Nineteen years, three fellowships, and what nobody told me at seventeen

I became a consultant in January 2021. I was thirty-seven years old.

I started dentistry in October 2001, when I was seventeen. Five years of BDS with the internship. Seven months writing entrance exams. Three years of MDS in oral and maxillofacial surgery from 2007. A cleft fellowship in Bangalore in 2010. Then six years of MBBS. Then Hannover for two months. Then Melbourne. Then Oxford, finishing November 2020.

Nineteen years and one month.

I want to put that number down at the start, because nobody put it in front of me and I would have liked to see it. Not to be frightened off. I would do all of it again, but to see the shape of the thing before I walked into it one door at a time.

This is for the trainee in India trying to work out what comes next: what a fellowship actually is, what it is not, and how you end up somewhere that will make you into a surgeon.

I was not good at dentistry, and I stayed anyway

Let me start where I actually started, which is not flattering. I wanted to do medicine. I did not get the seat. So I joined dentistry, the most cliche answer you will find from anyone who becomes a maxillofacial surgeon, and it is mine too.

And then I was not good at dentistry. In my first year I had a chance to shift into medicine. The door I had wanted was open again, and I did not walk through it. Partly that was naive, because my friends were there. But the other part I still stand by. I was not good at dentistry and I was already giving it everything I had. Leaving would have meant walking away from the one thing I had not yet learned to do well. I wanted to find out whether I could get better at the stream I was already in.

So I stayed, and I worked hard. I really worked hard to get my skill sets better. I meet a lot of young dentists who believe everyone else started off gifted and they alone are struggling. I was not gifted. I was offered a way out in my first year and I stayed, and I got better. That decision is the reason for everything that follows.

Then in third year, at a conference, I watched an oral and maxillofacial surgeon present a case series, complex reconstruction, surgery after surgery on the projector, and I sat there thinking, is this even possible? His name is Dr Sherry Peter. He had a long set of post-nominals: medically qualified, orthodontically qualified, and then maxillofacially qualified. Seeing that a person had done it made it possible. From that afternoon I wanted maxillofacial and maxillofacial only.

Seventy-two

I wanted craniofacial surgery. Clefts are part of craniofacial deformity, so clefts had to come first. In 2010 I approached Dr Krishnamurthy Bonanthaya, my mentor, and now my colleague, my friend, my guide, and asked if I could do some cleft training with him. He told me they had just started a fellowship programme and I should apply. I did. I got in. First batch of RGUHS fellows.

That year I finished with seventy-two cases in my operating log. Seventy-two. Not observed, operated. My hands, my decisions, my complications to sit with afterwards. In Bangalore. Not abroad.

That year taught me the one thing I really know about this profession. The degrees do not count. People ask me about mine and I discount all of them. It is what I can do that matters, not what is on the paper. The certificate was never the reason. It is just what they hand you on the way out.

So when a young surgeon asks me whether some fellowship is worth doing, I never answer about the title. I ask: what will you be able to do at the end of it that you cannot do now? If you can answer that in a sentence, it is a fellowship. If you cannot, it is a certificate.

And the reverse holds too. Maxillofacial surgery is a broad field, and there are more fellowships scattered around the country now than when I started, of very different quality. You can also get real training somewhere that never calls itself a fellowship at all, from the right mentor, with enough time. That counts. That counts fully. I know this cuts against my own CV. It is still true.

Then I was told I did not fit the bill

While I was still doing the cleft fellowship, I was already applying for the next one. I wanted craniofacial. I had a mentor who would vouch for me, I had cases, and I was ready to go.

The answer came back: I did not fit the bill. I was not medically qualified.

That is when I realised I had to do medicine. Not as a spiritual awakening, but as a door closing in my face, with a specific reason written on it. At eighteen I was offered medicine and turned it down to stay in dentistry. At twenty-seven I went and did it anyway, six years of it, because craniofacial surgery required it.

Because it is only in India that maxillofacial surgery is a single-degree specialty. In the UK, Australia, most of Europe and parts of the USA, it is dual. We say proudly that maxillofacial surgery is the bridge between dentistry and medicine, but you cannot be the bridge between dentistry and medicine if you are only qualified in one of them. If I ever wanted a fellowship abroad, the certificate was not optional. So immediately after my cleft fellowship, I dived straight into medicine. Six years. Full grind. No discount, no accelerated programme, no bridge course.

Sitting in first year at twenty-seven

For the first three or four months I did not tell my batchmates I was older than them. Then somebody in the management leaked it: this fellow is already BDS, MDS, and it went through the class like wildfire, and the tough time started.

I mention this because the fear of going back is mostly imaginary. It is a story you tell yourself about humiliation that does not really arrive. What arrives is anatomy, physiology, microbiology, and six years of work.

And here is the part I did not expect, which I now tell every dentist who asks me about this route. Do the MDS first, then medicine. Not the other way round. From the outside, those six years look like nothing. No new title. No promotion. But every year there was a conference in the specialty, and every year I went. I would go to my hospital, do some cases, present them at those meetings. So the fraternity kept seeing me, not as a student who had disappeared, but as the fellow who was doing medicine on purpose. My colleagues expanded. My value went up, slowly, in a way that showed up nowhere on my CV until it suddenly did.

If you do medicine straight after BDS, the specialty does not know you yet, and then you genuinely lose those six years. Do the MDS first and the six years cost you nothing but time. What those years actually gave me was smaller and more practical than people assume: a vocabulary. When I sit with an anaesthetist or a paediatrician now and we talk through a case, I have the right language. That is all it was, a shortcut to being understood by the people whose help my patient needs.

The doors that were shut

By 2016 I had finished medicine. Dual-qualified, cleft fellowship, and I still could not change the shape of a child's head. That was the whole point of the exercise, and I still could not do it. So I applied again.

A word here about craniofacial surgery in India. It is a loosely used term. Search for it and you will find a great many people offering it. The real thing is learned in units where the volume is high enough, where a fellow might see a hundred to a hundred and fifty transcranial cases in a year, and there are very few such units anywhere in the world. The UK has four for the whole country.

I applied to the Royal Children's Hospital in Melbourne for craniofacial surgery. The answer was no. That fellowship was open only to plastic surgeons. In 2017 I went to Hannover for two months as an AOCMF observer. It was worth doing, but I never mistook it for training. Two months of watching did not make me anything. It was an introduction.

Stop watching the pianist

Melbourne came in 2018. I was the only fellow in the largest oral and maxillofacial department in a children's hospital. I assisted on over two hundred orthognathic surgeries that year and did the cuts and the fixation myself under supervision, first assistant on every major distraction and reconstructive case the department did. And I still could not change the shape of a child's head.

So I applied again during the Melbourne fellowship. Two units in the UK said yes. I chose Oxford. I went to a plastic surgery unit, August 2019 to November 2020, the only fellow in the Oxford Craniofacial Unit, one of four NHS centres for the whole of the United Kingdom, a maxillofacial surgeon in a plastics department, under Mr David Johnson. That was the best year of my life.

David Johnson said something to me at Oxford that I have not managed to improve on since. You can watch a pianist play for a thousand hours, but it is only when you start playing that you will learn. Surgery is like that. He was telling me to get on with it. That is what a good unit does: it puts you in the chair before you feel ready, and stands close enough to catch you.

You can acquire knowledge by watching. You cannot acquire judgement by watching. Judgement is built when you are the one responsible, you are not sure, and you have to decide anyway, with someone senior close enough to tell you afterwards where you were wrong. That is the whole difference. It is not the country. It is not the letterhead. It is whether you are the one at the keyboard.

Where I am now, and what I actually want

I became a consultant in January 2021, two months after Oxford ended. I joined Dr Bonanthaya, in the unit where I did my cleft fellowship, as the third consultant for cleft and craniofacial anomalies. Nineteen years to walk back into the building I started in.

The craniofacial work has taken off, around twenty of those cases a year now, alongside forty or fifty jaw surgeries, in a department that treats six hundred children. I give you those numbers for one reason. In 2016 I was dual-qualified, cleft-trained, and could not change the shape of a child's head. The capability I have now did not arrive with the Oxford certificate in November 2020. It arrived slowly, afterwards, case by case, for five years.

That is the thing nobody tells you about fellowships. They do not make you a surgeon. They give you permission to start becoming one.

There is still a gap between what I can do and what I can offer. Most of these children cannot afford treatment. My aspiration is a children's hospital in Bangalore that is free, not just for my procedures but for everything a child needs. I have worked in two children's hospitals in the world now, Royal Children's and Oxford, and I want that here, and I want it free.

What I would tell you

Everything you can imagine can be made possible, but you have to believe it first. It takes shape here before it takes shape anywhere. I am proof of that, and I am not clever, I just kept believing it while I did the boring work.

Your shoulders will drop. You will feel dejected. You will hit what look like dead ends. I hit one during my cleft fellowship when I was told I did not fit the bill, and it cost me six years of medicine. I hit another when Melbourne said plastic surgeons only. None of them were dead ends. They were hurdles. I did not take the longest route on purpose. I took it because the doors I wanted were shut, and each time I went and found out what it would take to open them. That is the only method I have.

So train well. Invest time in training, not in certificates. Keep chipping away, even if you are a BDS: do a course, read something, update yourself. Incremental growth is the only kind there is, and it is almost always invisible while it is happening. And do not count the years. Only in India do we think eighteen means university and twenty-eight means settled. I was thirty-seven when I became a consultant. I am not late. There is no late. Healthcare keeps evolving. If we do not upgrade, we will be fossilised.

Dr Dipesh Rao is a dual-qualified maxillofacial surgeon in Bengaluru specialising in cleft, craniofacial and orthognathic surgery. He completed a cleft lip and palate fellowship at Bhagwan Mahaveer Jain Hospital, Bangalore (2010 to 2011), a fellowship in Paediatric Maxillofacial Surgery at the Royal Children's Hospital, Melbourne (2018 to 2019), and a Royal College of Surgeons accredited fellowship at the Oxford Craniofacial Unit (2019 to 2020). Read more about Dr Dipesh Rao.

Frequently Asked Questions

What is the difference between a surgical fellowship and a certificate?

A real fellowship changes what you can do. If you can name in one sentence a skill you will be able to perform at the end of it that you cannot perform now, it is a fellowship. If you cannot, it is a certificate. The value is in the operative training and judgement, not the title on the paper.

Is maxillofacial surgery a dual medical and dental qualification?

In India maxillofacial surgery is usually a single-degree specialty, but in the United Kingdom, Australia, most of Europe and parts of the USA it is dual, requiring both dentistry and medicine. Dr Dipesh Rao is dual-qualified in dentistry and medicine, which is required for international craniofacial fellowships.

Where did Dr Dipesh Rao train?

Dr Dipesh Rao completed a cleft fellowship in Bangalore, a paediatric maxillofacial fellowship at the Royal Children's Hospital Melbourne, and a Royal College of Surgeons accredited fellowship at the Oxford Craniofacial Unit, one of only four national craniofacial centres in the United Kingdom.