Continuing Medical/ Dental Education- Do the statutory bodies have jurisdiction?

 

The simple answer is NO! In my opinion any public notice to the effect by statutory bodies is probably ill- advised or a wrong understanding of the Dentist Act 1948 and the Regulations made by it as per 20 (1). It certainly must be ratified or challenged in a Court of Law.

Let me explain. Continuing Education is an absolutely necessity not only in health care but also in all professional arenas. I completed my post graduate training in 1986, nearly 40 years ago. What I learnt at college is not what I practice today. It has qualitatively and quantitatively evolved over the last 4 decades to keep pace with innovation, new skill sets and advanced technology. I am sure this is the experience of all professionals.

How did we acquire new skills? Obviously, by attending courses and workshops meant to upskill and adapt to newer methods. Continuing education also helps us fill in the gaps during training and produce better doctors. This is a boon to the public in accessing uniformly better and safer healthcare.

Recently more than one State Dental Council has issued a public notice prohibiting the conduct of continuing education by individuals or associations without taking prior permission of the Dental Council. This public notice is ostensibly based on the Code of Ethics regulation 2014 which was further amended to include CDE points as a mandatory requirement. The amended clause also provides direction to clarify the qualifications for the CDE provider. Let me quote the relevant provision of the gazette notified regulation no which came into effect in 2018.

Section 2 (b) defines a service provider to include all DCI /MCI recognized institutions having dental departments, government bodies and Armed Forces. Professional bodies such as Professional Associations and National Specialty Associations will need to apply to the DCI/ State Dental Councils for award of CDE points for meeting and conferences held under their aegis and this approval will be valid for a period of 5 years, subject to review.

The CDE points as per 6 (1) of the same regulation also says that there should a CDE credit system in India and each and every dentist shall inform the State Dental Council from time to time otherwise (SIC), it would amount to violation of the provisions of the ‘Revised (Code of Ethics) regulations 2014

For reasons best known to the DCI and State Councils the central theme of mandatory CDE points were never carried out in the last 7 years. In the absence of CDE requirements, where does the issue of the qualification for the provider arise?

Does this not mean that the regulation (DE-226-2017) is not implementable or was abandoned for the last 8 years? The old system of non –formal workshops and lectures can and should be continued in the interest of knowledge acquisition and continuing education.

Even if valid, a regulatory body can lay guidelines for acquisition of CDE points to fulfil regulatory requirements on those who wish to renew registration. The statutory body cannot prevent one qualified registered practitioner teaching another qualified registered practitioner any skill or technique or emerging treatment modality. Therefore, it is clearly outside the jurisdiction of the statutory bodies if no CDE points given or degree/ diploma is awarded.  The Dentist Act (the document of maximum reliance) only talks about recognized qualification. In fact, The Code of Ethics 3.2 encourages learning with the exhortation that “They should try continuously to improve medical knowledge and skills and should make available to their patients and colleagues the benefits of their professional attainments. and in fact encourages dentists to update their knowledge”. Implantology, for example, is not a recognized stand alone specialty. Dental surgeons became implantologists by learning it from the pioneers. Today it is a robust branch of dentistry, practiced by dental graduates, although it was not taught in dental colleges.  If the knowledge provider is spending time and resources on training, it is justified that they charge a cost towards imparting knowledge or skill.

In the final analysis it must be remembered that the Dentist Act of 1948 (with amendments) is to be relied upon if there is a conflict between the Act and regulations made by it. The Dentist Act  of 1948 and all amendments thereafter only refers to regulating registered qualifications like BDS, Dental Mechanics and Dental Hygeinists. If the Dental Council did in fact want to address the issue of non- registrable qualification it could have been done when amendments were instituted in 1992, 1993, 2016 and 2019. The issue was never addressed.

I sincerely hope that the National Dental Commission will address these issues more reasonably and allow flow of knowledge in the best interest of the profession and the public rather than drag these issues in court.

Caveat: the author George Paul has no vested interest in the matter as he does not conduct any courses or training.

The War Over Facial Aesthetics: Who Truly Holds Expertise?

 

Introduction

The question of whose domain facial aesthetics falls under is both a million-dollar question and a matter of professional identity. As an Oral and Maxillofacial Surgeon (OMFS) with a legal background, I bring a unique perspective to this debate.

Background in Oral and Maxillofacial Surgery

My training path has been through dentistry. To clarify, maxillofacial surgery is a specialty within dentistry, with varying international mandates regarding its scope and privileges. Contrary to popular belief, only about 10-15% of global OMFS practitioners require dual qualifications, mainly in Europe and Australia. In many countries, including India, a single qualification in dentistry is sufficient to practice this specialty. This is also true for many regions in China, Japan, South Asia, South America, Africa, and Russia. Any shortfall in the dental curricula is typically addressed through additional training in maxillofacial surgery.

It’s important to note that I do not perform aesthetic surgery and have no vested interest in this debate. However, I wish to emphasize the unique standards and requirements of Oral and Maxillofacial Surgery and its scope.

Evolution of the Specialty

At the time of my qualification, the core focus of my specialty included the surgical removal of stubborn teeth, jaw cysts, treatment of facial bone fractures, and surgery of the temporomandibular joint (TMJ). Over the decades, the field has evolved into a sophisticated specialty. Many practitioners, like myself, have exclusively practiced oral and maxillofacial surgery while remaining rooted in our foundational training in dentistry.

Dentistry itself is a demanding field, with a curriculum that includes essential medical sciences, enabling practitioners to treat patients safely and effectively. The culmination of this training results in a degree called Bachelor of Dental Surgery (BDS).

Interdisciplinary Perspectives

I have many talented physician colleagues, including dermatologists and plastic surgeons, who have also evolved their skill sets over the years. For instance, dermatologists have expanded from diagnosing skin conditions to performing cosmetic procedures. Although dermatology is a medical specialty that typically follows an MBBS degree, it now includes surgical interventions.

Defining Key Terms

A contentious issue is whether facial aesthetics falls exclusively under any one specialty. Before sharing my opinion, I would like to define some commonly used terms in our discourse:

1. Aesthetic Procedures: This term has sparked debate among specialties due to varying interpretations. Aesthetics, which emerged in English medical terminology in the 19th century, refers to the appreciation of beauty. In medical terms, it often relates to cosmetic beauty, including structural features such as the mouth, nose, eyes, and ears. It is much more than the just the skin.
2. Cosmetic Procedures: This broader term includes any intervention designed to alter or enhance appearance. It encompasses a wide range of practices, from eyebrow threading and makeup to surgical options like facelifts and orthodontics.
3. Plastic: The term "plastic" means "to mold" and is often misinterpreted as solely relating to plastic surgery. While plastic surgery has historical ties to specific specialists, many procedures—such as cranioplasty and urethroplasty—are performed by various medical professionals, including neurosurgeons and urologists. Pure dentistry itself has very challenging plastic procedures like gungivoplasty, mucosal grafts and use of botox and fillers.

Shared Responsibilities in Aesthetic Procedures

The National Medical Commission (NMC) and the Dental Council of India (DCI) have not defined exclusivity regarding individual procedures. Therefore, any assumptions about who performs what procedures are largely arbitrary and speculative, driven by a narrow view of ownership.

The ongoing "turf war" highlights the complexities of medical regulation in a country with diverse systems of medicine and multiple regulatory bodies.

1. Understanding Competence: The distinction in training and statutory competence between dermatologists and oral and maxillofacial surgeons is crucial. While both specialties have overlapping areas concerning facial aesthetics, the differences in their training pathways and regulatory frameworks must be acknowledged. This brings to light the need for a more nuanced understanding of the specific competencies each specialty brings to aesthetic procedures.
2. Regulatory Framework: The fact that the NMC and the DCI (soon to be NDC) operate under different legislative frameworks presents challenges for practitioners and patients alike. It raises questions about the clarity and consistency of regulations across different medical disciplines. There may be a need for inter-regulatory dialogue to establish clearer guidelines on who can perform aesthetic procedures, which could help mitigate conflicts.
3. Legal Interpretations: It is necessary to understand the absence of specialty registers in India. This is indeed significant. This gap in the regulatory framework allows for a broader interpretation of who can perform aesthetic procedures. However, it also raises the issue of patient safety and the quality of care, as not all practitioners may have the same level of training or expertise in aesthetic procedures. The deficiencies are addressed in the curricula whether it be knowledge of surgery or dentistry. The Role of Circulars and Notifications: The distinction between regulations and circulars is an important legal point. Circulars, notifications and guidelines, are often interpretative and do not carry the same weight as formal regulations. This creates an environment where practitioners may feel uncertain about their legal standing and scope of practice, which can lead to professional discord. Some state councils have placed too much importance to them and have exceeded their mandate in imposing restrictions without considering the possibility of competence by training.
4. Public Safety and Standards: The ultimate goal should indeed be the provision of safe and effective healthcare. Establishing minimum training requirements and standards for aesthetic procedures could help ensure that all practitioners, regardless of their specialty, possess the necessary knowledge and skills to perform these procedures safely. The health ministry and regulatory bodies should prioritize public safety over professional rivalry.
5. Future Directions: There is an opportunity for stakeholders from both dermatology and oral and maxillofacial surgery to collaborate rather than compete. Developing interdisciplinary training programs or joint guidelines for aesthetic procedures could promote a healthier environment for practitioners and enhance patient care.
6. Legal Action and Challenges: It is important to understand that India does not have specialty registers like in many other countries. The post graduate courses are ‘add on’ degrees used as essential qualification for teaching at graduate and post graduate levels in recognized medical and dental colleges. The essential and sole registration for practicing medicine or dentistry comes from being in the books of the MBBS/BDS register in the respective States or with the NMC. In the absence of a specialty register one cannot technically be restrained from practicing the full scope of medicine or dentistry. In other words, any registered graduate can practice the full scope of their basic qualification. The MCI / DCI has in the past issued notifications and circulars restricting procedures to specialists. These are arbitrary and has gone unchallenged. This aspect needs a judicial review.
7. Restricting practice privileges: I wish to reiterate that notifications, memos and guidelines by regulatory bodies are not actionable laws. These are mere administrative opinions. So the notices issued by state councils threatening to debar practitioners based on these memos or notifications can be challenged in a court of law. Qualifications and competence are two different things and need to be evaluated differently. The regulatory bodies have no right in law to prohibit teaching or upskilling courses because it is always in the best interest of the public that medical professionals, irrespective of their qualification, acquire greater competence through continuing education.
8. Patient-Centric Approach: Ultimately, the focus should be on patient welfare and informed choice. Patients should be educated about the qualifications of practitioners and the procedures they are considering, allowing them to make informed decisions about their care.

We need a collective effort to enhance healthcare delivery rather than restrict it. This collaborative approach could lead to improved outcomes for patients and a more harmonious professional environment for all practitioners involved in aesthetic medicine.

George Paul MDS DNB LLB Dip. Med. Law

 

 

Dr Kishore Nayak's Foreword to the book 'Riding the Pale Horse'

 

Foreword

"There is no cure for birth and death save to enjoy the interval."

George Santayana

 

 

 

I have known George Paul for well over three decades now, and his writings and ruminations, over the years, on various subjects have always left me fascinated. When he sent me a copy of the manuscript of his book ‘Riding a Pale Horse’ and requested that I write a foreword, I felt honored.

 

Reading the manuscript was no trouble, owing to the ease with which it flowed. I realized that he chose to ask me for a foreword because he has mentioned me at least twice in his book. My opinions obviously mattered to him.

 

He has approached and covered a subject that many people may consider macabre. He has, in the past, researched and written extensively about the subject of death and mortality from the perspectives of biology, law and ethics. Amongst other aspects of death and dying, he has also revisited the concept of brain death, which is so imperative in this age of cadaveric transplantation. And so, this book comes as a natural conclusion and compilation of his experience on a seldom-written-about subject.

 

An incident I distinctly recall is George narrating an anecdote to me where a person approaches a wise man and asks him what the key to happiness is. The wise man hands over a piece of paper to the answer-seeker who is shocked to read, "Father dies, son dies, grandson dies." The man who posed the question, demanded how such a morbid set of phrases could hold the key to happiness. The wise man reportedly answered, "follow this sequence; it's the natural order and progression of life; grief will be temporary and pass. Break the order, and life will never be normal." This was profound indeed. Happiness relates itself to how generations progress and pass on. It fails to account for numerous factors such as social standing, religion or wealth. Death, inherently, serves as a profound equalizer.

 

George had no qualms in telling me that he would like me to write the foreword for the very reasons he had mentioned me in the book. Since 2007, I have weathered numerous encounters with cancer. As I pen these words 16 later, I remain standing, despite the enduring trials of extensive medical interventions and surgeries. Currently, I have had a relapse of multiple myeloma. While I am getting the best treatment possible, it is likely that things may not go as planned. I will consider myself very fortunate to see the publication and print edition of this book. Many ask me how I can be so pragmatic and stoic about a matter that has so much implication on me and my family. Well, in the grand scheme of things, the day we are born, we are also hurtling towards our deaths, and both are destinies over which we have little control. Death as a consequence of birth is the most singular and predictable event we experience, and the acceptance of both, should be a thing of beauty, not ignobility.

 

The book adeptly navigates the intricate theme of mortality with remarkable fluidity, rendering what might initially appear as a sombre subject into a palatable and enlightening discourse. As healthcare professionals, we frequently encounter instances where families opt to shield elderly patients from the gravity of their diagnoses, and justifying it with reasons such as "It will frighten them; there is no need for them to know." George’s work has the potential to challenge such antiquated perspectives. Regardless of age, patients possess a moral entitlement to be informed of their afflictions, affording them the autonomy to choose the most suitable course of treatment or decline it altogether.

 

An alternative perspective presents the opportunity for individuals to acknowledge that life's conclusion may not be distant and to strategically plan the remaining chapters of their existence in a manner that aligns with their personal satisfaction and preferences. This allows for the prioritization of relationships and the allocation of time and energy towards cherished ones. Naturally, this does not negate the possibility that optimal treatments, capable of extending and preserving the quality of life, may be available and warrant consideration.

 

Understandably, this stands in stark juxtaposition to the abruptness of sudden death, which has the capacity to leave families in profound despair and disarray. Amidst the shadows of such gloom, the resilience of humanity and the inexorable march of life persist. Over the course of millennia, life has consistently demonstrated its innate ability to persevere. This fundamental truth unfolds in the culminating chapter of the book.

 

I was a few days late in reverting to George as I was shuttling between the hospital and home in trying to seek solutions for my recurrent malady. All the while, I had been subconsciously and consciously contemplating the content of my ‘foreword’. As I took a break between treatment cycles, one morning, I casually picked up The Week, a magazine that one invariably finds in waiting rooms of Indian hospitals. In the opening pages, I came across a quote from the famous filmmaker and director Shekhar Kapur. "A lot of human endeavor is based on the fact that you won't be able to make it…the possibility of human failure makes human effort worthwhile, just as the possibility of death makes human life worthwhile."

 

In the matter of existence, where mortality and the inevitability of death are woven into the fabric of our individual narratives, George Paul's most recent literary offering, "Riding the Pale Horse," emerges as a profound tapestry in itself, promising to unravel a distinct and personal perspective for every reader

 

Kishore Nayak

Bangalore

20th December 2023

An Open Letter to Shri M K Stalin, Chief Minister Of Tamilnadu

 Respected Sir,

My name is Dr George Paul. I am a practising Oral and Maxillofacial Surgeon in Salem, Tamilnadu. 

This is to bring to your notice that there maybe ineligible candidates for the post of VC of the prestigious TN Dr MGR Medical University, who have been short listed.

I wish to inform you through this open letter that I am acquainted with the case of Dr S M Balaji who has been interviewed. He is ineligible ( ab initio) for consideration on account of the fact that there is a criminal case pending against him. I am bringing this to your notice for two reasons

1. I am a complainant and a petitioner in the case no. Crl OP 25521/2021 which was quashed but has now been recalled by a honourable judge of the Madras High Court and numbered as Crl MP no 17942/ 2022. 
2. Dr S M Balaji has been short listed and interviewed despite the objections raised by me to the Convenor Shri V K Subburaj on 8/ 05/2023 through e mail and speed post. 

The application form for VC requires a declaration that no criminal case should be pending against an applicant. There is clear violation by the candidate and the Committee which short listed him. I have withdrawn my candidature for VC before making this representation to avoid speculation as to the motive for my posting this letter. I have all the documentation to show the complete details of the case which involves criminal intimidation and criminal offences under the Information technology Act.

In fact Dr SM Balaji has admitted in Court on 23/12/2021 that his employee was made to write a defamatory and intimidating letter under a pseudonymous name in 2014, casting false aspersions on several eminent surgeons including me. In addition to this being a bar on his candidature, it is also a matter of moral depredation and such a candidate is clearly unsuitable for a responsible position in academia.

I wish to further express my sentiment, as a former teacher and present practitioner in TN, with a long relationship with the TN DrMGRMedical University since 1989, that the person selected to head the state university should be an accomplished teacher ( private or government) with experience in academic administration and should have an honest unblemished personal record of honesty, and should be free of any moral turpitude.

If one were to believe the newspapers and social media, it is clear that the decks have been cleared to appoint a pre- determined person. There may also be conflict of interest between members of search committee and the candidates.

I have been a long standing supporter of the welfare schemes of the Dravidian parties and the legacy left behind by the founding fathers of the state and others who followed them. TN has always stood up for social justice and welfare, particularly in the field of health. This is because of the excellent medical institutions and healthcare network laid down by several governments, including the DMK. 

It has also come to our notice that several eminent persons who studied and taught in Government Medical and Dental Colleges have been ignored in the selection process and don’t find a place in the short list prepared by the Search committee to be forwarded to the Governor and Chancellor of the University. This includes highly accomplished professors , administrators, Deans of Medical / Dental Colleges, Former and serving Directors of Medical Education and even serving Vice Chancellors in Deemed Universities. 

It is therefore surprising and out of place when private medical or dental practitioners are given charge of a University with more than 800 medical, dental, nursing, physiotherapy and other courses. The fact that some of them like Dr S M Balaji did not obtain their education through merit and actually took two attempts to pass his post graduate examinations is a reflection on their background. I do not know if there are others like him. He has never been a full time staff in any academic institution and whatever may have been shown as full time academic tenure in past or present applications is possibly fabricated. This is borne out by the fact that he has never been an internal or external examiner even once. Dr Balaji has also tried to do MBBS in a private Medical College, while working full time in his private dental clinic. He was forced to discontinue for want of attendance. 

It is therefore distressing to understand the compulsions that make a responsible government or search committee to even consider such a person despite his basic ineligibility on account of a pending criminal case.

It is still not too late and I hope that the Chief Minister and Governor will use their good office to ensure that an unsullied person with genuine academic credentials occupies this high office.

Thanking you

Sincerely

George Paul

F 72 Brindavan Road

Fairlands

Salem-636016, TN

Cc: 

Convenor Search Committee

The illegality of fixing minimum charges for medical services

Introduction:

Recently, several private medical and dental organisations have been attempting to fix minimum charges for services amongst their members. This has no doubt been fuelled by price wars in the practice arena. Most medical and dental professionals, despite cautions, are unaware that fixing minimum prices by organisations for its members is an illegal act as per the laws of the country. 

The minimum price fixing by organisations are being done on the pretext that the recently introduced Clinical Establishment Act requires all medical and dental practitioners to publicly display the charges for various treatments. What the private organisations do not realise is that the CEA was legislated not for the purpose of minimum charges but rather in the interest of transparency for the public who can make an informed choice on who to take treatment from based on their charges for service. 

The minimum charge fixation, in addition to being illegal, is also going to work against the interest of the members because those professionals who are not members of these associations are free to fix their own charges and can undercut them by declaring that they are willing to offer services at a lower cost. The associations do not realise that they are putting themselves at a disadvantage if the recommended cost is publicly announced. In fact even members of these associations, may in private, offer services at lower cost by citing the recommended fees. 

However, the bigger issue is that it violates established laws of the country and the associations are liable to enormous fines for cartelization ( forming groups to fix prices) under the Competition Law of 2002 enacted in Parliament in 2003.

What does the law say?

The competition law in India was legislated in 2002 to replace the Monopolies and Restrictive Trade Policies Act ( MRTP) of 1969. (1)

This law gives overreaching powers to the Competition Council of India ( CCI) to impose exemplary fines for violation of these laws. The law was created in line with similar laws around the world like Anti Trust laws in USA which is enforced by the Federal Trade Commission or the Competition and Markets Act ( CMA) or the Competition Act of the UK and European Union respectively. (2)

So what is Competition law in India?

The Competition Act, 2002, as amended by the Competition (Amendment) Act, 2007, follows the philosophy of modern competition laws. The Act prohibits anti-competitive agreements, abuse of dominant position by enterprises and regulates combinations which causes or likely to cause an appreciable adverse effect on competition within India.[3)

There are some features of this law which we must be familiar with. 

Cartelisation: This refers to any group that forms into a cartel ( group) to fix prices or in any way impedes the process of competition. So let us see how cartels are defined in Indian law.

Cartel:Cartel includes an association of producers, sellers, distributors, traders or service providers who, by agreement among themselves, limit control or attempt to control the production, distribution, sale or price of goods or provision of services (3)

This means that competition  should be a product of market forces and cannot be controlled by any group or organisation that forms into a cartel to fix minimum prices.

Predatory pricing:Predatory pricing means the sale of goods or provision of services, at a price which is below the cost of production of the goods or provision of services, with a view to reduce competition or eliminate the competitors.(4)

This is the opposite of cartelisation. No person or group of persons can charge abnormally low prices to drive other competitors out of business. An example is telephone companies charging low prices, even at a loss, to eliminate others from competition.

There are several other commercial clauses but these two are most relevant to medical practice.

Do doctors and other professionals come under this Act?

 In India, like many other countries, medical service comes under the definition of contract for services ( under section 2 (1) ( 0) of the Consumer Protection Act) and are therefore commercial services as decided in the VP Shantha vs IMA and others.

In the USA,  ‘It was generally assumed that professions, such as the practice of law or medicine, would be exempt from antitrust ( Competition Law) considerations. The 1975 U.S. Supreme Court ruling in Goldfarb v Virginia State Barwould change that assumption’(5).

If and when any medical association tries to fix minimum prices, it will be a violation of Competition Law and the organisation fixing these prices can face enormous fines. 

Who can punish for violation?

Any complaint with the Competition Council of India (CCI) by any person affected by any violation can prefer a complaint to the competition council. This maybe a member of the organisation who is prevented from fixing his/her own charges or a person from the public who feels that the cost of service has been escalated by an association of professionals involved in cartelisation.

It is the duty of the Commission to eliminate practices having adverse effect on competition, promote and sustain competition, protect the interests of consumers and ensure freedom of trade in the markets of India.(6)

What is the punishment for violation of Competition Act?

According to the Act the punishment for violation is as follows

If any person fails to comply with the orders or directions of the Commission shall be punishable with fine which may extend to ₹ 1 lakh for each day during which such non compliance occurs, subject to a maximum of ₹ 10 crore.

Further disregard can invite 3 Years imprisonment and upto ₹25 crores.(7)

Conclusion

Associations such as the Indian Medical Association and Indian Dental Association should refrain from forming into a group and fixing minimum prices, in the same way that Government agencies should stop fixing maximum prices. 

There are at least three reasons why fixing minimum charges will work against the members of these organisations 

1. It is illegal and the associations are liable for penalty.
2. Only 15% of dentists are members of the dental associations. Dentists who do not belong to the association will see an opportunity to undercut members of associations as they are not bound by their recommendations or dictates.
3. Private teaching institutions have started paid clinics as income generating measures ( due to low demands for seats). They fall outside of these recommendations and members will lose patients to these institutions that deploy their paid staff who can earn more with lesser profit. 

It is high time that the matter is carefully thought out before making recommendations.

References

1. https://en.m.wikipedia.org/wiki/The_Competition_Act,_2002
2. https://en.m.wikipedia.org/wiki/Competition_law
3. "Section 2(c) of Competition Act 2002". Indian Kanoon.
4. The Competition Act – Act No. 12 of 2003"
5. https://www.healio.com/orthopedics/business-of-orthopedics/news/print/orthopedics-today/%7Bb4d25dee-71a8-44ba-8006-b7089a8dc5a0%7D/physician-mergers-antitrust-law-are-often-complicated-for-individuals-groups
6. "About CCI | Competition Commission of India". www.cci.gov.in. Retrieved 19 November 2015.
7. https://en.m.wikipedia.org/wiki/The_Competition_Act,_2002

An open letter to my professional colleagues

 India has just emerged as the third most affected country in the world. Covid 19 has a remarkable recovery rate and the Government is doing a decent job of containing the epidemic. Experts say the worst is yet to come and the soft underbelly of our health system is likely to be exposed when our health infrastructure and our already burdened doctors and nurses can no longer cope.

It is time to bring in more manpower from allied health care professions. I am not sure of  the indigenous systems whose concepts of therapeutics and  pathology of diseases are quite different from that of modern medicine. But professionals trained in dentistry and who have a common pathway of training like physicians should certainly be mobilised. Amongst them, maxillofacial surgeons, with extensive hospital and ICU familiarity can certainly amplify the manpower requirements.

Many cities are already reeling under the lack of medical personnel to deal with the number of patients requiring critical care. Even hospitals with adequate infrastructure are unable to function for want of man power.

India has a serious anomaly where we have a deficient doctor patient ratio for medical doctors whereas we have an enormous surplus of dentists, due to poor manpower planning and business interests a decade and a half ago. So here is our opportunity to deploy hospital based dental or maxillofacial surgeons.

In fact some cities have already called up eminent maxillofacial surgeons and some like Dr Neelam Andrade, a maxillofacial surgeon and Dean of Nair hospital has been appointed head of one of the biggest dedicated Covid hospitals in the world in Mumbai.  The NESCO jumbo facility which has a projected capacity of 3000 units has 1171 fully furnished beds with bedside oxygen, advanced monitoring and resuscitation equipment. It also has an impeccable, 0 mortality. Dr Andrade, who also happens to be a friend and professional colleague, directs the logistics of managing the facility, from the control room and on the ground. This includes non- contact triaging, computerized tracking and ensuring the safety of 62 doctors, 87 nurses and 103 ward boys and  includes, pulmonologists, intensive care physicians, dental and maxillofacial surgeons and doctors from various other indigenous systems. We are proud of the outstanding contribution of Dr Neelam, one of our fraternity, a dynamic woman and a past president, who heads this operation.

While Universities like RGUHS and some other universities have given Interns, PGs and staff an option, we need greater mobilization. So why are so few dental surgeons, particularly OMFS not deployed for COVID duty at this crucial time? India currently has nearly 10-15000 registered OMFS with dental background. The DCI has nearly 400,000 dentists registered in its various state registers.  Many young men and women are enrolled for post -graduation while others are in private or government practice. The government must seriously consider deploying them in this emergency. The DCI must make a firm commitment in this time of need. The majority of them are currently sitting at home, allowing their skills to be wasted, waiting out the pandemic, while thousand are seriously sick around the country. As a first step, the oral and maxillofacial surgeons who are trained in administering intravenous drugs, monitoring vitals and capable of several bedside procedures must be mobilised. Other dental surgeons, particularly hospital based ones, can follow and contribute with their medical knowledge, particularly if they are not engaged in active work.

While several State governments have compulsorily enrolled the services of their staff, many private dental institutions remain closed with their staff safely ensconced in their homes delivering and listening to webinars and online symposiums.  

The Association of Oral and maxillofacial surgeons and the Dental Council of India must encourage the members in private institutions and even private practice to join the endeavour against Covid 19 by calling for volunteers and even compulsorily deploying post graduates and junior staff of OMFS to be a part of the war against the deadly pandemic. Apart from being a corporate responsibility social responsibility, this will bring dignity and recognition to the profession by standing shoulder to shoulder with our medical colleagues at this crucial juncture. On the part of the government, there should be incentives in the form of attractive remuneration, additional marks for NEET (for interns) and decent food and living condition.

Recognition for OMFS as an important surgical speciality has to be earned by our actions, not by just claiming parity and privileges without taking risks. I have volunteered. Have you?

Dr George Paul

Past Hon. Secretary, AOMSI

Past President AOMSI

Should Doctors in India be allowed to advertise?

Introduction

This is a question that has been asked repeatedly amidst the recurring debate on the ethics of advertising. While many seniors strongly object to advertisements by doctors, a new young generation of medical professionals have been increasingly strident on the right to advertise about who they are, what their qualification is, their strengths, special skills etc. The new notion comes in the wake of several developments and questions about the medical professionals between 1980 and 2000. The argument in favour of doctors being allowed to advertise or provide information to the public have largely been fuelled by the following issues

1. The question of whether doctors are commercial service providers?

2. The existing pattern in countries like India, where large corporate hospitals advertise, whereas private practitioners are hauled up for doing so.

3. The increasing pressure from the public for a right to know as a principle of autonomy

4. Competition laws in many countries that have come down heavily on the monopolies by certain groups and the fundamental principle embedded in the law to allow equal competition.

Historical perspectives and reason for change

All over the world, the code of ethics for doctor's have been changed to permit doctors to advertise in the public domain about their practice details. This comes from several legislations and amendments in the laws governing medical practice. In fact the Councils which implement Competition law ( also known as anti -trust laws ) have forced Medical statutory bodies and Medical/ Dental Associations to remove clauses against advertising in their respective code of ethics. This has been enforced through legislations in several countries including USA, UK, European Union, Australia, New Zealand etc starting in the early 1980s. Let us take an example of UK where the ethical guidelines were systematically dismantled in stages despite the opposition from the GMC/ GDC. It is a lesson that India should pay attention to.

Let us look at this excerpt, 'To consider the desirability of issuing a general warning notice to medical practitioners against the practices of canvassing and advertising or the purpose of procuring patients' (1). If these words sounds familiar, the chances are that you are practising as a health professional in India or one of the South Asian countries. The above advisory is a recommendation from the British Medical Association to the General Medical Council in 1905. The view that any kind of advertisement or marketing strategy is inconsistent with the practice of Medicine or Dentistry was widely held in England and most countries in the commonwealth till about 1983. While most developed countries have reviewed the code of ethics for those practising medicine, a few countries like India continue, as always, with the hangover of the colonial era. 

After 1983, matters began to change in Great Britain when a series of consultative meetings between doctor's associations and public organisations resulted in a movement for major changes in the policy. Much of this was translated into a revised guideline published in 1986 which relaxed most of the restrictions on advertising by doctors. This was mostly due to the pressure from patient's groups like the Patient's Liaison group of the Royal College of General Practitioners (2) , that wanted more information about services available and also from some professional groups that felt that the GMC ( the statutory body) should play a role to 'lead the profession rather than simply reflect established opinion'(1).

Some further relaxations were made on the basis of an acceptance that it was easier to control the contents rather than preventing the dissemination of information per se. By 1987 the Government bodies started taking an interest in the matter through The Office of Fair Trading ( OFT) and thereafter asked the Monopolies and Merger Commission ( MMC) to investigate into the issue of restricting advertisement by the statutory bodies. The MMC took evidence from  a variety of bodies representing both the professional and the public and published its recommendations in March 1986. (3) . Eventually three questions were raised

1. The use of promotional advertising technique

2. Canvassing or touting for patients

3. Making disparaging statements about fellow professionals

With regard to the first two issues, the questions was whether the restriction should be on the method of advertising or the contents of an advertisement. It was decided that the contents should be honest and factual. There was to be a relaxation of the manner in which information was provided. The difference between providing information to the public or patients and promoting oneself is a difficult call.

 With regard to the third it was equivocal and therefore based on the situation. While it was necessary for doctors to bring to the attention of patients and authorities, evidence of gross negligence, it should not be used to benefit oneself. The lines are blurred. Today section 70 of Good Medical Practice in the UK has only this to say about advertising " When advertising your services, you must make sure the information you publish is factual and can be checked and does not exploit vulnerability or lack of knowledge."

At least 10 years prior to the UK relaxation, the USA had completely relaxed the restriction on advertisements by doctors as a result of the intervention of the the Federal Trade Commission ( equivalent to the MMC in U.K. And the Competition Council of India ). After the successful FTC suit in 1975 (Goldfarb v Virginia State Bar), the AMA removed all prohibitions to advertising, retaining only a weak restriction against false or misleading advertising(4). In fact, the FTC challenged the ethical restrictions imposed by the American Medical Association on the grounds of monopolies. Today doctors and dentists in USA can freely advertise provided it is factual. Breach of honesty is dealt with under tort and the statutes of the advertising regulatory authority.

This is the situation in other countries. The German medical statutory body called ARTZETAG, similarly withdrew all restrictions. From 2000, Doctors in Germany can publicise their formal education, experience, special diagnostic and therapeutic abilities etc on their practice signs, newspapers and the internet.(6). Other countries that expressly permit advertisements by physicians and dentists include Singapore (7), Australia and New Zealand (8)etc. In fact the Italian Medical and Dental Council was fined € 831,816 by the Italian Competition Agency ( ICA) in 2014 for imposing restrictions on advertisement by doctor's(9).

It is perhaps high time that the MCI and DCI restructure the code of ethics to permit fair competition for young doctors to be able to break the monopoly of the corporate establishments which indiscriminately violate the existing norms. The Competition Council of India can even initiate suo moto action against legislations and statutes that prohibit such marketing techniques based on archaic ethical principles handed over to us by the British, who themselves have amended their laws and regulation.

Conclusion: 

It may therefore be concluded that the time is ripe for the statutory bodies to take a re look at the issue of advertising. There is likely to be legal or statutory imposition on the Medical and Dental Council if the competition Council of India takes cognisance of the fact that medical practice is a commercial service and it is monopolised by some sections, particularly the corporates. There is of course a danger of doctors going overboard using the relaxation. I would quote from the Indian Journal of Medical Ethics to point out the impact of strict restrictions being bad in morals. "Relying strictly on word-of mouth has some negative implications 1. It favors the already established doctors, “the gray beards”, against the new entrants to the field of medicine. This bias is entirely in keeping with the hierarchical nature of English society that gave us our system of medicine 2. Allowing other doctors to be gatekeepers to consultants has promoted fee splitting. A transparent well-publicized schedule of fees and services of a consultant may help put a stop to this practice."(10)

References

1. Irvine DH, Journal of Medical Ethics, 1991,17, 35-40 ( General Medical Council. Minutes. Vol XL11: 138 London 1905)

2. Patient's Liaison Group of the Royal College of General Practitioners. Availability of Information for patients. Journal of the Royal College of General Practitioners 1984;34,269:672-673 ( also page 644)

3. Monopolies and Mergers Commission. Services of Medical Practitioners: A report on the supply of the services of registered Medical Practitioners in relation to restriction on advertising. London: HMSO, 1989. 

4. Burnham J C. American medicine's golden age: what happened to it? In: Leavitt JW, Numbers R, eds. Sickness and health in America, readings in the history of medicine and public health. Madison, W: University of Wisconsin Press 1985

5. http://www.gmc-uk.org/Good_medical_practice___English_1215.pdf_51527435.pdf 

6.http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)73346-8/abstract

7.http://www.healthprofessionals.gov.sg/content/dam/hprof/smc/docs/guidelines/2016%20SMC%20Handbook%20on%20Medical%20Ethics%20-%20(13Sep16).pdf

8. http://www.medicalboard.gov.au/Codes-Guidelines-for-advertising-regulated-health-services.aspx 

9. http://iar.agcm.it/article/viewFile/11063/10256

10.  http://ijme.in/articles/ethics-of-professional-advertising/?galley=html