Bob Cook (VIC), John Anker (NSW), John Norman (NSW), Sandy McAllister (NZ). David Poswillo (SA & NZ), Henk Tideman (SA), Peter Reade (VIC). first graduate completed in 1976 and, in the years following, six trainees finished. This program then developed similar programs in Melbourne and Brisbane. ANZAOMS in the late 1970s established a graduate training committee consisting of two young and determined academics, Frank Monsour of Brisbane and Alastair Goss of Adelaide (Fig. 6). They developed a well researched plan Oral Surgery in Australia A plan for the eighties which gave the speciality a strategic plan and focus. 5 There were 3 key recommendations: (1) A joint specialist advisory committee to standardise training throughout Australia and New Zealand to monitor and accredit training. In 1988 the Board of the Division of OMS of the RACDS was established. S6

4 Extractions to reconstruction Fig. 6 Graduate Education Committee. Frank Monsour (QLD), Alastair Goss (SA). (2) To conduct detailed surveys of all current training programs and trainees.these workforce and accreditation training surveys have been conducted over the last 30 years and are unique for any surgical speciality worldwide. ANZAOMS and the RACDS have based their strategic planning on this data. 6 9 (3) To established the minimum requirements for specialist registration in OMS. This covered three categories: formal training, clinical expertise and qualification. These were monitored by detailed studies. 8 This plan was adopted by ANZAOMS and progressively implemented over the next two decades. It was driven by the Council and by the two authors until it was implemented in full. FEDERAL HEALTH AUTHORITIES AND MEDICARE Significant surgery is performed in Hospital either Day Stay or In Patient. Rigorous standards apply nationally and to all medical specialties. 2 When the Medicare Rebate for funding of Medical procedures was introduced it was immediately apparent that there was an anomaly. If a jaw operation was performed by a medical graduate irrespective of their training and experience in jaw surgery, then their patient received a rebate. If the operation was performed by a dental practitioner, irrespective of their training and experience in jaw surgery, then the patient did not receive a rebate. This anomaly was first raised at the Nimmo enquiry into Health Insurance in The following year, limited access for jaw surgery was available for suitably trained individuals. This was significantly expanded in the early 1990s and has been reviewed and revised since. As training has changed, no new solely dental qualified surgeons have been added to the current Medicare Schedule for OMS from 2000 and the category will cease as existing surgeons retire. 10 ORGANISATIONAL INTERACTIONS Following the failure of the attempt to establish a Faculty of Dental Surgery in the RACS, ANZAOMS continued to interact with the RACS. In the early 1970s some individual surgeons were promoting the view that surgery should be restricted to persons with medical degrees and RACS qualifications. This came to a head in the late 1970s when the South Australian Government appointed Professor Tracy, a past President of the RACS, to conduct an enquiry into the demarcation dispute between Plastic and Oral Surgeons at the Royal Adelaide Hospital. Tracy produced a most balanced report confirming the equivalent standard of consultant surgeons for both disciplines. 2 This attempt by some individual Plastic Surgeons to take over OMS failed although there were some tensions for years to come. The dictum of Kelsey Fry and Gillies needed to be applied. 3,4 Concurrently ANZAOMS approached the RACDS to develop a Faculty of OMS. After protracted negotiations the College established a Division of OMS with an appointed Board from the RACDS and ANZAOMS. The inaugural Board first met in 1988 with Marsden Bell as Chairman, with the Directors of training in Adelaide (Goss), Melbourne (Cook) and Brisbane (Monsour) plus the Chairman of examiners (Norman) as key members. This influential group rapidly assembled a core curriculum, training structure and accredited training units (Fig. 7). An enquiry in the early 1990s confirmed that medical training in Dental Schools had greatly deteriorated so that registered medical training was needed. This was the international trend and had already been instituted at the individual training units. Dual degrees (Dental & Medical), training plus four years advanced OMS and completion of the FRACDS(OMS) were required for all trainees from Completion of this is required for access to the Medicare Rebate Scheme for OMS and has applied for the last two decades. ON FIRM FOUNDATIONS PRESENT OMS had established a firm foundation for the continued advancement of the speciality by the mid 1990s. ANZAOMS has a strong professional Fig. 7 Inaugural Chair of the Division of OMS. Marsden Bell (NZ). S7

5 A Goss and R Linn Table 1. Workforce of health practitioners in Australia & New Zealand 2 Australia 12 New Zealand 13 Population 22.7 M 4.0 M Number general dentists Ratio dentists to population Number general medical practitioners Ratio medical to population Number OMS Ratio OMS to population General dentists to OMS General medical to OMS organisation with an executive officer helping the elected officers. It has taken over the role of the Division and is co-located with the RACDS. Negotiations have continued with Commonwealth Health Department. In 1998 OMS received recognition as a principle surgical speciality with full equal rights to the other major surgical specialties. A comparison of the specialties and the workforce issues are presented (Fig. 8, Tables 1 and 2). One of the federal government recommendations following recognition as a principle surgical speciality was that a conjoint fellowship in OMS between the RACDS an RACS again be pursued. Working parties from ANZAOMS the RACDS and RACS labored hard for several years to implement the proposal. Massive documentation was prepared and the proposal accepted by ANZAOMS, the RACDS and the RACS interim Board. At the final hurdle the RACS Council rejected the proposal. While disappointing, OMS was left in sole charge of its destiny with its processes having been well scrutinised and organised. 11 There remains close cooperation between the RACS, RACDS and OMS and there is full access to the educational programs and educational opportunities offered by all parties. Accreditation of all of the training activities of the FRACDS(OMS) have now been performed on three occasions by the AMC, ADC, NZMC and NZDC. In parallel with these organizational achievements, ANZAOMS run an Annual Conference and there are multiple courses for general dentists wanting to improve their dentoalveolar skills. The speciality has been active internationally with respect to research and education, and the role of women in OMS. Internationally ANZAOMS was a foundation member of the IAOMS in 1956 and have had International Presidents (Sandy McAllister and Bob Cook). Many members have served in key roles, particularly in education and the Oceania Region of the IAOMS has run S Fig. 8 Projections of the number of OMS in Australia under different recruitment scenarios ( ). 7 *Current supply of OMS. Table 2. Number of Surgeons in Australia & New Zealand by speciality and population ratio 2 Number Ratio General Surgery Orthopaedic Surgery Otorhinolaryngology Plastic Surgery Urology Neurosurgery Oral & Maxillofacial Surgery Cardiothoracic Surgery Paediatric Surgery training courses for the Pacific Islands. Major International Meetings have been held in Sydney in 1976 and Melbourne in Research has always been a strong component of OMS and has been strengthened with the Fig. 9 Overseas Aid. (a) Barry Fitzpatrick, (b) Surgical team Dacca, (c) Vietnam Team.

6 Extractions to reconstruction Fig. 10 Leading women in OMS. (a) Barbara Woodhouse (QLD), (b) Anne Collins (NSW), (c) Jocelyn Shand (VIC), (d) Lydia Lim NSW, (e) Emma Lewis (WA). collaboration of University and College education. To facilitate this, the ANZAOMS Research & Education Foundation was established in A fund of over $1M was rapidly established and is currently being replenished from member and trade contributions. These funds support, in particular, trainee and young member research. Individual ANZAOMS members have long given their time and expertise to train young surgeons and treat patients from the less developed world. The first major initiative was started by Barry Fitzpatrick who established links with Bangladesh. Over the years many missions to train Bangladeshi surgeons were undertaken. The University of Dacca now has a fully fledged four year course in OMS. Overseas aid is currently coordinated by the ANZAOMS Overseas and Outreach Committee. Regular surgical missions are conducted to Cambodia, Vietnam, the Philippines, Papua New Guinea, Fiji and Tonga (Fig. 9). There have been major gender shifts in Medical and Dental Schools, from the virtually all male classes of the 1950s, toward the current female majority of today. This shift has also occurred in OMS. At the recent International meeting in Hong Kong, Lydia Lim presented on the increasing influential role of females in Australian OMS. Currently OMS in Australia has the second highest percentage of female surgeons, second only to paediatric surgery (Fig. 10). So, as demonstrated in this supplement on Contemporary Oral & Maxillofacial Surgery, Australia can be proud of its strong and well educated surgical workforce meeting its commitments to provide high quality care to the community, the dental profession and our patients. A recent controversial and arguably retrograde development has been the commencement of a threeyear postgraduate Dental qualification at the University of Sydney for registration in Oral Surgery. This course was introduced with no supporting workforce studies demonstrating a public need and with a limited curriculum that is already well encompassed within the existing high-level scope of OMS training. Curiously, this course appears to reflect a return to the aspirations of the s. Santanya s wise words need to be heeded: Those who cannot learn from history are doomed to repeat it. ACKNOWLEDGEMENTS The research for this paper was supported by the Australian and New Zealand Association of Oral and Maxillofacial Surgeons Inc and the Goss Clinic Fund. REFERENCES 1. Stoelinga PSW, Williams J II. Fifty years of IAOMS. The development of a speciality. Illinois: IAOMS, Goss AN, Linn R. Extraction to reconstruction. The development OMS in Australia and New Zealand. Cherry Gardens: Historical Consultants Pty Ltd, Meikle MC. Reconstructing faces. The Art of Wartime Surgery of Gillies, Pickerill: McIndoe and Mowlem. Dunedin; Otago University Press, S9

7 A Goss and R Linn 4. Brown RH. Pickerill: pioneers in plastic surgery, dental education and dental research. Dunedin: Otago University Press, Monsour FN, Goss AN. Oral surgery in Australia: a plan for the 1980s. Brisbane: ANZAOMS, Goss AN, Gerke DC. The Scope of Oral & Maxillofacial Surgery in Australia & New Zealand. A postal survey. ADJ 1991;36: Spencer AJ, Szuster FSP, Brennan DS, Goss AN. A consensus approach to projections of the supply of oral and maxillofacial surgeons in Australia. Int J Oral Maxillofac Surg 1993;22: Szuster FSP, Nastri AL, Goss AN, Spencer AJ. Survey of Australian and New Zealand oral and maxillofacial surgery trainees and recent specialists - education and experience. Int J Oral Maxillofac Surg 2000;29: Goss AN, Gerke DC. Effect of training on scope in oral and maxillofacial surgery. Int J OMS 1990;19: Medicare schedule. Oral and maxillofacial surgery. Guidelines for use. Canberra: Commonwealth Department of Aging and Health, Handbook of accredited training in oral and maxillofacial surgery. Sydney NSW: The Royal Australasian College of Dental Surgeons, Goss AN, Helfrick JF, Szuster FSP, Spencer AJ. The training and surgical scope of oral and maxillofacial surgeons. The International Survey Int J OMS 1996;25: Doctor of Clinical Dentistry in Oral Surgery. The University of Sydney. Available at: tistry/postgraduate/coursework/dr_clinical_dentistry/oral_surgery. shtml. Accessed 15 May Address for correspondence: Emeritus Professor Alastair Goss Oral & Maxillofacial Surgery Unit Faculty of Health Sciences The University of Adelaide. Adelaide, SA 5005 Australia alastair.goss@adelaide.edu.au S10