The maxillofacial factor: not just for dentistsBMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7435.s55 (Published 07 February 2004) Cite this as: BMJ 2004;328:s55
You don't have to be a qualified dentist to do a senior house officer job in maxillofacial surgery. Ross Anderson and Martin Telfer explain how it can be a valuable experience for wannabe head and neck surgeons
Surgically qualified senior house officers (SHOs) have few opportunities to work in maxillofacial surgery. Maxillofacial SHOs are usually qualified dentists who return to the specialty as a specialist registrars (SpR) after completing a medical degree, surgical training, and passing the examination for membership of the Royal College of Surgeons (MRCS). But I managed to work in maxillofacial surgery as a medically qualified SHO planning to be a head and neck surgeon, and I'd recommend it to SHOs with similar qualifications and ambitions.
I obtained my MRCS during a surgical rotation in the north of England and, having done six months of ear, nose, and throat surgery (ENT) on the rotation, decided to pursue a career in head and neck surgery. I realised that I needed to improve my surgical skills and broaden my experience of head and neck surgery. I thought my best options were jobs in plastic surgery, neurosurgery, maxillofacial surgery, or another ENT job. In the end, I applied for a six month standalone post as an SHO in maxillofacial surgery.
I was one of four SHOs in a district general hospital practising all aspects of modern maxillofacial surgery, with an appreciable commitment to head and neck cancer including a large skin cancer practice. My fellow SHOs were all dentally qualified.
Some of the dentoalveolar (surgery involving teeth and closely related structures) work was daunting. Initially, I had difficulty in diagnosing some conditions; it was hard enough just describing them using terms I had never heard before. I found my fellow SHOs helpful, as were the middle grade staff, consultants, and even dental nurses. It took about eight weeks of twice weekly day case lists with supervised training by a staff grade and on the job exposure in the emergency department before I felt confident. It was like starting a surgical job as a complete novice, but this time I was expected to be even more hands-on than in most surgical specialties. In a short space of time I had to become familiar with a substantial amount of new anatomy, pathology, and surgical procedures—for example, orthognathic surgery (facial deformity) was a mystery to me.⇓
I was more familiar with the trauma surgery and fracture management since I had done orthopaedics in an earlier rotation. Accident and emergency referrals often involved facial lacerations. Some were treated by primary closure, others needed skin grafts or skin flaps. On-call duties cross covered with ENT. This was particularly good experience for me, and meant I could keep my ENT emergency skills up to date.
Head and neck surgery wasn't new to me, but we were entirely responsible for patients having excision of oral and oropharyngeal cancers and reconstruction with free flaps from, for example, their forearm or leg. I worked for a consultant with a specialist interest in surgery for skin malignancies and was regularly involved in their diagnosis and treatment. I rapidly developed my soft tissue surgical skills. I became confident in harvesting full and partial thickness skin grafts, and now have experience in raising the common skin flaps used on the face.
Oral medicine was a notable deficiency in my medical school training. I was well trained in this post, however, and I didn't have any problems with the practical aspects of the clinic. An SpR or consultant was always available to help with the more challenging procedures. I was expected to take oral and skin biopsies, perform dental extractions (including third molars), and take impressions for soft bite raising appliances. I had a lot of exposure to cases of skin cancer, both preoperative and postoperative; overall, I found work in the clinic rewarding.
The learning curve
With so much exposure and responsibility at SHO level my confidence with patients and surgical skills soared. I now feel happy managing most aspects of head and neck cancers. I learnt a lot about oral medicine, which figures strongly in both ENT and head and neck surgery. Trauma inevitably took time to learn about. As in other units, SHOs tend only to assist in internal fixations; however, x ray interpretation of facial views and orthopantomograms is no longer a problem to me.
Anatomy comes alive
I found it useful to be on the ward with dentally qualified SHOs, most of whom had not worked in a hospital before. On occasions, they asked questions about patients' medical management and I found the teaching process useful. It brought alive the anatomy and pathology that I had previously associated with dusty libraries and fear of failing exams.
Advice for SHOs interested in a maxillofacial post
Ensure the post is approved for MRCS training by the postgraduate dean
Visit the unit before your interview—make sure there's an appreciable head and neck workload
Find out which specialty is on call for facial lacerations referred from accident and emergency—you'll generally get more experience in hospitals without plastic surgery units
Be prepared to do some extra studying, especially dental anatomy and pathology
There's normally plenty of opportunity to do elective tracheostomies—just pester the consultants
You'll probably get more out of the job if you've done an SHO job in ENT or plastic surgery
I also carried out a completely new set of surgical procedures. I am already finding some of the skills learnt during this time have put me in a better position as an SHO in ENT.
The other side of the coin
Taking on a medic into a dentally orientated specialty requires effort from both parties. Issues with clinical governance inevitably reduce unsupervised surgery and increase the workload on other dental SHOs for routine procedures. But with appropriate rota changes and intelligent use of the skills available, the disruption can be kept to a minimum. An initial period of more thorough supervision was required in surgery and clinic, the responsibility resting with senior trainees, staff grades, and consultants.
There were advantages for the unit, too. Teaching and dissemination of information from a well motivated surgical trainee benefits other staff on the unit. The surgical SHO is competent in surgery and can handle the medical management of patients on the ward. The introduction of the European Working Time Directive puts pressure on all units to cross cover on-call duties with other specialties. No special training was required for ENT cross cover, so easing the pressure for locums to cover while dentally qualified SHOs were trained to manage ENT emergencies.
The surgical colleges and senate are currently discussing plans for higher trainees to join a joint specialist training pathway in head and neck surgery towards the end of their time as an SpR. The trainee would be from maxillofacial, ENT, or plastic surgery and would rotate through each of these specialties to emerge as a consultant in head and neck surgery.