A Master Class with Dr. Shahid Aziz

0:00I'd like to welcome our audience back to the OMS Insights Podcast. This is episode 8 of season 2. My name is Bruce Huberman and I'm a board certified oral max off facial surgeon and I'll be your host for this episode with my co-host and colleague Dr. Stephen Roser. This evening we are so fortunate to have one of the current leaders in our specialty in the disciplines of orthodontic, reconstructive and TMJ surgery. Dr. Aziz has been an illuminating fixture in academia and hospital-based practice mentoring a new generation of surgeons. His work ethic and dedication to advancing our specialty is second to none. He has guided OMS residents at Rutgers and multiple other academic institutions throughout the U.S. Dr. Aziz is the founder of Smile Bangalod Dash since its inception in 2006.

1:04Dr. Aziz has led numerous mission trips to provide repair of cleft lip and palate to numerous children and adults throughout the country of Bangalod Dash. Dr. Aziz has also penned a number of journal articles, book chapters, and recently is the co-editor of a book with Michael Turner of Amount Sinai, called The Classic Papers in Oral and Max Little Facial Surgery. Before I properly introduced Dr. Aziz, I'd like to acknowledge Dr. Roser, who has been a previous guest on the podcast with Dr. Hawk. Dr. Roser has been an exemplary leader in our profession and has been an indispensable mentor and colleague to Dr. Aziz as they remain close friends to date. Dr. Roser was also a guest on season 1 episode 8 of the podcast and it was very, very well received. So, welcome to the podcast Dr. Aziz. I've been an amire of your work and dedication to our specialty from a short distance and

2:05for a long time. So can you give our audience a glimpse into your pathway to Oral Max Little Facial Surgery and how you landed a new jersey? I know your parents were very, very big influences on you. And now your children seems to be sort of following in your footsteps. So give us a little bit of a how your journey took place and where you got to today. Thank you. Well, thank you, Bruce, for having me on tonight. I'm thrilled to be here and also share the stage with Dr. Roser. As you mentioned, as one of my mentors, I basically grew up in New Jersey. I moved to New Jersey when I was 9 and lived in Princeton and went to Rutgers with College. The only time I really stayed out of New Jersey or the New York New Jersey area was when I was up in Boston at dental school. So I'm really from the age 9 on, I've been sort of a fixture in New Jersey and obviously came back to the area after dental school and did training and obviously went into academics

3:06in New Jersey. In terms of your first meeting with Dr. Roser, could you tell us a little about that and how that all evolved? Well, that would have been... I graduated dental school in 1996. That would have been probably the summer of 1995 where I did a one month externship at Columbia. I knew that I wanted to do a six year best program. I knew that I wanted to come back to the New York New Jersey area to be closer to my family and back at that point, there were only about 13 dual degree programs available. Outside of in the New York area, there were a couple, Columbia, Kings County and Rutgers. Obviously, of the three, I thought Columbia was the strongest and best fit. It also helped that Dr. Roser and I attended the same dental school up in Boston at Harvard and the person who trained him was also my dental school mentor, Walter Garamick.

4:10Obviously, there was a strong connection between the oral surgery program at Columbia and Harvard dental school. That prompted me to do my month at Columbia and that's where I met Dr. Roser for the first time. I was a little bit shy and a bit nervous, a bit intimidated by him and everyone else there, but it was a great month. I got to scrub and watch multiple ortho-nathoc surgeries and multiple different surgeries and really fell in love with the place. I still, to this day, feel very blessed that I was able to train there. So Steve, do you have that same recollection and you remember this young upstart coming into your program? I do, actually. It was fun. I had been as far as days are concerned.

5:13We were not one of the earliest six year programs, but we were notable because we were somewhat new. When I got to Columbia in 1981 or yeah, 1981, there was really no program there. So started a four year program and I think one, two, three years later, we got approved for a six year program. So we sort of knew at it when when Shia had relatively speaking with Shia, came to see us. And Shia stood out for a number of reasons. He was a little shy, a little withdrawn, but very smart. And that was great. Plus, he was extraordinarily curious. But in a non-murion, the kind of guy that you ask questions, ask questions and you just give up. And he also was in the five year program at Harvard, which had been discontinued and was

6:16going to go off and spend a year as a sort of an intern. And you did that in what institution did you intern at? Mount Sinai. Mount Sinai. It was a research year that I combined into an intern year at Mount Sinai with the Dr. Bookfinder. So I sort of, I did that to get more oral surgeon experience. Also I got paid, which helped pay the tuition. I was back in New York, but the goal all along was to expose myself to oral surgery for that year, to oral surgery research, with the goal of ultimately going to Columbia. So Shia, did you entertain it all for your program? Were you sort of knew that the six year was where you needed to be? You know, it's funny. You say that back then at Harvard, Dennell, they sort of, the curriculum was set up at Harvard, Dennell, that you do two years of med school before your two years ego into dental school, 100%. So we had a very strong medical background, basic science background.

7:20And subsequently, it was sort of expected that you would do a six year program. There were, you know, it's a very small school. My class graduated 22 kids. And six of us went into oral surgery. All of us went to dual degree programs. Four of us are still oral surgeons. The other two, one is an anesthesiologist, one is actually an hematologist. But I think it was expected of us to only apply to six year programs. Now it's very different. But back then, it was sort of one of those things, you know, Dean Donough was leading school. And he obviously is a big advocate. And as was Dr. Gronk of the Medical Education for oral surgeons. So certainly, it was expected of us. And none of us ever thought even of applying to a four year track. One of the other things is most of the six year programs at the time had a very strong connection with Harvard, Dennell School, either their chairs or program directors or H.S.D.M. graduates.

8:22So again, it was a high expectation, it was sort of expected that we would apply to a six year program only, which is what all of us did. So I was going to save this for a little later on in the podcast. And since we're talking about a four to six year track, it's very much invoked now the controversy on whether you need to be in a four or six year program. So now that you've gone through and been there, educating residents, what is your opinion on that? Do you think there may be a form of a hybrid, maybe a four year with fellowship? What do you think of the current, you know, residency education and how we can improve it as we need to, you know, there's a lot of headwinds coming at us as oral maxill facial surgeons. So what are your thoughts on that? You know, Bruce, what I would tell you is if I ruled the world, among other things, I would make oral maxill facial surgery a dental and medical specialty, which then in turn would mean that we would all be due to degree.

9:23I think it would allow us to, I really have to say this, but be taking a lot more seriously in the hospital setting by our surgical colleagues. And again, I do feel very strongly about the six year program, you know, my son is a senior at Penn undergrad. He's going to do a gap year with Dr. Lay in the oral surgery department in her lab at Penn and then apply to dental school. And if he does want to do oral surgery, the anticipation for him is to do a six year program because I do think that is more valuable than from an educational standpoint. However, that being said, I will say having spent 20 plus years as a full time faculty at Rutgers, some of the best residents I trained, some of the smartest residents I've trained are four year people. And so it really depends, I guess at the end of the day, what you want to do. If you want to do academia, if you want to be hospital based, if you want to do fellowships, I think the six year program opens a lot more doors to you.

10:27If you are looking to be somebody who's going to go into private equity, do teeth and titanium insidations, yeah, you probably could get away with not doing a two degree track. It all comes down at the end of the day to your training. And if you have a good training program that trains you well in the basics of maxill facial surgery and oral surgery, good anesthesia training, you're going to be a success. But again, I would love to see our specialty evolved into not just a dental specialty, but a medical specialty. And to do that, I think we need to have really integrate the MD into our training, that my opinion. Ed Steve, would you like to comment on that please? Sure. Shia and I have talked about this for 30 years. And I feel exactly the same way. And Harvard was a terrific dental school. You went to Harvard for four years.

11:29First and second year were with the medical school. And you had to be promoted to the third year of the medical school and then transfer to the dental school. And so people at Harvard really put down a foundation in basics. And the double degree program was natural to finish medical school, get the MD. As Walter Garnellic often said, it's not the MD. It's the year of general surgery where you put all this together. And that gives you the confidence to take care of patients during their perioperative period. And that in itself is what leads to the confidence that people have going into academics because that's the salary, first year salary for an assistant professor at Emory is literally a third of what a first year clear choice. And you may have to edit that out.

12:30A very clear choice, you know, salary offer will be for somebody graduating from either four or six year program. And so it's not the money that people in academics have. There are some forces that are going on now. And you mentioned, you know, what kind of forces are upon us, you know, certainly, certainly you know, healthcare delivery. But our board is looking into being part of the medical board of specialties that would recognize all of the surgical specialties. And that would be helpful. And you know, we talk often on, I think more on right now about ACGME. Accreditation, especially for the six year programs. And so that I some of that will help to set directions. But to shine its point, the amount of training and oral surgery that a six year person gets is probably no different in any, any place than a four year person gets.

13:34And in fact, some programs, the four year people get more exposure to oral surgery than the six year people. And so I think until we decide what we want to be when we grow up and what the health case delivery system is going to look like, I think we have an option out to, you know, be eight, nine thousand strong, which isn't a lot to keep the message going because my fear is sustainability of our profession. And there are people that are doing what we do. General practitioners have anesthesiologists or nurse and ex-discent, but the sleep, put in implants, take out wisdom teeth. So we need to look at that as well as what we want to be like in Tweeties. Well, I do think that you're right. You just mentioned it about, you know, in terms of, you know, general practitioners and

14:36non-specialists who are going ahead and doing, you know, a lot of the things that we do and run into problems because they don't know how to, you know, remedy them if they develop complications and then sending to our offices. So I'm always a big proponent if you can't, you know, fix your complications. You really shouldn't be doing the procedures. But you know, you're right. There's a lot of headwinds coming at us. If there be any way, Shaheed, maybe the restructure, you know, residency education for the oral maxillofacial surgeon, there are things that you feel that maybe aren't as necessary as they were, you know, 15, 20 years ago as compared to today. And the needs are obviously different. I think, you know, the work ethic of, you know, I don't want to characterize all the young, you know, practitioners coming out, but it doesn't seem to be like when we were training. It's just, it's different now. So is there any way to adjust, you know, our training regimen that would be helpful?

15:39I think the biggest area of weakness in our training is learning about the business of dentistry medicine or oral maxillofacial surgery. I think that I certainly got very little of it, you know, and I don't think the regents that I work with right now get enough of it to really understand what they're getting into when they graduate. I do think that that's an area that certainly is very important because, you know, 90% of trainees go on in a private practice now, I'm probably at least a third of them going in a private equity and not knowing exactly what they're getting into. So I do think a little more business training and business background and education is important. You know, I think in response to some anesthesia issues and anesthesia politics, we now do a significant amount of anesthesia as part of the training program. And on one hand, it's very important because it ultimately keeps the patient safe,

16:43but on the other hand, we had to take away from somewhere else. And so, you know, I think a lot of training programs now, unfortunately, are getting away more and more from doing really complicated maxillofacial surgery to focusing on implants and focusing on anesthesia. And while there is benefit with that, I would love to see trainees come out being able to not necessarily be the testiae, but be able to get into a trauma case and, you know, a complicated, mid-facial trauma, a pan-facial trauma, and be comfortable doing it, doing a ortho-nathocase joint replacement, which I think is one of the hardest things that we do outside of a head and neck cancer. You know, I would like to see more complex oral and maxillofacial surgery being done. I would like to see the opportunity to do, I'd like to see more fellowships available to us. And I would like to also, again, an ideal world, create pathways

17:50where we can financially support, especially the six-year guys, because tuition now is becoming, you know, really significant. And that obviously, at the end of the day, in the country, we live in dollars and cents make a big difference and they do guide us into our choices in many ways. I think that a lot of the trainees come out with six figures of debt and understand that academics may not allow them to recoup some of that debt. And they need to go into private practice. So there's a lot of things I would love to see change, but it's sort of a mindset change about education, about finances, about training that, you know, certainly will not happen, I think, in my lifetime. But we certainly have come a long way. And what I don't want to see is, you know, Dr. Roser's generation really fought to get oral and maxillofacial surgeons established in hospitals, get hospital privileges, be able to admit patients on their own. And interestingly enough, you know, you pull the most recent group of graduates, how many of them have probably have hospital privileges very few.

19:00Take call very few. And so we're doing a little bit backwards. And why are we doing that? It comes down to dollars and cents. It's a lot easier to go into a private equity group, make Dr. Roser said three times what you would as an academic or hospital-based surgeon, but then you pigeonhole yourself into doing minimal scope oral surgery, basic oral surgery. And if that's what you want, great, more power to you. But I think we are so much more than that. We get trained in so much more than that. And I would like to see more of us follow and take call and do a hospital-based stuff and do maxillofacial surgery, because, you know, Dr. Roser was spoken about this multiple times, because it's worth it. I mean, you're really making a difference in patients' lives. And, you know, the system has to change, though, to do that. So you mentioned fellowships, and maybe, you know, we're access to fellowships for recent graduates. I guess Dr. Zuniga at Parkland is now going to have a nerve fellowship, which I was thinking about that, you know, six or seven months ago,

20:07and then I brought it up on one of the podcasts, and it ends up that he's established that, and it's had code approval. And I think that's fantastic, because there's a limited number, you know, you have Dr. Zakarate, you have Dr. Moloro, and then there's a bunch of others. But that only, you know, comes about 10 throughout the country, where there's a big shortage, and obviously, you know, there's a lot of nerve injuries out there that, you know, people have difficult and access to care. So I think that's a huge thing. Steve, what do you think about that new fellowship in, you know, nerve reconstruction and the diagnosis and treatment? Half of me, half of me, you know, because I came up from, you know, a long time ago where we did everything. And, you know, the putting, putting nerves together now with some of the products that are available from companies is really not hard. Nerve grafting has been relegated to a small group of people because of donor morbidity or potential.

21:12And some of the nerve graphs that come in bottles and just some of the mechanisms for sheathing cut ends that really do seem to help good results. So what it comes down to is do you want to get into the not just nerve injury or repair business, but, you know, facial pain, or you could probably go to headache surgery, like plastics has, my brain surgery. I think, I think the fellowship should be more than just repair of nerve injury. And I think that there should be a curriculum within the OMS, a core. I mean, if they spent six years with us, you know, putting nerve injury repair into that core is not hard. The injury part, they just have to choose to want to do that as a specialty. TMJ is going that way. They're increasing number of TMJ fellowships.

22:15So the group is more or less saying, well, you know, core should be, you know, diagnosis, maybe, orthosynthesis, and maybe, you know, type one, you know, foroscopy or orthoscopic surgery, but the joint replacement and more complex, you know, probably does require a fellowship. But that leads to, you know, another thought, you know, should you train only to take care of one joint? Should you not in your fellowship, you know, be in a situation where you take care of more than one joint, which means, you know, working with orthopedics and designing something along those lines. Anyway, so my response overall is in summary. I think we need to separate sort out what's core, what we should train to, and what should be in fellowship. We train in our program to

23:16encore nerve repair. And the fellowship and nerve repair would not be needed for a graduate who wanted to do that because we could expand opportunity within our program. I think it would be available and would be good for people who did not train and want to come back to it and specialize in it or or make it a part of their already going practice. I think that would be, that would be perfect for that fellowship would be perfect for that. All right. In terms of maybe switching gears a little bit, another issue that I find that is very important in our specialty and it was in the past research. I know you've done, you know, a lot of written a lot of papers, textbooks, but I think it's a problem with in terms of residency training and finding time, you know, for residents to do research because if practitioners aren't seeing, you know, information from us on, you know,

24:22in front of them on their desks in their periodicals, I think we've lost our way in a bit. So any thoughts on improving research for our specialty and what we need to do and going forward because I think we've lost our tracking, you know, with research and I think it's become an issue in our profession. Yeah. I mean, I think I think you're 100% correct for use because, you know, for example, with implants, most of the research comes from the prosome parriol world, not oral surgery. I think again, because there is a lot of clinical training required in the 30 months of oral surgery, it's hard to get real true hard and fast research in. I think it would be nice to see more programs offer PhD options as part of their training programs. They could do, you know, OMS PhD program or MD PhD, OMS program so they can get some more research experience, research training and

25:26develop into, you know, cutting edge researchers. You know, we have a couple people who are really the next generation of cancer researchers in our specialty, Chevette out in California and Simon Young was the new chair of OMS at UT Houston, you know, I think both of them, these, if not mistaken, on top of, you know, oral surgery and MD degrees. So, you know, that's a great track. It just takes a long time to do and it takes, you have to really find the right people to do that. But the night is where the desire starts in dental schools and the dental schools, you know, I was lucky, Dr. Rosar was very fortunate. We both went to a very research oriented dental school and so there were plenty of research opportunities and I think that's how both of us sort of pursued academia, etc. But I'm not sure that all dental schools are that research heavy and I'm not sure they focus and encourage research as much. So I think a lot of dental schools probably can do a better job cultivating researchers and I think a lot of the oral surgery faculty at those schools

26:28can do a better job cultivating researchers mainly through mentorship involving kids with dental students with research projects. And again, once you're in training having in that program, somebody who's dedicated to research, you know, it's hard. I mean, you know, I know Parkland for years had a dedicated researcher and non-oral surgeon dedicated PhD in their program, for example. And it would be great if there were more people like that who were really in oral surgery programs but they were researchers, you know, I look at somebody like the chair at Penn Dr. Lay who's an oral surgeon but also a basic science researcher and has her own lab. I mean, things like that are really phenomenal and I would love to see more of that and it comes from the dental school level to cultivate the design already to research then ask to cultivate it some more internally in the oral surgery program and there have to be opportunities and avenues to do more research. Maybe, and I'm sure this is going to be very unpopular but there are training programs in general surgery

27:33who have a required year or two in some cases of research. On top of that, a lot of general surgery specialties will expect you to do research, take a year or two off to do research before applying to their fellowship, especially in pediatric surgery, cardiac surgery, things like that. And maybe that is something that we should cultivate as well in our training because at the end of the day, you know, yeah, you went to medical school, you went to dental school, you did training. I mean, I finished at 31. I think most people, I was a little young, most people finished at 32, 33. But that is young when you think about other surgical specialties. Most of them are getting out in their mid-30s because they had to do research and they had to do, you know, different things. And so maybe it would be worth having that option available at all the training programs. Maybe it comes down to, you know, having NIDC-R funding for training programs to cultivate research, NIDC-R,

28:40NIH, externships for residents to spend six months with the researchers at the NIH. You know, there's there are opportunities, but it also has to come from within. And, you know, it's one of those things where the whole system has to change because right now you ask the average dental student why they want to do oral surgery. And a lot of them will say, oh, we love the surgery. We love implants, you know, orthomathics, whatever. But at the end of the day, you look on social media, oral surgeons are the highest paid dental specialist, one of the highest paid, you know, surgical specialties in the country. And that's obviously important to all these kids because they have debt, you know, they all have six figured debt or higher. And they have to pay their bills and they know that with oral surgery, they're going to have a good life and also pay their bills. So, taking that time off does lead to reduced income and the long run. And that may not be tenable for a lot of kids. So I think to make a lot of these changes, we have to change the way we think.

29:42We have to provide more financial support to our residents and encourage them through mentorship and again, financial support that they can go on to fellowships, they can go on to research, they can go on to academia and not worry about money. And that would be a great thing. This episode of the ONS Insights Podcast is brought to you by Dental Wint Review. Most dental specialists spend thousands of dollars marking when they're still not getting any jobs. What if they're to smarter way? Dental Wint Review is a two-year 24-topics and 50-based public education that focuses on the medical management of dental patients. Our format is designed to provide dental skills with quick, term material, and a concise and handy way. A new topic is delivered to your first office every five weeks a three-fold year. Each one is granted with your name and practice. It keeps you on top of the referral without a single lunch for lunch. But here's the real ticket. It's not just a marketing

30:47tool, it's your investment and your firm effort. Every issue is to leave your minds with general practitioners to do the reperture of their patients. The company can be reached at dentalquickreview.com for Bicolody 718-226-1251. So I think you're absolutely correct. I think the financial aspect has to, I mean, I don't see residents maybe seeing the value of research because they're thinking about they've got to get out, they've got to recoup the debt that they've incurred. So I think that's a huge problem. And I think that's a universal problem in healthcare at the moment, training the cost of training residents and to be surgeons or to be general practitioners is astronomical. And if you don't have the financial support, you're stuck before you even get out into private practice or whatever path

31:53you choose. So I think that's a huge problem. Steve, would you like to comment on that? I agree with Shodd. It starts in the dental school because the research done by, in the other surgical specialties aren't done by community surgeons. They're done by the academic surgeons and many of those academic surgeons, especially if they're clinical, pair with folks that are full-time research and work in the lab. Emery's general surgery program doesn't require people to take time off in the lab, but a good percentage do. They leave to spend one or two years in the lab. But the lab is usually one of one of the medical center medical school faculty. So it really is a dental school if you want to, you know, pigeonhole it for us. It's really a dental school phenomenon.

32:54A Harvard does it well. Bruce Donoff, when he was dean, was dean at the time that they rebuilt or remodeled some of it. And all was said that what he did was to put the clinician's offices on the same floor as the researchers' offices, not necessarily their labs. So they had to run into each other. They had to mingle. And sure enough, these hallway conversations turned out to be fruitful. But the, you know, by the time somebody gets, you know, through dental school and into a residency program in LMS, it really takes a strong pivot if they're not already interested in research. And so I think the dental school is where this has to start. It's interesting. I think it may have been Simon Young may have mentioned it. But you know, there's like 90 residency programs throughout the country. And if each residency program produced one article

33:58per year, that would totally increase our numbers. And that's really not asking for a lot. I mean, it's pretty incredible. Speaking of Harvard, I just wanted to acknowledge the Shaheed is the recent recipient of the Harvard dental gold medals Distinguished Alumni Award. And it's funny Dr. Roser had received that reward, I think like 30 some odd years ago. Could you tell us a little about that award and what that meant to you? I was really honored. Harvard is really where I started to shape my career and profound impact on me. I'm really grateful to the dean of admissions at the time, Ellen Liebert for, you know, except me and allowing me to be a part of such an amazing place. So yeah, having that award meant a lot to me. I think it's from what I gather and you know, it's funny the new dean since Dean Donna Frittired is as Will Jean Obley, who was a perial postdoc when I was a dental student. So knowing him from the time I was a dental student,

35:01I thought he was a great guy and he's a great dean and he's a perfect fit for that position. You know, HSDM is just a magical place. It really cultivated my need to do something with my life to become an oral surgeon or to become an academic and to be awarded in that way was really profound and also very surprising because there are a lot of people like graduate from there that I have done remarkable things. So I was very, very humble to have that. I think a big part of that is, is receiving that is because of my work with Small Bangladesh and and the work I've done in global surgery, being in academics and also from the day I graduated, I was always still involved in some degree with the dental school as an alumnus. So whether it was attending alumni functions or being an active, you know, alumnus in their network, it was always a very important thing. I think I'm very blessed to have been attending there and graduating there and it's really where I

36:05started my career, so to speak. And I met amazing people that really deemed Donna of Dr. Gromick, Dr. Kambin, you know, multiple people at the MGH, you know, had seldom there. August people in, you know, even the restored of faculty and, you know, a couple of my best friends were classmates of mine from there, you know, Joe Marchana, and Jotorio, they're both the oral surgeons and, you know, we really made a profound, the five years I spent that, that really made a profound impact on me and that's where everything started for me. So I'm very grateful, very blessed to have been recognized for that and very humbled as well. Steve, could you talk about the culture at Harvard when you were there? I sure, I can. I would, I'll start my response was the, the major technological or technology advance in my years there were chairs that went

37:07up and down and reclined because when I, when I first started there, it was stand up. Secondly, we had this, this substance or this, this restorative material called a malgum, of which we do we are diligently mixed, you know, in a little mortar and pestle, and these little cheesecloths things that we squeeze the mercury out of. And, you know, you brush the mercury here and there and the waste basket and, you know, took it home and played with it on your desk and, you know, those were the days. But, you know, Harvard, Harvard also had a profound, profound impact on me. A little more history. My father went to dental school there. He was a German dentist who, with his new wife, my mother, escaped from Germany in 1938 and one of the last, last boats out and landed in New York and then

38:11had to get his dental degree. So, got accepted to Harvard. Walter Gurellneck, graduated from Harvard a year after a year before him and they knew each other. Paul Goldhaber was also a period, honestly, my father referred to. And if you go back a little bit more in history, Verstead Consangian, the father of plastic surgery, was a professor at Harvard and in the dental school and he went off to World War I and came back, that is medical degree and, you know, continued his facial restoration career. And, you know, that, that kind of history, that kind of story history for Harvard really, really does have a profound experience. So, it made me a profound impact on people. So, my father, unfortunately, passed away when I was a freshman in college. And, you know, I had been always more on the dentist and so, I kept that up although I wanted to

39:17go into practice with him, but my practice was, his practice was sold and long before. And I went to Middlebury College. There's a point to this story that relates to Harvard, sorry, to make this long. But so, the Middlebury College, which was a Middlebury Vermont, which was known for its languages, you know, had three people in our class, two were pre-med and I was pre-dent. There were only three of us. And so, I get a call from the dean's office that the associate dean from Harvard School of Dental Medicine was stopping in. And, would I come down and visit with him? I thought, wait a minute. Middlebury Vermont, you know, no dean from the, you know, associate deans, you know, in the neighborhood. They don't live here and so on. So, I met with Jay Howard Oaks. And we had a pleasant enough conversation. And he left and I said, hmm, you know, maybe, maybe I

40:18should apply to Harvard. I wanted to. Well, a long story short, my father, who passed away at, I think it was at Beth Israel, referred all his perio to Paul Goldhaber and referred all his oral surgery to Walter Grownick. And on his, essentially, he was hospitalized as a major in the hospital and before he passed away, essentially told both of them to kind of keep their eye out for me. And sure enough, said Howard Oaks up there to see if I was, if I was a viable candidate. And so, unbeknownst to me that my father had had that influence. But, but that's, that's typical of Harvard in the sense that they really do treat everyone as family. It's small. They can do it. And I think the, if you look at the success of the graduates and talk to, you know, I mentioned six

41:23people in oral surgery and, you know, they've all made impacts except for the two that didn't finish. But I think it's a, it's a place that really does, does give you opportunity. But it was hard. First day in medical school, we're sitting in with the dental students, we're sitting with the medical students. And one of the medical students stood up and said, Oh, will all those, you know, after orientation meet all those Phi Beta Kappas from college, meet down, down here by the podium at the end of the lecture. I think I might have been the only one sitting in that, it wasn't a Phi Beta Kappa. And I said, Oh, this is going to be a kind of bumpy journey. So, but, but Harvard, Harvard really didn't have a problem. And, you know, we, we talked about Harvard for two-thirds of this time already. And, you know, I think, I think that the message is that it starts in dental

42:27school. It starts in dental school. And Harvard is a very special place, which recognizes the value of what we do. Whether, and whether it's karaoke or indoor or restorative dentistry and the faculty that attracts their role models and examples. And I think that, you know, even those people that, sorry, let me study it. The people that go out into general practice for the most part become community leaders because that's the inspiration they have and that's the obligation they fail. So, I would like to see more dental schools, you know, look at that. And, but I think that, you know, the way some of the, some of the way things are going now is, is dental schools are becoming closer to sort of edging towards being trade schools as opposed to professional schools, unfortunately. Shaheed, I think, as you mentioned before, about smile, Bangladesh. I think that is a huge, huge part of your life. And it's amazing how you've been

43:35able to orchestrate that. So, could you tell us a little bit about the Genesis? I think it was around 2005, 2006 when that got started and what sort of prompted you. And it's a lot of work. I mean, like I understand you're working really hard, teaching, you're operating a lot. How did you find time to sort of get that all instituted? And now you're on your like 20th year. And what a feather in your cap. Oh, thank you. So, you know, it goes back to, that's where I'm originally from, that's where my father's from. My father was a researcher. He worked for the World Health Organization when I was a child. And we moved around quite a bit, spent time in Africa, the UK. And before settling, he went, when I was six or seven, he ended up going into the pharmaceutical industry as a researcher, initially at Pfizer. And then when I was a seven or eight, he moved the dust outside of Philly and worked, started working for Merck where he championed

44:41utilizing a veterinary drug called Mechdesen, and Iver Mechden to treat something called river blindness, which has basically been eradicated now. So, that was a very significant thing. But as such, you know, he passed like Dr. Rosa's father, he passed when I was a senior in high school, but he didn't still on me the need to get back in the world. And fast forwarded to my training program. So, one of the reasons I wanted to go to Columbia is because Dr. Rosa was very involved in global Orlando, facial surgery. For years, leading, you know, taking residents and leading teams throughout primarily South America to do cleft-flutten palat work. And so I had the opportunity to experience that several times as a resident. And even as an attending, he would, he would bring me initially early in my career on his missions. And one of the reasons I think that he allowed me to come is because he and I spoke about starting my own, my own missions

45:43because that was an interest of mine. And then, you know, I, speaking to family from Bangladesh, I learned about the need for cleft surgery. You know, there were very few surgeons properly training cleft surgery in Bangladesh. They're only in a country that's, you know, 165 million people, half of the population of the US has two training programs at the time, 20-odd years ago, one in plastic surgery, one in oral surgery. And it was estimated that there's one in 500 births or higher of clefts because of variety of issues, malnutrition, constant guinity, and things like that. So, you know, it was estimated that there were 300,000 children and adults with untreated plus deformities, facial plus deformities. And so I realized that I had an opportunity to make a difference and go back to where I was from.

46:46I still have a ton of family there. And that's really the genesis of smile Bangladesh. And I never thought it would get to this level, meaning that we've done 30, this is our, we've done 33 missions. We have our 34th coming up in November, treated about 2,000 kids and adults with cleft deformities. So yeah, it's been a lot of work, but I have a great team. You know, I have Christina Rosario, who is now part of the Global Health Department at Rutgers. She is our from Bangladesh. She ran an NGO called Impact Foundation when I first met her in Bangladesh. Her son later went on to seat normal for college. So she immigrated to the US, took a job at Rutgers and has been our executive director and really our backbone of the organization. It was a big Harvard impact, Harvard Donald impact in the organization. Our number two is my best friend, Jose Marchana, who's an oral surgeon, academic oral surgeon at UT Houston. One of our plastic surgeons on their board

47:50is Greg Bora. Greg is a 90, 1976 graduate of Harvard dental school and he went on to do oral surgery at the general and get his MD and then went on to plastic surgery. And he's currently chair of plastic surgery at the University of Mexico. And he was actually at a Robert Wood Johnson as chair of plastics for a long, long time, which is where I first met him. And he's been a stalwart part of our organization. So everything seems to travel back to Harvard dental school. But you know, I'm very blessed to have had the mentors like Dr. Rosa, Dr. Gromacoup. Dr. Gromac was also instrumental in global surgery and I think inspired Dr. Rosa as well. If I'm not mistaken, took him to China early in Dr. Rosa's career and it is a lot of work. Bruce, you're right. You know, it doesn't allow me for a lot of spare time because frankly, it's grown a lot but it's still a very grassroots organization in that probably 90% of the work is done by me, you know, behind the scenes.

48:50But we do need a team and when we go and we have a great group, a court group of surgeons, anesthesiologists and that participate. And most importantly, in addition to what we do for our patients and we also do two other things that I'm really proud of. And that is one educating the local surgeons. One of our more recent initiatives, which is a very tough one, but we're succeeding at it, is training the local, max official people in orthographic surgery. That's not an easy task. We have to bring all the equipment drills. We get donations with striker and synthies and KLS when it comes to hardware and we bring all of that with us. We have a storage facility in DACA and we have some posiums on ortho-nathic surgery. Greg Jacob, we know, and Jess Lee, we know from New Jersey, come with me and they're instrumental in helping me train the local surgeons and ortho-nathics because that's sort of a need there. And the other thing that I'm really particularly proud of is the fact that I open this up to oral surgery,

49:54plastic surgery, ENT residents throughout the country who are interested primarily oral surgery residents. And we've had, you know, over 200 residents travel with us these last 20 years. And I think I can't think of one who didn't say that's just one of the highlights of their training program. And it's not to make them, you know, the next, you know, TSEA. It's really to just inspire them to give back in their career that they have the ability to give back. And that's what is most important. And a few of them have done their own things and gives me a lot of pride in that, you know, I helped sort of inspire them just like I was inspired to give back on a local and a global stage. And so again, I'm very blessed to be able to provide this and start this organization. And it amazes me. You'd never asked me 20 years ago what you'd be here now. I would never have imagined that in a million years. So could you tell us maybe I think our audience would be

50:54really interested maybe just like a typical day on your mission. And you know, what time you start in the morning, how that's all, you know, transpires. Christina Rosario mentioned before she and I really are very strict, keep a very strict timetable and plan before we leave. Because again, we're in another country for many of the team, especially the residents. This is their first time in a place like Bangladesh. Bangladesh, by the way, is one of the nicest, most warmhearted people that you'll ever meet. They encourage. If you have an opportunity to go, I think you'd love it there. But, you know, our typical day. So I used to be able to get there and it's a long trip. It's, you know, we usually fly through the middies. So it's a 12 to 14 hour flight to Dalar or, you know, Dubai. And then another five hours to DACA with a layover. So it's, you know, good 22 hours of travel time, 11 hour time difference. When I was young, I could literally land and start working.

52:01Now I need to come in a day or two in advance because the jet lag gets me in a, I'm just very tired. I don't sleep well on planes and I'm just very tired. You know, so I get there a couple days early, start planning. Christina gets there a couple days early. We meet, we plan, we meet with the leadership of whether it's the Bangladesh or a surgery society where whatever NGL we may be meeting with Christina often will be scouting future sites for us as well. And we also meet with donors. We have donors in Bangladesh. And so that's what we do. Christina and I do pre pre mission. But once the mission starts, everyone arrives. So our mission can be twofold. Well, now it's twofold. One week we stay in the capital in DACA. And that's primarily because we now are doing ortho-nathic surgery. And it's not something that we can easily do in rural community hospitals. So we primarily do ortho-nathics that first week. And the first day is screening. So we work in one

53:04of the dental colleges. Now the dental colleges in that part of the world are called dental college slash hospitals. So they actually have awards. They have hemacizologists, ORs, hospitalists that take care of patients. So it really is like a mini hospital. It's a dental hospital. So our first day typically is evaluating patients, screening patients. For the ortho-nathic component, we've already have an idea of who the patients are because they're pre-selected. And actually we have CT scans and either impressions or more recently intraoral scan was uploaded to 3D systems, which is striker. And they pro bono plan the surgeries for us and provide us with the splints. So we know those patients ahead of time. And then we have three or four days of surgery combined with cleft surgery. When and the following week we'll travel to a rural community and do primarily cleft surgery. So the first day in both weeks is screening patients. And screening day,

54:07half the team screens, anesthesiologists, the surgeon screen the patients. We rank them who is the highest priority versus who is not a good candidate. And then we come up, I come up with a schedule. And the next four days we operate. Typically we run three to four tables and we'll try to do 15 to 20 cases per day when it's clefts. When it's ortho-nathics we're doing maybe two or three a day over a couple tables and then there's a cleft table where we're doing some clefts. And then we wrap everything up. So in a nutshell, first day is screening. And that's the hardest day I think because we have to really evaluate who can we operate on safely. And for those who can't operate on for whatever the reason, how can we figure out how we can operate them on them in the future. We obviously prioritize people with primary clefts, lips and palettes. We prioritize young girls because they need to get married in the rural communities. We do ahead of time get blood work,

55:10chest x-rays EKGs by the local NGO that we work with and the anesthesiologists we're evaluating with them. So we do all of that truck work to prepare for the visit and select our patients. And then again the next several days of surgery. Over the years we have created sort of a warehouse in Indaka where we keep all our instruments and all our supplies that aren't perishable. We purchase from the local you know pharmacies medications IV fluids all that sort of stuff. Each mission runs about 30 no sorry 40 to 50 thousand dollars and it's all fundraised. So two missions it's a hundred thousand dollars for both missions. We raise most of that but whatever the balance is I pay out of my pocket the difference. And then we need a little bit of money to run the organization. Get back here in states. We have some big fundraisers we have one in Dallas. John

56:11Wallace is one of our board members as an oral surgeon. Down in Dallas has a big fundraiser every year. We do a lot of corporate grant writing from different areas and also you know during Ramadan because of Bangladesh is a Muslim country. All Muslims are supposed to give 2.5% of their income to charity. So during Ramadan we do fundraisers where we focus on the taxpayer from the best community and we've had some very generous donors from that community supporting us. So again it is amazing that we have come this far. I never would have imagined it. I think that's incredible. I'd be remiss you know as we're getting towards the end. If we didn't talk about a little bit about your current or to natto surgery practice and I think at this point you've done close to 2,700 procedures and I think our audience would want to know is you know what you have learned from the days back training with Dr. Roser until today what you think

57:13has helped you propel you to improve your outcomes with your patients. What do you think that sort of things that you've over the years have sort of mastered that have been a part of your regiment today that you weren't doing maybe 20 years ago because you're treating a lot of patients and you're getting a lot of really good results. What is the secret ingredient you think to or to natto surgery? Is it the VSP or what do you think? Well first and foremost it's good training. So I have very good mentor and good person that I trained under and he has you know one of the most amazing work ethics of anyone I've ever met in our specialty and so it was infectious and I really inherited that work ethic from Dr. Roser as well as having that immigrant work ethic from my parents. But when I first started as a young attending at Rutgers developing the practice

58:15back then there wasn't a virtual surgical planning there were not custom planning. We did it old fashion with model surgeries and you know face bows and spending a lot of time in the you know dental lab mounting stuff coming them up burning our fingertips would you know hot glue or hot wax. What would take normally several hours you know because what's the point of model surgery? Point of model surgery is eventually to create the splints that guide us in surgery and that could take hours and I would drive the residents at the time crazy and just like Dr. Roser would drive us crazy you know I just remember spending you know a lot of weekends we one of our big hour days it was Mondays and we would spend I would spend Saturdays you know finishing up model surgery and they're you know and making splints and in preparation for you know Monday surgeries things like that and it was very time consuming. I don't think now that the current crop of residents for

59:15the last five to ten years have any idea how lucky they are not to have to do model surgery not to have to make splints. I do think that they all should experience and learn how to do it just just because it shouldn't become a lost art but you know what would take several hours now is literally can be done in a 15 minute training DSP session. It's an amazing improvement and virtual planning makes us much more precise it adds a lot of precision to what we do we're looking at movements at the 10th of a millimeter we can look at YAH and look at things three dimensionally which we couldn't really do with model surgery so it really makes us better surgeons more precise surgeons more efficient surgeons but ultimately provides a better product to patients. So virtual planning certainly allowed me to expand the practice and do more surgery. One of the things I pride myself on is that you know I take all comers I take all insurance as whether it's Medicaid private insurance

1:00:21charity care. I don't care you know and I'm very proud of the fact that you know a big heart of that 2700 you know probably half of them are Medicaid patients and it does mean a lot to me that I'm providing care for a patient population that may not necessarily had an opportunity where it not for me to be hearing New Jersey to get you know their occlusion corrected about I don't know 10 years ago just before COVID that custom planning came out and that I think is a big boon as well it really has sped up my ability to operate it allows me to do up to three ortho-nathocases in a day which I think at one point would have been unheard of and so those two things custom planning and virtual planning have really allowed me to become a very precise efficient surgeon but also allowed me to do the volume that I do without having you know

1:01:25residents rebelling against me and you know you know it really allowed me to really spread my wings and do the surgery that I love the most which is ortho-nathocase because I know Dr. Rosa agrees with me because he's you know I'm even more experienced ortho-nathoc surgeon than I am but the difference you make in somebody's life with ortho-nathocase is so profound you know I got a picture recently of two people I did ortho-nathocs on then ended up marrying each other and now I have kids I have started it's starting to reflect on how old I am but I've actually treated a couple children of ortho-nathocations you know so it's an interesting thing but you know again you make such a profound impact and it's an area that as an Orland-Maxle-Facial Surgery surgeon we own there's nothing more that we do I think that makes such a profound impact on a young person

1:02:26you know you see the change in their eyes when they're under bite or over bite is fixed and they can speak properly they can look normal they can go into public and not be teased at school so it really is profound so I'm very blessed again to have been trained by Dr. Rosa and had the career that I had in ortho-nathocs and you know every year I don't think you'll get busier but it does every year it's getting busier and busier and again now I have a fellowship in ortho-nathoc surgery for the last five six years and you know on top of training residence and so it's great I mean I have no complaints do you have a recollection of your first ortho-nathocase with Dr. I do I mean I was an intern and the one thing I remember is that back then we had a CD player you know a boxer the CD player and speakers and one of the things I was in charge of was making sure the order of CDs were to his liking and it was mainly Jimmy Buffett back then

1:03:29but you know we listened to a lot of Jimmy Buffett in the OR but that's one of the things I remember you know the other thing I remember is we did a lot of stuff with Archbars as well which was interesting so it was definitely a very different mindset and time and a lot of the basic principles are still the same but things have changed and as it should you know we evolve healthcare evolves surgery evolves and you know I think a lot of things have evolved but you still need to know the basics but again as I said it's it's probably one of the most profound things I do in the states well I think it's amazing you may have gotten here you know from a different pathway but the influence Dr. Roser the work ethic all the things that he instilled you know to you as a resident is just pretty incredible so Steve as we wrap this up you really produced is like almost his your child you really produced a thoroughbred so I just like if you have any words as we come to an

1:04:30end here regarding Shaheed and what he's meant to the profession he's just a recipient of in 2017 I think the humanitarian award from Amos so not only has he become a renowned surgeon but he's given back and I think you know giving back is so important you know that's one of the aims of this podcast is trying to give back to the profession and try to discuss issues going forward that are important and because I think we have the best profession in the world and I like to see that you know maintain so any parting words Steve thank you Bruce and thank you Shaheed for you know making me so incredibly proud I remember a case that you and I did but I stepped away and you were a senior and you took and I can't remember who it was through the case and I just was you know my heart was was just so gracious and happy that you're a fantastic teacher

1:05:38and so I knew that you would you would go on to an academic career but what you've done is just just amazing totally amazing but what you've done I mean you're so far ahead in global surgery for cleft for cleft care with with the comprehensive surgical treatment that you've not been able to to model and and when people come to me to talk oral surgery residents come to me to talk about you know global surgery I I refer them to smile bang with dash and to to your model and to call you if they have questions so you've done us proud you've you've done Columbia proud you've done Harvard proud and you know you if I passed off the face of this earth tomorrow I would be I would be a happy man because I had some something to do with with your career and and the lives that you've touched as you've said so thank you Shaheed I'd really be remiss if I didn't mention two things I want your opinion on the NFC East and your Eagles and how do you think the

1:06:44season will play out you know unfortunately for the Giants fans I heard Jackson Darts out for indefinitely and so that opens things up for the Eagles you know the Cowboys look better than they have in a while granted there's only been two games and the one thing that an eagle in giant fin has in common is our hatred for the Cowboys so the hope is that you know they will implode as they normally do and the Eagles will then easily make it through and win the East the question will be can they beat a team like Seattle can they beat a team like the Rams I'm not sure you know but the fact that they won two Super Bowls in my lifetime is two more Super Bowls than I ever thought I would see so I'm very content I'm very content all right and the last question is what's it about Costco it could you tell us you know the listeners you must have some like inside tracked when you go and how that all works out you know I've been a Costco member from you know 25 years and it just

1:07:47is a great value it's a great you know it just makes sense viscally to shop there and the hot dogs you know I love the hot dogs and they are the best value meal in the United States they've been a buck 50 forever and you'll never be able to find something that beats it and you know it's a great place to go if you want to get the crap but bite the eagot dinner whatever I will I think if I ever decide to retire I would consider maybe trying to work their part time just for the experience and the free hot dogs hopefully but you know that would be that would be something but yeah it's it's such a great store I mean everything about it makes sense to me all right well listen I think we can end on that note I think we all got to go to something to eat right now making me making me hungry but I want to thank both of you this is important I think you know you become a leader in our profession Shaheed and you're really I mean the fact that you how much you give back you know your foundation smile bangl dash is really I mean I think it's sort of setting the template for

1:08:53other mission trips you know for different countries and I hope people you know can follow in your footsteps but thank you again I think this has been illuminating and Dr. Roser is always nice to see you and I love your friendship and camaraderie with Dr. Aziz and it's really special to learn about you know both your paths so thank you again and have a good evening and I really appreciate your time thank you very much thank you very much thank you thank you very much thank you