So you're thinking about getting an MD during your OMS residency? | Part 2 of 3
Your MD is an asset; licensure unlocks it
I want to point out that the integration of medical school into OMS training programs takes many different forms, and each is a product of the unique philosophies, beliefs, limits, and traditions of that particular sponsoring institution. This means if you’ve seen one OMS MD program, you’ve seen one OMS MD program. Here in part 2 I’ll aim to discuss features that are common to (almost) all programs.
The MD as asset
In Part 1, we discussed why you might want an MD, but now let’s think about it as an asset and where that asset could be threatened. In part 3, we’ll discuss what could be done to mitigate these threats.
Investopedia defines an asset as a ‘resource with economic value that you own, with the expectation that it will provide a future benefit’ — and the MD fits this definition. Like any asset:
its acquisition requires resources: time, money and, for the OMS, the opportunity cost of delayed entry into a highly compensated surgical marketplace,
it provides utility (usefulness, satisfaction or benefit), and
you never want to lose it.
Medical Degree vs Medical License
The biggest threat, by far, to your hard-earned MD asset is the ongoing evolution of state medical licensure requirements. As I will explain in detail, medical licensure is evolving at a pace that the OMS MD curriculum is not matching and, since you are considering this big commitment, it’s crucial for you to understand why. Let’s start with a couple of very distinct but often-conflated concepts: the medical degree and the medical license:
Degree:
An academic title conferred by an institution
Signals satisfaction of a program of study - at a single point in time
Valid everywhere
No maintenance required
Cannot be suspended or lost
License:
A renewable legal permission granted by a US state to engage in an occupation
Signals up-to-date qualification under the law
Valid only in that state
Must be maintained (continuing education/ renewal fees)
Subject to sanction, suspension, or revocation
And while we’re at it, some more terminology: ‘Dentistry’ and ‘Medicine’ are professions. Those from Dentistry are dentists and those from Medicine are physicians; both can be surgeons (one who practices surgery). Domains like "Oral and maxillofacial surgery” and “Neurology” are specialties within a profession.
At the completion of medical school, you are awarded an MD, but until you have a medical license, you are not a physician (defined as ‘someone qualified to practice medicine independently’). A medical license unlocks the legal privilege to engage in the occupation (work for compensation) of physician in a particular state.
It’s important to understand that the academic degree of MD alone, without a license, has very limited utility — mostly because without a license you cannot practice or bill (engage in economic activity) or portray yourself as a physician. Of course if you’re planning to use your MD for status in the business world (like pharma or venture capital), licensure won’t be an issue, but let’s assume you’re planning to practice clinically.
The main point I want you to understand is that the OMS curriculum offers a path to an MD, but the OMS MD has differences that can make licensure problematic.
You might ask, “Can’t I practice under my dental license and just put the MD after my name without a medical license?” No, you can’t — because without a medical license from your state medical board, you aren’t considered a physician. But why is that the case? After all, one doesn’t need a license to put ‘PhD’ in their title.
This is because PhD is not equated with an occupation, in contrast to MD, DDS, or RN. The public has come to expect the title of MD to signify up-to-date qualification in medicine and good standing with the medical board, not just completion of a medical curriculum at some point in the past.
Keep in mind that one role of the state medical board is to maintain the quality and brand of physicians in that state. Displaying an MD without a license is akin to declaring membership in their group, reaping all its advantages, but remaining outside of their ability to verify your qualifications or take disciplinary action for infractions of their rules. It’s membership without subscription. This is why many states statutorily forbid MD-without-license. All boards have a keen interest in managing anyone claiming to be a member of their group and, consequently, affecting their public perception.
In summary, you should plan to need a license to unlock the utility of your MD. And right about now you might be saying, “Well, yeah, I wasn’t planning to do all that extra training without getting a license!”. But, as an OMS, getting that medical license could prove to be a bit trickier than you thought.
OMS MD obstacles to licensure
Alright, now we understand that:
medical degree and medical license are distinct
medical licensure is essential
Next, let’s look into why licensure for the OMS MD can be challenging compared to licensure for otolaryngologists, anesthesiologists, and others from a traditional medical education pathway. The shortened OMS MD curriculum (most OMS residents do about 2 years of medical school) is not the problem. Remember, a degree is a certificate of completion of a course of study and it’s binary — once you have it, you have it, no matter how many months you were enrolled in medical school.
Instead, the problems with licensure lurk in what happens after medical school — in the GME (residency) curriculum — because residency is where you qualify for licensure. Residency turns your degree into a license. To understand why the OMS MD can be limited, we must visit another abstract concept: accreditation of post-graduate residency training programs.
Accreditation: ACGME vs CODA
Accrediting organizations set residency standards, verify quality and ultimately report to federal agencies. ACGME is the educational accrediting body for the profession of Medicine and all of its specialty residency training programs in the USA. Depending on each state’s medical practice act or legal statutes, you will be required to have 1, 2, or 3 years of ACGME-accredited residency training time in order to qualify for medical licensure.
When applying for licensure, medical boards look for one particularly important value: time spent as a learner in an ACGME-accredited residency program; let’s call this value ACGME-time. It’s important to clarify that the medical licensure process does not take into account the kinds of things you did in your program. Put another way, psychiatrists do not perform surgery but they qualify for medical licensure because their residency programs are accredited by ACGME.
CODA is the educational accrediting body for the profession of Dentistry and its specialty training programs. OMS programs are accredited by CODA, not ACGME, so in order to acquire sufficient ACGME-time for medical licensure, every OMS MD program must enroll you as a learner within some ACGME-accredited program — and this program is almost always General Surgery.
It’s important to understand that your OMS program director does not arrange this time on General Surgery because it offers the optimal experiences for you as an OMS; they do it because you’ll need this ACGME-time to satisfy statutory medical licensure requirements. Understanding this point, and its ramifications, is critical.
So why don’t ACGME and CODA overlap? After all, this training happens in the same building with the same patients; shouldn’t it all count in the same way? To understand the difference, it’s helpful to imagine your general surgery rotations as if you are temporarily leaving the country of CODA to work in the neighboring nation of ACGME; a nation that has the same language and culture, but different governance — kind of like an American moving to Canada for a year or two.
It may not feel like much has changed while you’re doing general surgery rotations, but that is an illusion. In fact, as long as you are working in the territory of general surgery, and under their laws and governance of the nation of ACGME, your education is officially under the standards and supervision of ACGME, and you are earning valuable ACGME-time — the only kind of time recognized by state medical boards (with one notable exception explained later).
Medical licensing boards (with the partial exception of California) do not acknowledge CODA-time for medical licensure and therein lies the essence of the OMS MD curriculum trade-off problem :
you have to spend a lot of time in the land of general surgery to earn enough ACGME-time to get licensed and unlock the value of your MD asset,
the amount of ACGME-time required for licensure has steadily increased and will likely continue to do so (but the total duration of OMS residency time has not increased),
increased general surgery comes at the expense of OMS time, siphoning away training time OMS needs to improve our field,
and even after all that general surgery you still may not qualify for medical licensure in many US states.
Every month matters
So for the OMS program, the biggest onus, burden, or obligation created by the MD is not medical school (we add two extra years for medical school), it’s the overabundance of general surgery time necessary to meet medical licensure requirements.
This is an obligation unique to the OMS MD because other surgical fields (like otolaryngology and neurosurgery) don’t have it. Instead, their entire program is accredited by ACGME, so those programs always have enough time to satisfy licensure, no matter how much general surgery they do.
Extended general surgery time creates an obstacle for OMS training because
it redirects considerable OMS energy and time to another field (a field in which you will not be credentialed) where it cannot advance the field of OMS.
it requires dependence upon another field to maintain a path to medical licensure.
Recall that the reason all of this general surgery is required in the first place is because the professions of Dentistry and Medicine have legally disjoint licensing processes. In OMS, we don’t have many options, so we put our head down, do the extra general surgery, and silence our cognitive dissonance by telling ourselves that more general surgery is ‘probably good for us anyway.’
I don’t think it is good for us. I think we have as much to teach our residents as any other surgical subspecialty. I think OMS (and all of Dentistry) should dispense with the mindset that we need to prove we belong in the academic health center - a place that exists to solve the problems of the human body.
We belong - de facto - because we treat faces and humans have faces, not because our residents respond to emergency department consults faster than other residents. We belong because the mouth is as vital for human health as any other region of the digestive tract, and essential for communication.
The mouth is not important because “studies show that inflammation of its parts is correlated with inflammation of cardiac valves”; the mouth is important because it, and all of its constituent parts, are the end result of 800 million years of natural selection. The mouth is not an ornament or an accessory structure. OMS belongs because we treat human beings.
OK, with that rant complete, let’s get back to general surgery.
Throughout the 20th century it was customary for all surgeons of every stripe to do a 12-month general surgery internship as a right of passage into surgery. However, in the past 20 years our surgical specialist siblings (neurosurgery, orthopedics, and otolaryngology) have steadily reduced the amount of general surgery in their curriculum in order to make time for more training in their own specialty. These fields are rapidly advancing and they have more than ever to teach their residents.
So now, in 2023, these specialties spend only about 4 months on general surgery rotations. This means that single degree OMS residents today spend as much time on general surgery as neurosurgery residents do.
If one can become a neurosurgeon with 4 months of general surgery rotations, why do OMS residents need 9–18 months and, therefore, a year less OMS experience? Because, (you already guessed it) in the case of OMS, the extra months are not about building competence with maxillofacial problems, they’re about satisfying medical licensure requirements. Its a tax we pay to belong to another profession.
If your OMS program director didn’t have to be concerned about satisfying medical licensure, they would gladly reclaim that extra time from general surgery because in OMS we also have more than ever to teach you in our own field.
But isn’t it good to do more general surgery anyway? In some ways, yes — rotations build relationships and insight, and every surgeon should do some. But while on general surgery you are:
mostly acting in the role of the lowest level resident (who operates the least),
acquiring small amounts of rapidly forgotten experience with surgical problems that you will not be asked or credentialed to manage when you’re in practice,
working alongside attendings who do not have sufficient time to get to know you well enough to develop trust and allow you to do things.
To bring visiting rotations into perspective, consider for a moment the depth of the OMS skills and understanding acquired by the otolaryngology resident who does a month-long OMS rotation.
For the OMS program director, this is made all the more burdensome because OMS training is relatively time-constrained to begin with. OMS accreditation standards require a minimum of 30 months of OMS experience, and most OMS MD programs provide 30-36 months, while Otolaryngology requires 58 months of otolaryngology-specific rotations. So, with the relatively short duration of OMS training, every single extra month really matters.
General surgery dependence
We rely on general surgery to grant us access to the ACGME experiences that we need to unlock our right to call ourselves physicians. This reliance on another specialty, even a friendly one, leaves us vulnerable and diminishes the security of our MD asset. I’m sure general surgery will remain friendly, but they have their own priorities and growing pressures that could impact future access to their experiences.
For instance, there are are significantly more MD graduates than residency positions in the United States. In 2020, 40,000 MD graduates applied for 37,000 residency positions. There is a sense of increasing urgency for medical schools to find more residency positions for graduating medical students (their customers) and it’s not difficult to see how general surgery might need to reallocate some of these increasingly valuable training rotations.
Although we find comfort in the fact that OMS has enjoyed access to plenty of general surgery in the past, this is a form of inductivist reasoning and Bertrand Russell’s turkey is a memorable example of how this kind of reasoning can fail. I do not fear that we will be cut off entirely but we could find our extra ACGME-time significantly reduced — closer to what is allocated to other surgical specialties.
Its difficult to predict but one thing’s for sure: when you’re not at the table, you’re on the menu. If general surgery ever needs to reduce our access to their experiences, we are not in a position to negotiate and could do little more than plead. This differs from other aspects of our training like Anesthesia where our accreditation standards provide a strong negotiating stance within our sponsoring institutions.
At this point you might be asking, well, why would anything like that ever happen — aren’t we really just ‘free labor’ for them? Well, no. Your rotations are not obligations, they are opportunities that are being reserved for your consumption. Remember, learning experiences (the program’s product) are incredibly valuable and, while on any rotation, you are consuming product that could be allocated to others. Also, some general surgery attendings wonder why they are training OMS residents at a 2nd year level when those residents will never become general surgeons. These are difficult questions to answer.
To sum it up, because the total duration of specialty training in OMS programs is relatively short, every extra rotation required to satisfy medical licensure costs you valuable OMS experience. Of course general surgery is also valuable, but the OMS MD curriculum contains far too much of it, as demonstrated by our surgical specialist colleagues who do only four months of general surgery.
Until we have control of our training — until we are no longer dependent on other specialties for access to medical licensure — we will have fewer opportunities to improve our own field and maintain our own path to medical licensure.
50 states; 50 statutes
We now understand that the main metric for medical boards to grant licensure is ACGME-time and that general surgery is where we get it, so now we can finally start discussing the factor creating the greatest risk to your MD asset: the steady increase, across the country, in ACGME-time required for medical licensure.
The figure below demonstrates the changing landscape. On the left is ACGME-time required for medical licensure in the USA in 2000 — the year of my OMS graduation — compared to the year 2023 on the right side.
In 2000, I graduated with one year of ACGME-time which was sufficient for medical licensure in 48 of 50 US states; so I was licensable for about 95% of the US population. Things were looking pretty good for me as an OMS MD with one year of ACGME-time in my pocket.
But if I graduate OMS with one year of ACGME-time today (and I pass of all 3 steps of the USMLE process), my MD is reliably licensable in only 30 US states in which live ~57% of the US population. So, over the past 20 years, the cost to acquire the MD (i.e. tuition/ opportunity cost) has increased, while the overall nationwide utility of the MD for OMS (who rarely have more than 2 years of ACGME-time) has declined.
While you may trifle about state-by-state details (work arounds, reciprocity laws, etc.), the point is that this trend is concerning for the OMS MD and, because there’s no reason to believe it will change in the coming years, it deserves your attention and consideration.
Without action, OMS will eventually face serious difficulty maintaining a legal pathway to medical licensure in the United States.
What’s driving this trend?
What’s responsible for this trend towards more ACGME-time and why would it continue? The shortest ACGME-accredited residency programs today are 3 years in duration and the generation of older physicians that trained in 1–2 year-long programs are retired/ retiring. So state medical boards no longer see a need to maintain a path to licensure for physicians with fewer than 3 years of ACGME-time.
And as more states make these changes, the physicians in remaining states don’t want to be the only ones with lower licensure standards (incentivizing more physicians to compete with them), so they increase requirements for ACGME-time in their own states.
States are not making these changes with OMS MDs in mind; nonetheless, their effects create some of the biggest (in my opinion, the biggest) problems in OMS MD education today. MD licensing statutes are drifting in a direction that makes it more difficult for OMS to acquire a medical license. As time goes on, these trends could seriously impact the OMS MD, allowing you to become licensed in far fewer states than your medical school classmates. In the next post, I’ll discuss what can be / is being done about this.
Two years is the new one year
Many OMS programs offer two years of ACGME-time and, in my opinion, this is optimal as you start a career that will extend into the 2050s . While it’s possible that the licensure landscape depicted in the map above will obediently stabilize for the next 30 years, it’s reasonable to assume that evolution will continue with medical licensing laws converging towards a minimum of three years of ACGME-time in most states.
Therefore, in a world where ACGME-time is increasingly vital for licensure, although “what will be in my log book?” remains the most important question, the second most critical question you can ask as you consider a dual degree OMS program is:
“How many free-and-clear years of ACGME-time will I have when I graduate?”
1 vs 2 years might make a huge difference to you down the road (say, 2033) in ways you can’t predict right now. Think of 2 years as an insurance policy protecting you and your asset against loss in the coming decades; keeping in mind that even with 2 years of ACGME-time you may still be excluded from many states as licensing laws evolve.
Free and clear
Why the ‘free-and-clear’ part? Well, if you earn an expensive and valuable asset like the MD, then you want to own that asset completely and have it under your control, not the control of others.
“…but you can always petition for more”
As an applicant, you might hear, “You’ll get 1 year of ACGME-time but you can always petition (request a personal exception) for an extra year later if you need it.” This is never untrue because, well, we can always petition for… pretty much anything.
When I hear this, what I want to ask is, “Why do I have to petition for something I’ve already earned?” and “Why don’t my medical school classmates have to petition?”, but instead I’d advise you to ask “Is this petition process reliable?”, “Is there a written agreement that I can see?”, “Will this process work 10 years from now? How about 20?”
You should view petitioning for a credential with skepticism because the process leaves your valuable asset out of your control, and up to the interpretation of some unknown person. An OMS program may have, at the moment, an understanding with the current general surgery program director (PD), but these roles change frequently and no one can predict the next PD’s willingness or ability to grant ACGME-time (remember the inductivist turkey).
My skepticism is not merely theoretical — it’s born of experience. For the longest time, I worked with a general surgery PD who would sign off on an extra year of ACGME-time whenever one of our OMS graduates made a request. All was well. But when that person stepped down, the next PD had a different perspective and our access to extra ACGME-time disappeared - literally overnight.
So in response, we did the only thing we could do - we replaced OMS-time with (you guessed it) significantly more general surgery time so that the new general surgery PD could legitimately sign for two years of ACGME-time. And of course, by now you understand that the sole reason for these changes is to satisfy the requirements for medical licensure. This isn’t the kind of change we can make again if (when) licensure requirements evolve further.
When you graduate, the credit for your work should be yours, free-and-clear, under your control, and documented in ink when you leave your program — not up to the interpretation of someone else at some future time. Program directors everywhere are under increasing regulatory scrutiny with less freedom to interpret accreditation guidelines as they like. You will work very hard in your OMS residency and deserve to own your credentials, so my advice is to get them before you leave, if you can, and rely as little as possible on the process of petitioning.
You’re moving, but is your MD coming with you?
For the OMS MD, problems with medical licensure most commonly arise when moving across state lines. In the past few years, three somewhat recent graduates of our OMS program have informed me of plans to move to a new state where they found, to their considerable dismay, they didn’t qualify for medical licensure because they lacked sufficient ACGME-time. Their options were:
decline the job opportunity,
accept the job but lose their identity as a physician,
petition the state medical board and hope for a favorable judgment, or
(swallowing hard) explain to their spouse why they need to find just one more year of general surgery residency… somewhere.
I too have had to personally reckon with the limitations of OMS MD licensure. More than once I’ve silently passed on an exciting job when I realized that my single year of ACGME-time wouldn’t qualify me for medical licensure in that state.
It flies in the face of intuition but, in a country where professional licensure is delegated to individual states, it can be surprising to realize that each additional credential may actually constrain your opportunities, rather than enhance them. To put it another way, the need to satisfy requirements for every credential can sometimes adversely affect our geographic mobility, economic options, and career trajectories if our bucket of credentials do not easily transfer across state lines. This phenomenon is not experienced by other physicians who benefit from a streamlined (compared to Dentistry) national medical licensure environment.
Just how common is this problem of losing licensure after a move? Well, it’s difficult to say because these occurrences aren’t reported, so there’s no data. It’s unfortunate, but we in OMS education have mostly adopted a caveat emptor mentality around this issue of MD brittleness - probably because we don’t have many alternatives. Since we are not members of the profession of Medicine, we rely on handshake relationships (the kind not backed up by accreditation standards) for access to the training required to be physicians. Its hard for us to dictate terms along our OMS MD educational path, so we humbly accept those we are offered.
Should you get an MD?
The answer to this question is a reflection of the person making the decision, not the degree’s costs and benefits. In terms of decision analysis, “Should I get an MD?” is in the same category as “Is this the kind of person I should marry?” or “How many kids are the right number of kids to have?” — by definition, the answer can only have meaning to the particular mind to which the question is being posed. We will never know if anyone’s choice was ‘right’ because there is no counterfactual we can run, no end goal we can point to; there is no definition of success and no scale to measure it on.
When discussing the MD with any practicing OMS, whether single or double degree themselves, you’re unlikely to hear any of them say, “I think I took the wrong path.” This is good because it means both paths generate fulfilled surgeons. When taking their advice however, we should avoid the post-hoc rationalization fallacy, where we mistake their current status (happy practice) as caused by particular prior events (attended XYZ Residency program). I believe its likely that no matter which path they took, that surgeon would be skilled and fulfilled because of who they are, not how or where they trained. You can’t (shouldn’t) incorporate someone else’s preferences as your own.
When I was in your shoes, I never gave a thought to licensure, or imagined it could ever make a difference to me; I wanted the credential mostly because of the status and belonging within the wider healthcare community that I expected it to give me, and I was not wrong. I went to medical school because I anticipated that, given my psychological need for status, the absence of the MD might nag me (status is, along with nutrition and reproduction, one of the main drivers of all human behavior — I’m no exception). I felt excitement about becoming a physician, a member of an ancient and esteemed profession. I wanted to satisfy my curiosity of what it was all about and prove to myself and others that I could do it. And I did; I took it seriously and graduated AOA.
But what the MD means from my perspective as an educator on the other side of my career is different than I imagined as an applicant. Based on 20 years of interviewing OMS applicants, I think most applicants perceive the MD as a knowledge module that will finally bring into crisp focus all of the physiology that’s still fuzzy after dental school. And it does, to a point. But a few years out of medical school (or any curriculum), what you know is what you do; all OMS will have a solid grasp of the concepts they employ on a regular basis — but not others.
I’m sometimes asked if I was an applicant today, would I still get an OMS MD? Given my personal desires, inclinations, and experiences, I think I would still opt for the MD, just like I did 25 years ago - but this time I wouldn’t do it for the status. Instead, I’d do it because I learned that I love working in large (and therefore mostly physician-led) healthcare organizations where the MD can be beneficial.
But most of all, I would get the MD because I am the kind of person who gets the MD.
As an OMS, no matter how many letters are appended to your name, those marking you as a dentist will always remain the most indelible, and this is most definitely a feature, not a bug, of the double degree. As an OMS MD, I belong to two professions but I am distinct within each one. It’s like having dual citizenship - very useful in certain settings depending on who’s checking your passport that day.
That being said, I have numerous single-degree colleagues who work in academic health centers with thriving practices and booming careers and the exact same scope of practice as me (I focus on facial injuries, orthognathic surgery, and the bony reconstructions of cleft patients). None of them wish their degrees were otherwise.
When I started training I had no intention whatsoever of being an educator; it’s difficult for most people to know where their career will take them. The best you can do is try to envision that future job and ask yourself a couple of questions about the environment there, “Are there many physicians around me?”, “If I want to thrive as a surgeon there, will being one of them make a difference?”, and “…will it make a difference to me?”.
Then go from there, but go informed.
In the last part of this series, we’ll discuss strategies for addressing some of these OMS MD issues.
All three parts are very well-written. I think this is crucial information for OS hopefuls... I would love to see Dr. Engelstad write more about all things dentistry and OS residency.