Maxillofacial Training is No Longer than Other Surgical Specialties

Abstract

INTRODUCTION

There is a perception that the training pathway for oral and maxillofacial surgery (OMFS) is unduly long and arduous, as consultant oral and maxillofacial surgeons must be doubly qualified (that is, hold degrees in medicine and dentistry) and be holders of two higher fellowships.

MATERIALS AND METHODS

We reviewed the data regarding the average age of National Training Number (NTN) holders and GMC data on the year of first registration and the year of entry onto a specialist surgical list for all 9 surgical specialties.

RESULTS

The results showed the average age of the surgical SpR populations ranged from 33.5 to 38.2 years with an average age of 36.14 years. OMFS SpR's average age is 37.69 years. The GMC data showed the average number of months from full to specialist registration ranged from 90.83 months to 135.24 months, with OMFS surgeons having the lowest average.

CONCLUSIONS

These data suggest that OMFS surgeons are of a similar age to other surgeons whilst in training. In addition, they have the shortest transit time between full GMC registration and entry onto the specialist list. The length of this training even with dual qualification is similar to other surgical specialties.

Although no hard data are held, The Royal College of Surgeons of England has suggested that the majority of consultant surgeons, including maxillofacial surgeons, are appointed in their mid-to-late 30s (personal communication, June 2006). Various aspects of UK maxillofacial training have previously been scrutinised by Devlin et al.,¹ including the age of appointment. Despite this, it is perceived that the training pathway for maxillofacial surgeons is excessively long as they must be in possession of both a medical and dental degree and have obtained MRCS (or equivalent).

In order to be short-listed for a specialist registrar (SpR) post in the UK, applicants must hold the qualifications as detailed above. MFDSRCS or equivalent is also desirable, but not essential, at that stage. Shortened medical degrees have long been available for holders of a dental degree. There is now a reciprocal arrangement whereby shortened dental courses are available for doctors.² These shortened undergraduate courses take between 3–4 years. Furthermore, dental and medical students on courses where a second degree is a requirement for entry to specialist training are eligible for means-tested bursaries which pay tuition fees from year two of the 4-year graduate course and help towards living costs.³

Subsequent basic surgical training will then add at least 2 years prior to gaining a National Training Number.⁴

We set out to establish whether the average age of OMFS consultants at first appointment is higher than that of other consultant surgeons.

Materials and Methods

We applied for information from centrally held data bases under the Freedom of Information Act (2000). We reviewed data from multiple sources:

1. Deanery data on the age of NTN holders for all 9 surgical specialties from London, Kent Surrey and Sussex (KSS) and the Welsh deaneries.

2. GMC data on year of first registration and year of entry onto a specialist surgical list for all 9 surgical specialties.

3. Deanery data on number of applicants per NTN post.

Results

Table 1 and Figure 1 summarise amalgamated data from the London, KSS and Welsh deaneries and show the average age of the surgical SpR populations per specialty which ranges from 33.5 to 38.2 years, a distribution of less than 5 years. Overall, the average age of the surgical SpR population is 36.14 years.

Table 1.

Average age of surgical SpRs by training specialty

Training specialty (surgery only)	Average age of SpR (years)
Cardiothoracic surgery	38.22
General surgery	35.27
Neurosurgery	37.35
Oral and maxillofacial surgery	37.69
Otolaryngology	33.51
Paediatric surgery	36.63
Plastic surgery	36.43
Trauma and orthopaedic surgery	35.18
Urology	35.01

‘Part’ years are shown as decimals and not months/weeks/days.

Figure 1.

Average age of surgical SpRs.

Table 2 and Figure 2 show the GMC data for doctors entered onto a surgical specialty list between 1997 and 2005 (see discussion). Note that these values do not include the (typically) 12 months spent as a preregistration house officer.

Table 2.

The average number of months from full registration date to registration on the GMC specialist list

Surgical specialty	Time (months)
Cardiothoracic surgery	135.24
General surgery	124.32
Neurosurgery	116.32
Oral and maxillofacial surgery	90.83
Otolaryngology	131.56
Paediatric surgery	118.84
Plastic surgery	126.96
Trauma and orthopaedic surgery	121.88
Urology	122.96

Figure 2.

The average number of months from full registration date to registration on the GMC specialist list.

Discussion

We set out to establish the average age of OMFS consultants at first appointment. However, as the senior author (MC) found in a brief telephone pilot study this would have proved difficult: individual NHS Trusts hold such data and are not obliged to release it quoting the Data Protection Act as reason. Therefore, collecting the information from all UK NHS Trusts would have been time-consuming at best and doubtless incomplete. Moreover, given the fact that consultants move between posts, we may have been unable to establish if a post was the first, second or greater as a consultant surgeon. This would obviously invalidate the answer to our question. Therefore, we elected to ask instead when are surgical trainees fully trained and able to take up a consultant post.

The GMC introduced its specialist lists in 1996. Existing consultant surgeons were ‘grandfathered’ onto these lists if they were appointed prior to this date. Our data exclude these ‘grandfathered’ individuals and also those trained overseas who would have been registered and entered onto a specialist list simultaneously (appearing to have become fully trained in zero months).

The data show that OMFS surgeons are of a similar age to other surgeons whilst in training. In addition, OMFS surgeons have the shortest transit time between full GMC registration and entry onto the specialist list. This occurs as many OMFS trainees obtain a dental degree prior to medicine and, therefore, enter the GMC register comparatively later. This is not unlike many doctors who entered medical school on graduate entry programmes having previously read another undergraduate degree. Of the total number of medical student places available each year, 17.9% are reserved for graduates on 4-or 5-year courses.⁵

At present, the duration of surgical training is fixed by the relevant advisory body for each specialty. OMFS and urology are 60-month training programmes whilst the other surgical specialties are 72 months.⁶ The advent of MMC means that the surgical training pathways are likely to change further in the future with the aim of reducing the age of appointment. Time spent in fellowship programmes is likely to be increasingly desirable.

Requirement for OMFS training is dual qualification and this is appreciated early in the career of trainees. As such, the ‘bottleneck’ for OMFS trainees occurs sooner by comparison to other surgical trainees – effectively when the doctor or dentist decides to pursue a second degree. The consequence of this is increased certainty in obtaining an NTN later in their career as shown in Table 3.

Table 3.

Number of applicants per NTN available in 2004/2005 within the London, KSS and Eastern Deaneries (combined data)⁷

Cardiothoracic surgery	59
General surgery	7.74
Neurosurgery	12.44
Oral and maxillofacial surgery	1.6
Otolaryngology	22.71
Paediatric surgery	8.63
Plastic surgery	16.14
Trauma and orthopaedic surgery	16.39
Urology	8.5

Thus, the career pathway for OMFS trainees is relatively direct when compared with the other specialties. Indeed, the average SHO takes 5.5 years to obtain a surgical NTN and even then only about half are successful.⁸ Analysis of the GMC data demonstrates that this cannot be the case with OMFS trainees who, on average, spend 7.5 years (90 months) between full and specialist registration. Of those 7.5 years, 5 years are spent as SpRs and, therefore, 2.5 years in other grades, the majority being SHO posts. This is 3 years shorter than other surgical SHOs.

It is accepted that the early years of OMFS training are prolonged by reading for two degrees. The question arises of where do delays in training come from for the other surgical specialties? This has long been considered and, in part, has been responsible for the MMC recommendations. The expansion of the SHO grade to meet the European Working Time Directive meant a bottleneck at the SpR level that led to excess years spent as an SHO or a deviation of students into higher surgical degree programmes, the value of which has been questioned.^9,10 These factors appear to ‘level the playing field’ with regard to the duration of training across all surgical specialties.

MMC recommendations will hopefully reduce the length of training in the future for the surgical specialties; however, we must await events. The British Association of Oral & Maxillofacial Surgeons has addressed this issue along with the SAC and recently published guidance on future training arrangements which will bring OMFS training in line with other surgical specialties.¹¹

Conclusions

The length of OMFS training, even with dual qualification, is similar to other surgical specialties and should not deter interested surgical trainees.