Are you a special kind of doctor?

John Competing in the 2016 New York City MarathonJohn Competing in the 2016 New York City Marathon

Dublin Dental School graduate Dr John Ahern on his decision to study medicine and his route to Harvard

An elderly female patient asked me the question in the headline of this article during one of my night shifts in St James’s Hospital Dublin, late in 2015. In 2010, I had treated the same patient in the accident and emergency department of the Dublin Dental University Hospital when she presented with a dental abscess. In early 2012, I carried out an emergency root canal treatment for her when she happened to present as an emergency to a dental clinic where I worked in Dublin city centre.

Then, in late 2013, another chance meeting occurred when I was on placement as a fourth-year medical student in her primary care practice, where I was asked to take blood from her, and give her the flu shot. I guess it was only a matter of time before our paths would cross again, so when I was called to see a patient in the middle of the night in St James’s hospital, I remember she looked at me suspiciously and, after I had finished the bedside procedure, she said: “You seem to be hanging around in lots of different places, are you a special kind of doctor?”

Multi-tasking

Since qualifying as a dentist in 2010, I’ve worked either full-time, or part-time during medical school, in a variety of hospital-based and community-based settings. Both of these settings demonstrated a need to integrate oral health with primary care.

I can remember a period during medical school when, during the day, I was on placement in a primary care practice in Dublin and, during the evening, I would go and work as a dentist in a nearby dental practice. Both practices were treating the same population of patients, who were exposed to the same types of risk factors and with the same spectrum of common, systemic diseases.

Generally, the patients presenting to the dental practice were presenting with advanced oral disease. However, the patients presenting to the primary care practice seemed to take a more fastidious approach to their systemic health management, and attended proactively rather than reactively. The patients presenting with advanced oral disease would often have had multiple visits to their primary care practice in the preceding months as part of their chronic disease management, which presented the primary care clinician with a fantastic opportunity to promote oral health and encourage these patients to engage with an oral health professional, especially given the presence of common risk factors.

In my hospital-based role, I encountered a lot of oral cancer cases. I worked primarily in the emergency department, and it was not uncommon to see a patient presenting with a tumour in the oral cavity, which may have been misdiagnosed in the primary care setting for some time, which further delayed the diagnosis and, of course, impacted the patient’s overall prognosis. These patients were usually smokers and drinkers suffering with other chronic diseases, and yet they had not engaged with an oral health professional at any stage, despite access being available for the majority of these cases through the Irish medical card system.

I found that what all of these cases had in common, was a lack of oral health input from the primary care team, which is understandable, given the absence of oral health training for primary care clinicians, or non-dental health professionals generally.

Branching out

My decision to study medicine after dentistry was an enormous one, because I was very content working as a dentist. It had so many benefits, so I really felt like I was giving up something significant. Growing up I loved school, but looking back, I think I took school somewhat for granted and tended to think of it more as an extra-curricular activity, while I focused the majority of my thinking and energy on sports, especially competitive tennis, which required a lot of hard work and travel.

I think this lifestyle influenced my career choices heavily at that time. I decided that I wanted to be a pharmacist or a dentist because I felt those professions afforded a flexible lifestyle. At the time, one of my sisters was working regular hours as a pharmacist and playing international hockey, so I naively thought I would try to emulate that model and essentially prolong my adolescence into adulthood! My parents encouraged me to study law or medicine, but I didn’t like the idea of either, so, of course like most teenagers, I didn’t listen to their advice.

In my second year of dentistry at Trinity, one of my siblings announced she was getting married in June, right in the middle of my summer exams. So I thought, how am I going to get around this unfortunate calendar clash? At that time, students who scored higher than 65 per cent in the foundation scholarship examinations were awarded exemptions from their summer exams. Those who scored higher than 70 per cent were put forward for election to scholarship, which is something I had not considered at the time.

In April, I found out that I had got the exemptions from my summer exams, so I knew I could enjoy the family wedding without worrying about an immunology paper the next day. On 14 May 2007, Trinity Monday, I found out that I had been awarded the scholarship. I had focused so much on the process rather than the outcome that I really had not thought about what it might feel like to win this amazing scholarship. It really changed the way I envisaged my future career. I felt a responsibility to do something more and not to take this fantastic opportunity for granted.

After sitting my final dental exams in 2010, I was offered one of the house officer positions in the dental hospital. This was a wonderful opportunity, usually attracting those who were interested in pursuing specialty training. Through my work in the dental hospital, I was introduced to a group of dual-qualified teaching clinicians, all of whom were working in the field of oral and maxillofacial surgery, pathology and medicine. I was really inspired by their breadth of knowledge and array of skills. So, I decided that I would pursue dual-qualification, with the hope of working in this field in the future, specifically head and neck pathology.

The scholarship I had won some years earlier essentially supported my three-year medical degree, which made my decision to return to full-time study so much easier from a financial perspective.

Leadership and public health innovation

During my house officer year, I was also fortunate to be part of the first National Mouth Cancer Awareness day in Ireland. This day was without a doubt the best day I have ever spent in the dental hospital. There was such a positive energy in the building that day, thousands of people poured through the doors, everyone from students to staff helped out.

I remember I was in the West Clinic carrying out oral soft tissue screening examinations with several other house officers and consultants. It was just an amazing experience, and it was great to see all disciplines working together. This initiative inspired me to pursue a part-time masters degree in public health, because I wanted to lead my own studies in the future and contribute on a broader scale to population health.

By pursuing dual-qualification in medicine and dentistry, I was focusing my energy on the oral and maxillofacial milieu, which is an amazing discipline of medicine and dentistry. It is also, however, very specialised, with the clinicians usually based in a secondary or tertiary care setting. The potential, therefore, to have a direct impact on population health may be impacted by not working as front line primary care clinicians.

Having expressed these views to my mentors, I was encouraged to combine my clinical, teaching and research experience in both medicine and dentistry, to design a population health project, which would improve the capacity of non-dental health professionals to integrate oral health with general, systemic disease management.

Although not a head and neck pathology project as such, as a dual-qualified clinician, I felt a responsibility to push for this project to happen. The majority of head and neck cancers in Ireland arise in the oral cavity; it is difficult to advocate for mouth cancer awareness among non-dental health professionals without extending a broader appreciation of what oral health means, and how it links in with other commonly encountered systemic conditions and shared risk factors. The mouth is part of the body, oral health is part of general health and dentistry is part of medicine.

Fulbright Scholarship to Harvard

What was meant to be a summer project in 2014, turned into a doctorate degree and a Fulbright Scholarship to Harvard.

The summer preceding my final year in medicine, I worked as an intern at the World Health Organization’s Department of Oral Health, working specifically on oral health integration in medicine, which was topical at the time and has become increasingly so since then. Following this internship, I had organised an elective in oral pathology at the Brigham and Women’s Hospital in Boston. While in Boston, I was introduced to some of the Harvard faculty who were just beginning to talk about oral health integration in medicine, and given my recent work, they were very eager for me to join them in their project.

When I returned to Ireland after that visit to Boston, I was updating Professor Stephen Flint about my recent activities at the World Health Organization, and telling him my goals for the future, which involved working with Harvard. He sat back in his chair, put his arms behind his head and, just when I thought he was going to tell me to stop wasting my time, he leaned forward and said: “John, this is a fantastic idea and it screams Fulbright.”

Naturally, I was thrilled to receive this glowing endorsement, and he, along with some of my other professors and consultants, including Dr Mary Toner and Professor June Nunn, who was dean at the time, fervently supported my application for a Fulbright Scholarship. I was already familiar with the Fulbright Program, as one of my head and neck pathology mentors, Dr Esther O’Regan had won a Fulbright Scholarship several years earlier, to carry out research on oral cancer.

She also served as a great support during the application process, which was quite tough, as there were numerous essays and an interview, which really sought to examine who you are as a person, and not just through your professional life, but also through your extracurricular activities and personal life. I found out much later that Professor Flint was also the person who told Dr O’Regan, the only other medical/dental Fulbright Scholar, that she should apply several years before then, so the moral of the story is, if Professor Flint tells you that you should apply for a Fulbright Scholarship, don’t ask questions, just do it!

The Fulbright Program is a prestigious international scholarship, which was very helpful to me when promoting the research question of how to integrate oral health with primary care. At first, I was getting mixed messages from both medical and dental audiences and I was even told by one medical doctor at a conference in England that the idea I was promoting was “very controversial”.

This is something I had not been accused of since I was a prefect in boarding school, when I suggested that senior students should be allowed to stay up later at night than the junior students, so that we had more time to study. So ironically, here I was again, 12 years later, causing controversy, and still in the name of education and learning.

Winning the support of the Fulbright Program was a very significant milestone, as it provided me with a platform to promote this idea on a larger scale and to a broader audience. It also encouraged people to engage more with aspects of the research, and it certainly fostered a greater interest from important stakeholders.

Time in Boston so far

I arrived in Boston immediately after completing my intern year as a medical doctor. A few weeks prior to my arrival, I had received a rejection letter for funding from the Irish Health Research Board. This was hugely disappointing, as my application had received a very positive international peer review, and yet the rejection letter was quite pointed, which caused me some concern about the future of the project in Ireland.

However, at the same time this was happening, the Harvard School of Dental Medicine and the Harvard Medical School had received a $3.5 million grant to support the integration of oral health with primary care, the very same title as my own project in Ireland.

This was hugely rejuvenating and encouraging, because although I had been unsuccessful in securing funding for my project in Ireland, I was now afforded the opportunity to work on the Harvard-based project during my Fulbright.

I have learned so much during my time in Boston, because the door is always open to you as a Fulbright Scholar, and faculty are always eager to offer mentorship and build relationships. The idea of integrating oral health with medicine is extremely well developed in the US. Just recently, I presented some of my own work at the “Oral Health Integration in Medicine” conference hosted by Harvard, where hundreds of delegates from across the US attended.

It has been an incredible opportunity to gain feedback from experts working in this area, and I have made many new connections in the field. That has been the most valuable part of the Fulbright experience, the ability to make many meaningful connections across the Harvard network, and internationally.

As part of my Fulbright experience in the US, I volunteered some of my time to local projects at Harvard. I also decided to run the New York City Marathon in aid of the Miles for Miracles charity at Boston Children’s Hospital.

There is a huge culture of volunteering among staff and patients at the Harvard hospitals, and it was a great way to meet people working all over Boston.

Running a marathon was somewhat symbolic in respect to my route to Harvard; plenty of challenges along the way, moments where you rationalise giving up, but ultimately persevering to cross the finish line and reflecting on what was a very rewarding pursuit.

I firmly believe that non-dental health professionals will start to play a more important role in oral health, both in Ireland and the rest of the world. Whether it is mouth cancer awareness and referring at risk patients for oral soft tissue screening, improving diabetic care by incorporating oral health with overall diabetes management or simply fostering a greater capacity for interdisciplinary collaboration. Truly including dentistry as part of the health care team in a meaningful way will improve the profession of dentistry and the health of the population it serves.

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