Transformations

HSDM Dean Donoff speaks to graduates about science, policy and compassionate care

Dean Donoff for Harvard School of Dental Medicine in front of microphone
HSDM Dean Donoff, Image: Steve Lipofsky

This is such a special day for all the graduates of the Harvard School of Dental Medicine and Harvard Medical School, the class of 2019. Congratulations to you and to all your loved ones who have helped you to reach this point in your lives.

You are at a major milestone of a long journey of education and training designed to permit you to help people through the discovery, application and communication of knowledge, competence, compassion and caring. The development of wisdom and clinical judgment through lifelong learning and further experience represents the road ahead.

Read more about HMS/HSDM Commencement and Class Day.

Each year, I associate the graduating class with a particular event or accomplishment in order to create a lasting memory for myself. This is easy this year, for you are the first class to complete the Pathways curriculum, not the old New Pathway, but the new Pathways. You are also the first class to complete all national testing exams without a failure. Congratulations.

Two years ago, we celebrated the 150th anniversary of the founding of the the dental school at Harvard University, a momentous occasion marking HSDM as the first dental school in America affiliated with a University and its medical school and the first to grant the DMD degree. That philosophy is our legacy and our mantra.

This morning, when I presented the degree candidates to President Bacow, he granted their degrees and welcomed them into a demanding branch of medicine.

It is no secret that medicine and dentistry have evolved with an unnatural professional separation that is helpful to no one and often leads to unnecessary suffering on the part of patients. No one quite knows whether the physicians who started the Baltimore College of Dentistry in 1840 were thwarted by the University of Maryland and its medical school or whether they wanted to be separate. This history is taught to first-year medical and dental students in the Practice of Medicine course.

This began the siloing of the two fields, supported by the Gies Report of 1926 calling for dentistry to stay close to medicine but separate, by the Institute of Medicine Report of 1995 calling for integration and by the first-ever Surgeon General’s report on oral health in 2001, which called oral disease a silent epidemic and noted that oral health is critical to general health and well-being.

Our belief that dentistry is a branch of medicine distinguishes our education, our values and the careers of our graduates. But increasing knowledge supports the now widely recognized links between oral health and medical health. The mouth is often a wide-open window into what is happening in the rest of the body and sometimes a source of risk as well. A second Surgeon General’s report on oral health is now being prepared, emphasizing the importance of oral health to general health.

Louis Menand, in his book The Marketplace of Ideas, states that the key to reform of almost any kind in higher education lies not in the way that knowledge is produced. It lies in the way that the producers of knowledge are produced. You will be the leaders in oral health because of the way you were selected and produced. And you will have an impact on health care as dentists.

It was Dan Federman, former HMS dean for medical education, who called me one day in 1986 when I was chief of Oral and Maxillofacial Surgery to say that he had attended a session of the AAMC [Association of American Medical Colleges] meeting on teaching medical students about dentistry and oral health, and that Harvard should do this, too. In fact, that program was presented by Dr. Mort Lorber, a graduate of HSDM and HMS. Yes, there was a brief time when all dental students received the MD as well as the DMD. Dr. Lorber developed his course for the students at Georgetown University School of Medicine. So, I at Mass General, along with Steve Sonis at the Brigham, initiated sessions for medical students during their clerkships in the essentials of dental medicine and oral health. This led to the current Oral Health Day, which the combined classes enjoy during the first year of the current Pathways curriculum.

Our Initiative to Integrate Oral Health and Medicine, which began four years ago, seeks to advance the education, clinical practice, outcomes and policy regarding comprehensive disease management and the economic imperative of good oral health. We work with the medical school’s Center for Primary Care to foster integration and hope to create an integrated medical dental practice that will be a teaching unit for all students.

Only two weeks ago I had the privilege of listening to two MD-MPP students discuss their reasons for pursuing primary care and family medicine at a session billed as a revolution for primary care. One of those students is graduating today.

I like revolutions. Goodness knows the American health care system needs some transformations. We believe in integrating oral health and medical care. Doing this will be difficult. It will require that we change the cultures of medicine and dentistry, develop new payment models, improve shared information systems and improve outcomes measurements.

When I had just become a professor and head of OMFS at Mass General and Harvard, I had a series of patient encounters that were remarkable because of the patients involved, but also because each was prescient of the remarkable future of health care that you, the graduates, are now entering.

First, I had a patient whom I had cared for two years earlier present for a tooth extraction. He said hello and then told me to put on gloves before examining him. Mind you, most dentists and physicians did not wear gloves for general exams at the time. He said he had just returned from Seattle where he had a bone marrow transplant, developed graft-versus-host disease and had something called an HIV infection.

In the next year I had many calls from dentists, distraught because they had cared for a patient who then told them that they might have AIDS. You cannot believe the distress and emotional tenor of these calls. Interestingly, even late into the 1980s as I was teaching Patient-Doctor I and had a patient from the AIDS Action Committee attend a class meeting, students would ask if it was okay to shake hands with the speaker.

A disease that was a diagnosis for death is now a treatable illness. That is part of health care’s past and future, and science made it possible. Pursuit of science and primary care are not incompatible.

I also recall a group of a dozen young women with tongue cancer who were the antithesis of the usual oral cancer patients. They had none of the usual risk factors and despite detailed study of them all, we could not identify any reason for them to have such cancers.

However, just last month it was shown that these patients have a marker, PD-1, which can be a very useful indicator for patients with a relatively well-behaved tongue cancer. I just received an email from the New England Journal of Medicine with the editor-in-chief’s list of the journal’s 12 most important papers since 2000. One of those papers was about HPV infection, the vaccine and prevention of cervical cancer. But in fact, its relationship to oropharyngeal cancer is as important and vaccination prevents this oral cancer as well. Why should mucosa in one orifice of the body be different from another?

We have come a long way, and science makes this possible. Medical treatment of surgical disease is becoming a reality for dental decay as well as for cancers. We’ve come a long way since Australian physicians Barry Marshall and Robin Warren won the Nobel Prize in Physiology or Medicine in 2005 for the discovery that gastric ulcers are caused by bacteria. The discovery of Helicobacter pylori was groundbreaking and opened up the study of the human microbiome, which is so important to today’s understanding of many diseases. It will just take one of you to discover how the human immune system turns these normal inhabitants into pathogens. I liken the concept of natural microbes being involved in disease with the realization in the mid-1800s that cholera could be transmitted by water, when at the time only airborne spread of disease was acknowledged.

So, congratulations to the 34 individuals receiving the DMD degree, the 10 with honors in a special field and the five receiving the degree with general honors; the 11 receiving the MMSc degree and the eight receiving the DMSc degree. And congratulations to the residents and fellows who are receiving specialty certificates and will go on to make an impact in their chosen fields.

Always remember, we are privileged to take care of people. Treat them well, treat them kindly and treat them with respect. Above all, treat them all equally, with one high standard of care. Don’t allow missions of mercy, thousands of people lined up for free dental care once a year, to become the profession’s scar of oral health delivery for the underserved. Don’t permit our growing elderly population’s oral health needs to be excluded from Medicare.

Your achievements should make you very proud. Those who have helped you reach this day and those who have nurtured and sustained you share that pride. The entire HSDM community and I feel no small measure of joy and pride in your accomplishments. We look forward to your future with justifiably high hopes.

Congratulations, Class of 2019. I hope your memories of HSDM and HMS will always remain a treasured part of who you are and who you become. Be the leaders you are in transforming our health care world through science, policy and compassionate care.

Most importantly, do the right thing—especially when no one is watching.

And now, I would like to invite the associate dean for dental education, Dr. Sang Park, to join me on stage for the conferring of the DMD degrees.