So you're thinking about getting an MD during your OMS residency? | Part 1 of 3
Degrees make a difference, but they don't matter
In the United States, applicants pursuing a career in Oral and Maxillofacial Surgery (OMS) must choose between a single or double degree curriculum. Debating the merits of an optional second clinical doctorate is a favorite pastime for OMS applicants, but I’ve observed that they’re often unaware of the more deeply nested issues around it.
This three-part series is written for the US OMS applicant with the goal of making you a more informed consumer of graduate medical education, specifically the ‘OMS MD’ (OMS MD is how we’ll refer to that particular subspecies of medical degree that’s earned in a double degree OMS program in the United States).
I’m a career-long OMS educator, including a decade as a double degree program director and all of its medical school committee work. This informal essay is the distillation of countless conversations I’ve had over the years on this topic with OMS applicants.
You should approach this series like you’d approach marriage counseling — it’s meant to prepare you for the rough spots on your future path, not to dissuade you from tying the knot with your beloved. My aim is to inform, to give you a perspective not available from your end of the educational pipeline. I want to help you avoid unpleasant surprises.
This post may seem critical of the OMS MD and the brittleness of the product it creates; if it feels that way, then you’re my target audience. Herein I will follow Darwin’s dictum: ‘All observations must be for or against some view if they are to be of any service to the reader’. In education, like in science, there is no improvement without criticism. Of course, I could write about the countless wonderful aspects of OMS, but that would be of no service to you.
I believe American double degree residencies are designed for a medical licensure landscape that existed 30 years ago, not today. I believe the OMS MD has some serious vulnerabilities and, without significant change, things will worsen in the coming years.
In this series I want to take the OMS MD apart and lay it on the table in front of you so you can inspect its components and understand its inner-workings — in ways you probably don’t understand right now. My perspective is not truth — its just the one I have; it’s born of my personal experience, and it’s what I’m sharing with you because its all that I can share with you.
To understand the full picture, we must start with some basic education principles, and build up from there.
The goal of all healthcare education is a well-trained mental model
The goal of all healthcare education is the development of mental models that make good predictions about problems in some domain. Diagnosis is a kind of prediction, but so is most other things surgeons do.
For instance, your mental model provides the framework for you to predict which procedure will achieve your goal and that the goal will satisfy the patient; you predict that the facial nerve will be found under this structure and that that instrument will divide that muscle in the way you desire; you predict the thickness and density of tissue and just how much force to apply and at what angle. These are all predictions generated by your mental model. It’s predictions all the way down.
OMS residencies create great mental models of maxillofacial problems and their solutions; dermatology residencies do the same for skin problems. To a cognitive scientist or computer scientist, the use of the word ‘training’ to describe what happens in residency would seem quite apt.
It’s easy to see how training residents in surgery is analogous to training machine learning (ML) models in computer science. In ML, many instances of data (like images of animals) are provided to a neural network along with feedback ( “cat” / “not cat” ), allowing the network to fine-tune its parameters and improve its future cat-spotting performance.
In healthcare education, your biological mental model (your mind) is trained on sensory input, but from things like lesions, processes, structures, and objects, along with feedback from your interactions with the world (“this graft integrated”, “that incision dehisced”, “that fracture became infected”), tuning your mental model along the way and improving your ability to make better predictions in the future.
We call these sensory units of training ‘experiences’ and they are far-and-away the most valuable thing you get in residency. There’s no where else you can get them.
If surgical education is a business, then the University Dept of OMS is a company, residents are its customers (or, if you prefer, its end-users), attendings are its agents, and experiences are its products; these products are used to fine-tune your mental model, which is later applied to your future customers (patients) to solve their problems (disease/ injury).
Experiences are the only kind of information your brain can use to train your mental model sufficiently to solve surgical problems.
It's not just that experiences are a good way to learn surgery, experiences are the only way. You cannot read, seminar, lecture, degree, YouTube, or Insta your way to surgical competence.
Experiences are so difficult to acquire because they must occur in-person, on costly real estate, with the use of high-priced technology on living people under very high-stakes circumstances. They must include the input of a teacher (an expensive person who already possesses a strong model and is willing to guide you), and occur within the legal framework of an institution that creates a learning environment and takes responsibility for your actions and their consequences while your model is still developing.
The training process takes so long because it can only progress one random experience at a time, and must include long-term feedback about your decisions and actions, which is often delayed by many months or years (i.e. ‘that tumor recurred’, or ‘that patient got better without an operation’). Nothing tunes your model like long term follow-up.
So it’s this mental model that gives you special value to society and it is the main goal of healthcare education — not professional degrees like MD or DDS.
If we could go back in time and shuffle the healthcare professions we have today (Medicine, Dentistry, Nursing, Podiatry, etc), different professions would evolve with different boundaries, different curricula, and different degrees letters after your name. But the kind of mental model required to solve problems will come out the same, because solving problems is a function of the unchanging properties of healthcare entities (entities like anatomic structures, chemical substances, microorganisms, blood flow, and wound healing), not the arbitrary boundaries of professions.
Nonetheless, degrees are still very important because, right or wrong, others will use them to classify you. Degree(s) become an indicator of — or proxy for — others to predict what you might know and how you might think. For other healthcare providers, degrees function as personal labels that establish whether you are like them (in-group) or different (out-group), triggering the all important in-group bias and its profound effects on human behavior.
To summarize, while experience and mental model is what matters most (because they allow you to solve patient problems), we live in a society that is keenly attuned to degrees and uses them to differentiate people. We love to categorize and rank; indeed, we cannot help but do so.
What is medical training anyway?
It’s not uncommon for OMS applicants, coming from dental school, to conflate medical school and surgery residency into a single bucket of medical training. But the roles of medical student and surgery resident are as different as… dental student and OMS resident — in fact, probably more so because, unlike medical students, dental students actually get quite a lot of hands-on clinical experience.
In the recently overheard words of an upper-level OMS resident, a month in the role of medical student is, “not even remotely equivalent” to a month in the role of resident.
As a medical student, you’re a customer of undergraduate medical education (UME); you’re a novice apprentice observer— a role designed to provide the raw civilian recruit with their most nascent clinical skills. Much of the focus is on understanding the healthcare system and how to work within it, its vocabulary and traditions.
In contrast, residency is graduate medical education (GME). In residency, you are a real healthcare provider with tangible responsibility and progressively increasing autonomy. If medical school is like watching game tapes and shooting hoops until you understand the rules and strategies of basketball, then residency is like getting on the court and playing in hard, sweaty games for four continuous seasons.
Residency is designed to flood your brain with sensory data in a supervised formative laboratory where you can predict, act, get feedback, and understand how all of the parts of your clinical domain — from the cells of your patient up to abstract concepts like Medicare and Medicaid — relate to each other.
Try to maximize GME
With these differences in mind, and a clinical doctorate from Dentistry already under your belt, my advice for double degree applicants is to seek an OMS MD curriculum that minimizes time as medical student so you can maximize higher value experiences as a resident (see explore/ exploit later in the post). You may not get a lot of choice in which rotations you do in medical school, but try to prioritize experiences with problems related to those you’ll encounter in practice.
Benefits and Value of the MD
For those considering OMS but not convinced of the value of the MD, let me take a moment to address any potential FOMO: the MD is not a requisite for becoming a full-stack 10x OMS.
We know this must be true because half of the board-certified surgeons that our excellent specialty produces every year didn’t opt for the MD, and many of the most notable and productive experts in subdomains of OMS (trauma, orthognathic surgery, pathology, and reconstruction) don’t have one.
But if an MD is not required, is it valuable? Yes, of course it is. I believe that if any OMS could simply snap their fingers and be endowed with all the affordances of the MD, we’d all snap. But as the economist Thomas Sowell said, ‘there are no solutions, there are only tradeoffs’ — so the problem is we can’t just snap our fingers. Instead, in exchange for the MD, we must trade significant time, money, and opportunity cost.
Price is the amount you pay. Value is what the MD pays you.
Because all degrees have value, it may be better to ask, “is the MD overpriced?”. More specifically, “is the OMS MD overpriced, given its brittleness in regard to licensure?” (a lot more on licensure in part 2). Its very difficult to answer this question because of the how the endowment effect contributes to our thinking: we place a much higher value on things we already own, especially if we paid a lot for them. This is why you’re unlikely to meet a double degree OMS who tells you they wouldn’t do it the same way all over again (or a single degree, for that matter).
We can run the numbers on medical school tuition, loans, interest, and opportunity costs, but I’ve never found that kind of valuation satisfactory. Most of the MD’s value cannot be priced or even measured because its usually difficult or impossible to know when and where having an MD made a critical difference to you.
That being said, I do not believe the MD’s value lies in the early (and short-lived) boost in ‘medical’ knowledge. Instead, I believe its value is its power to signal group belonging and insulate the OMS MD-holder from out-group bias of physicians.
Like having a second passport or an influential family name, the MD can enhance your opportunities in some parts of the world of healthcare because:
Physicians are the group of people most likely to administrate, make decisions, and allocate resources in American healthcare, especially in the surgical/ hospital setting.
Right or wrong, the American public views physicians as having special knowhow, and as the profession that manages extra-oral problems.
In-group favoritism is one of the most reliable of all human social behaviors. (If you didn’t earlier, now is a great time to click on that link and read about it).
The MD insulates the OMS from some of the out-group bias of physicians while simultaneously leveraging, to your advantage, common public (mis)perceptions about the scope of Medicine vs the scope of Dentistry.
What difference will the MD make?
One thing that both shocks and excites me is that the value of a 50% increase in the duration of an educational curriculum (4 years for single degree vs 6 years for double) is even debatable at all. One might reasonably assume that, given so much extra work and expense, the benefits would be indisputable.
But I recently asked 10 of my OMS colleagues, “Could you reliably predict the degrees held by an OMS totally unknown to you, just by watching that OMS interact with their patients and do their work, while observing the quality of that work?” For what it’s worth, 10/10 said they could not.
I’m not suggesting that the MD won’t make a difference to you, but I am suggesting that the bigger and more meaningful qualities behind your future success will be found in your individual characteristics: your curiosity, drive, and experiences - and none of these come packaged with the envelope holding an MD certificate.
In other words, when it comes to single and double-degree OMS (just like other categories of people), there are probably more differences between individuals within each group than differences between groups.
I firmly believe that opting for the MD says more about you than it says about the intrinsic value of the MD. So when we’re discussing whether or not it’s ‘worth it’, we’re not really discussing the degree, we’re discussing ourselves.
There are two general overarching motivations cited by MD-seekers: knowledge and group belonging. Let’s unwrap those a bit further.
Different kinds of knowledge
Explicit medical knowledge is the kind of knowledge that can be transferred to others through passive methods like readings or lectures; it’s widely distributed, commonly tested on exams, and knowable without any real-life healthcare experience (this is the kind of knowledge on written medical licensing exams, which is why chatGPT, an entity with zero real-life experience, can pass them).
Because the internet has made this kind of knowledge so accessible, clinicians are no longer valued (as they once were) for how much of it they’ve memorized. Medical and law schools focus on explicit knowledge because it is more readily testable and measurable.
In contrast, tacit knowledge (aka experiential knowledge) can only be acquired through real-life experience. It’s much more valuable because the only place it can be found is within the brain of a person who has focused their attention on a certain kind of problem and tried to solve it — over and over and over again, made mistakes, and improved their understanding. If explicit knowledge is reading about a country, then tacit knowledge is living there. It is the kind of knowledge that powers intuition, creativity, judgment, and knowhow.
Unlike explicit knowledge, your tacit knowledge cannot be transferred to anyone else. It cannot be acquired in the classroom or through a device. It can only be acquired through information coming through your sense organs from active interaction with real patients over countless cycles of decision, action, and feedback. Residency is designed to build tacit knowledge.
As a surgeon, you are valued for your ability to solve certain kinds of problems (missing, injured, or abnormally formed structures, abnormal function, lesions, etc); but the only way you can learn how to solve them is… by solving them. You must make your own attempts and experience your own errors. Its the only way your mental model is improved.
The sum of all of your degrees will not matter without doing (and continuing to do) the work. Opus docet te facere: “The work teaches you how to it.”
The vital question: How thick is your surgical logbook?
Because tacit knowledge is so valuable, I maintain that the most important metric at the end of your residency is not the character count of your degrees but the thickness of your surgical logbook.
Remember, you are the customer and experiences are the products — so an important question to ask during your interview is, “how much data will my mental model get trained on here?” The more data (amount and variety) your model is trained on, the better it will be at making predictions and avoiding future errors.
I believe that it’s probably possible to pass both written and oral board exams by reading, studying, and attending enough didactic seminars, but becoming an expert surgeon - who not only knows but can also act - is only possible through real experience with real patients in the operating room and clinic.
When people are deciding whether or not to trust you, the single most relevant question they can ask of you is “What have you done (in the past)?” or “How often have you treated problems like mine?” Really, questions like those are just a polite way of asking, “Have you had many opportunities to make mistakes on others in the past that you won’t have to make on me?”
Learners in both single and double degree OMS residencies have access to great experiences — to opportunities where they can figure out how the world works. But no matter which path you choose, only those who do the work - who have the experiences - will ever have the judgment and knowhow. This is why I say degrees make a difference, but they don’t matter.
In the US, we fetishize degrees, but what I hope to convince you of is that although credentials are a proxy for your experiences, credentials are not equivalent to your experiences — just like a map is not the territory and the menu item is not the dish.
In an ideal world, we would not characterize providers by degree, we would characterize them by what they have done.
However, until that day comes, your credentials offer an important (albeit low-fidelity and full of noise) signal to others about what you might know.
Going to medical school for the knowledge
I will define knowledge as “The awareness of what things exist, and how those things relate to each other”, and OMS applicants routinely cite some form of knowledge enhancement as the reason they want to go to medical school.
“I want to take better care of my patients” and “I want to understand physiology better” are common responses to the classic OMS interview question, “Why do you want to get an MD?” — and these are legit motivations, in my opinion. However, keep in mind that medical learning is like any other kind of learning, in that:
1: it’s the product of attention and effort; merely enrolling in medical school and satisfying degree requirements will not endow you with what you seek.
2: if you don’t use it, you’ll lose it.
To illustrate this last point, now is a good time to find your last Calculus test, and try to answer a few questions.
In your career, you’ll become very good at things you do frequently but other knowledge will atrophy — no matter what degree(s) you have — because in cognitive science the forgetting curve is just as real as the learning curve.
This is not criticism of a broad education, but a recognition that our value as doctors is manifest by what we are able to do and the problems we are able to solve, not our ability to recall facts or stories about that ‘one rotation we did’. Those facts are good to know, certainly, but in isolation of the kind of real knowhow born of experience, facts can’t be turned into treatment.
The concepts around hemodynamics, wound healing, nutrition, and metabolism can be perfectly understood by the brain of an OMS enrolled in either degree curriculum - as long as it includes high quality experiences with real patients in medicine and general surgery. But the only way you will ever truly ‘have’ that knowledge is by treating your own patients, time and again, and observing the results. You can only know well what you do often.
In the end, the knowledge advantage of medical school comes from about 12 - 16 months of additional opportunities to learn from experts in concepts like hypertension and endocrine disorders. Also, most medical schools demand that you take exams, which is a great motivator. Nevertheless, OMS residents in any kind of program should have ample opportunity to see and solve complex medical problems and build the knowledge they need.
Medical school makes residency easier.
The OMS MD resident acting in the role of Surgical ICU Intern for a month will probably feel more confidence and find it easier to communicate than the resident who hasn’t attended medical school. In the field of OMS, where almost all of us come from Dentistry, working in high acuity settings like the ICU can feel like validation that we belong. It feels great to have those experiences as a 4th year OMS resident, but its important to remember that,
unless you continue to work there, the skills you acquire in settings like the ICU will fade rapidly
you will not qualify for any credentials in that setting.
This doesn’t mean that the off-service (non-OMS) rotations aren’t valuable but knowledge acquired in short term settings (like month-long rotations) is fairly superficial and, as such, not very durable and therefore less valuable.
This brings up the exploration-exploitation dilemma — the trade-off between the need to obtain new knowledge (exploration) and the need to use that knowledge to improve performance (exploitation). If we divide your residency into time off-service and time on-service, off-service rotations are exploration.
In OMS, we do way more than our fair share of exploration. Between dentistry, sometimes medical school, anesthesia, medicine, and surgery, we take a long and winding path to our final destination and become the jack of many trades. Of course all of the stops along the way are useful in some way but at some point, the value of more exploration diminishes (see the law of diminishing returns) .
Because there’s so much to know, any one person, no matter how smart, can possess only a very small sliver of healthcare knowhow at an expert level. As doctors, we all share some foundational knowledge but we are all, at the same time, pretty ignorant by the definition of any field other than our own.
All doctors, no matter their specialty, end up with a deep but narrow profile of knowhow. Unlike my regularly updated Mac laptop, there’s no version upgrade sent from my medical school to update my cerebral MD module so, unless I use knowledge in the regular practice of my craft, most of it will degrade into vague recollection.
Here I want to clarify that I’m not arguing against doing the ICU rotation; experiences like that have some value but they can also be characterized as mental cul-de-sacs — places we turn into but don’t stay long enough to develop durable skills or deep understanding, then quickly turn around and leave. Double degree OMS do more exploration than any other healthcare professional because we have to qualify as members of two professions.
But the atrophy (degradation from disuse) of the forgetting curve is as real as the hypertrophy (growth from use) of the learning curve and this is the balance we are trying to strike: how long do we continue to explore before moving on to exploit?
Its a strange thought experiment but, if I had to give up either my MD credential or the portion of my knowledge that is a direct result of medical school, I would definitely give up the knowledge and keep the credential. I struggle to think of physiologic concepts I wouldn’t understand today because I didn’t acquire them in medical school but, as an OMS who works in an academic health center, I frequently feel the advantages of in-group belonging in a setting run by physicians.
For these reasons, I do not believe knowledge acquisition is the main objective of medical school (for the OMS).
Going to medical school for the in-group belonging
In my opinion, the chief advantage of going to medical school is the power of ‘MD’ to leverage the twin advantages of in-group favoritism and the general public’s ingrained perception that physicians manage extra-oral problems.
Like any other group, especially in a setting where there is competition for resources, MDs favor those they perceive as ‘in-group’. More than any other group, MDs are likely to be making and implementing policy and managing healthcare organizations and, like any group of people, they tend to prefer to work with — and give the benefit of the doubt to — those from their own tribe.
This kind of advantage matters most at the ‘frontier’ of our OMS specialty because it is at the frontier where clinical territory is being contested and the OMS is competing for resources (referrals, patients, and operating facilities) with physicians. These are the places where being a physician (being in-group) probably carries the biggest advantage.
When the OMS MD was born (1970s), our frontier territory included ‘making incisions on facial skin’ and ‘admitting patients to the hospital’. And while that territory can’t be taken for granted, it is enshrined in our accreditation guidelines and is unlikely to be ceded or lost. Today, the frontier comprises the places where we are more likely to find physicians doing much of work - oncologic surgery, free-tissue transfer, cranial vault and skull base work, and facial cosmetic surgery. The frontier is where group-belonging matters most.
The invention of the modern OMS MD
Its worth understanding why our surgical ancestors invented the MD because it’s the same basic reason we continue to pursue it today. In the 1960s and 70s, modern OMS pioneers were developing innovative surgical techniques that required more access to the work settings controlled by physicians — the hospital, operating room, and ICU. At that time, interdisciplinary lines were drawn much more starkly than they are today, and it was very difficult for dentists (those from the profession of Dentistry) to access these settings. For more details, I recommend reading the excellent Historical Overview of OMS by Dr. Daniel Lew.
Unlike today, hospitals at that time were not run by people with MBAs and corporate mindsets; they were run by the physicians who worked there. Hospital leaders were often surgeons and, by controlling hospital credentialing under the guise of public safety, they could control clinical territory and market share.
This is another example of in-group bias and the reluctance to cede opportunities, resources, and growth to those from a competing group. Under these conditions, OMS found themselves anatomically constrained - often limited to the mouth and lower jaw, forbidden from making skin incisions, and denied hospital admitting privileges.
Around the country (actually, the world), the justification for constraining the OMS always boiled down to the same main point: “they’re dentists” (which is latin for “they are other”). Although this was an overly simplistic reduction of the OMS, it was powerful because it sat firmly upon the knowledge of the average citizen and their superficial understanding of the differences between Dentistry and Medicine. Cynical but effective.
But in a few special places where OMS faced limitations and there was access to open-minded medical schools, pioneering OMSs developed a double degree curriculum with the intent of overcoming, once and for all, that main objection. After all, if an OMS was both dentist and physician, the objection was no longer justifiable. We created the OMS MD in an attempt to neutralize the label of ‘other’ in these places.
Today hospitals are run by people wearing suits, not scrubs. They are much less concerned with your degrees than they are with your ability to safely solve the problems of their customers. The kind of surgical expertise that you will have after OMS residency is hard for organizations to find, no matter which academic degrees you carry.
Next, we’ll look at the MD as an asset, and where that asset is exposed to risk.