Wednesday, June 25, 2014

Why was the BDS course duration increased in 2007?



Have you wondered why there is so much time taken up in the electronic media about Delhi University’s Four Year Undergraduate Course (FYUC)?  The motives maybe dubbed as dubious if the only reason was because the American Universities do so. I am not suggesting that the DU’s decision was unfounded as I do not know if there were other reasons, valid or not,  behind the move. I am only saying that mimicking ‘foreign’ Universities is not a great idea because our needs and resources can be different.
In 2007/2008 the Dental Council came along with a similar hare brained idea. It was ridiculous because the unilateral decision by the Dental Council to increase the course duration from a four to five year course was justified on the same grounds- International standards. It could have been justified if it was not done at the expense of the one year Internship. The Internship in medical courses in India provide for ‘on patient’ training under supervision. It also provides for some autonomy in decision making in the bridge between being a student and an independent practitioner. In short the decision to scrap internship and increase the duration of the course was in complete variance with all the medical courses in India.  The reasons for the increase of the course duration from 4 years to 5 years was justified by the then DCI as
1.       The Americans do not have internship
2.       It provides more time for study
3.       Training (Internship) is not necessary because students are anyway exposed to patients during the course
4.       Students will not attend internship!!!
5.       Private managements will be financially benefitted!!( The DCI secretary actually sent out a memo to that effect and it is attached)
The only acceptable reason to any rational person is the last one- more money in tuition fees for the private managements. Several of them did charge a 5 year fee for the course which was eventually decreased to four years! More importantly the Colleges will not need to pay the compulsory internship (which many of them still do not pay). A rough calculation for a college with 100 seats charging 2 lakhs per year as fees would be 2 crores a year. Add to this the benefit from not paying the compulsory stipend (which I have fixed at a conservative Rs3000/ a month). The saving for private managements would be a saving of approximately 36 lakhs a year. A financial gain of approximately 2.5 crores a college is no small profit. This involved at least 250 colleges (excluding the Government Colleges) in the country. Something worthy to lobby for! You do the math and see how many crores would have accrued to private managements each year! The question therefore is why did the DCI make such a move and try to stifle the objections raised by several of us? The move was staunchly promoted by the then President, Vice President and some members- significantly a DCI member from Kerala who was in the fore-front of its promotion. There are several reasons why we can pick holes in the rationale of mimicking the US Universities. One of them is that the 4 year US dental courses are done after a four year pre-med graduate degree. It is true that there is no formal internship but the US has a statutory licensing examination before they can practice in any state. Without any of these safe guards, just scrapping internship would have been dangerous to the public. Imagine sending college fresh graduates on to the general population. One senior DCI proponent of the course who was also dean of a dental college said it would enable American Dental Association accreditation. His college was trying for accreditation. It is these kind of personal agendas that hijack our teaching and training!!
Fortunately, a new President was elected and the decision was reversed without causing too much harm to the students. This could have been done in DU too, with a little mediation and planning. Regarding what happened in the DCI, nothing short of a full fledged investigation will reveal the motives behind the attempted move by the previous President and his men. Some skeletons may actually spill out of the ancient cupboard!!

Tuesday, June 17, 2014

The Clinical Establishment Act- How will it affect the practising dentist



The Clinical Establishment Act 2010 became effective in Feb 2012 through an extraordinary gazette notification and is today applicable in 4 states with at least three more poised to adopt the same. There is no doubt that this is a landmark legislation which very few people in the dental profession noticed. One of the reasons is that, dentistry as an important clinical branch of health care has been grossly under represented. The DCI has represented the meeting of the national Council in two of its four meetings through its secretary. The minutes of the meetings are available on the website of the body ( 1). Scanning through the minutes it is surprising to see that while all the branches have strongly voiced their opinions, dentistry has not spoken out a single sentence (as per the recorded minutes).  It must be said that the National Council has made an exhaustive list of the regulations required for starting and running of clinics. In fact the requirement for a dental clinic is rather well formatted. It is divided into Dental Center for a single dentist practice and a Dental Hospital for those with inpatient facility. The Dental Hospital requirements are a little difficult to fulfill- at least for the new practitioner starting in a metro city! Dr Anmol Kalha is the member from the Dental Profession and we hope that dentistry is well spoken for. The State Council will be the implementing authority through its district officers. The District registering committee will be nominated by the Collector and will have three members including a senior police officer and a representative from the profession. It is at this level that one can expect problems if any for the practicing dentist. The inspectors are nominated by the District authority.
Since most of the States have yet to adopt the Act, it may be some time before all dentists face the nuts and bolts of regulation. We sincerely hope that it will not be a source of harassment for an already struggling profession. On the other hand regulating practice may eliminate quackery to a large extent. More importantly it will ensure safety for the public.
I thought I will touch upon a few of the requirements and comment on them so that eminent persons who will eventually represent us will be able to get an idea about how laws are likely to affect the common dental practitioner. I was recently told by someone that impossible guidelines like an OPG in every clinic etc were suggested. On reading the clinical requirements, it is clear that these were exaggerations. It is titled as Standard No CEA/ Dental Hospital-38 and 39 for Dental Hospitals and Dental Centers respectively. This is unusual because the Code of Ethics Regulation prevents Dental Clinics from being called Hospitals. That may change because the new code of Ethics is almost ready as per information from the DCI.
In any case the new requirements will cover all dental clinics including single person run establishments and exceptions are only for the armed forces. The format available on the website (2) is comprehensive and covers all specialties. The norms for infection control, cleanliness and safety (including bio and radiation safety) are quite rational and practical. However there appears to be some need for pragmatism in the space requirements. It says that for Dental Hospitals 30% of carpet area should be reception and circulation. 30% of carpet area for one Chair is expected to be 6 sq meters of carpet space (i.e 18x18= 324 Sq Ft). In addition 30% carpet area should be for ancillary purposes including sterilization, toilet etc. This means that a clinic should have a minimum of 1000 Sq Ft for one chair. For every extra chair there must be an additional 60% or 600 Sq Ft. I will leave it to the reader to decide if this is practical in a city like Mumbai. It does not say where the patients will be admitted. On the other hand Dental Centers need only 60 Sq Ft for a chair and 35 Sq feet for reception etc. The 60Sq ft will be a little tight if a patient needs to be shifted after a syncope. I do not understand why one needs 5 times more space around a chair in the hospital category! There are several other small glitches including a number of inspections for bio safety, lift safety, drug expiry etc. While I think it is necessary, I am not sure how many dentists will be comfortable with buying Oxygen and other gases and all monitoring systems and equipment. Another difficult task will be the employment of ‘qualified’ assistance (diploma recognized by state dental council) and providing minimum wages according to the labor laws. Some requirements like waste disposal etc are definitely important. Some others may need tinkering. Some other requirements may worry dentists and doctors. One is expected to put a price list for procedures for patients to see and the rates are decided by the competent authority, not the dentist. I am not sure if this will work for health care.
My biggest issue with the construct of the legislation is the absence of the IDA inputs, whereas the IMA, Ayurveda, Unnani, Yoga and Homeopathy associations (not just councils) are very well represented. How in the world are they going to implement ground level regulation without technical inputs from the dental profession- particularly practicing dentists!
While you chew on that information, you can go to the very informative website and troll through all the sections at  http://clinicalestablishments.nic.in/En/1066-national-council-members.aspx.
http://clinicalestablishments.nic.in/WriteReadData/449.pdf

Thursday, June 12, 2014

Open Letter to the President and Members of DCI



Dear Sirs/ Madams,
We are informed that the DCI is preparing to conduct its General Body Meeting on Friday the 13th of June! As practicing dentists we have several concerns. We have personally raised these issues in the past as well and would like you to once again look into it.
1.       Following our persistent objections the slew of new dental colleges has thankfully ceased or at least decreased dramatically. We however note with some alarm that a backdoor mechanism is in function. The seats in the existing dental colleges are being increased. Several Dental Colleges have applied for doubling of existing seats. I wonder if you realize that the reason for asking for moratorium on new dental colleges was based on the fact that there are too many dentists in ratio to population. By increasing the seats in existing colleges, the problem persists. It might even be said that this amounts to favoring existing dental colleges who benefit from this. The Health Ministry and the recommending body (The DCI) must call for a complete moratorium on the number of dentists graduating. The Dentist to population ratio has already been highlighted and the increase of seats must be based only on the manpower resources required. The State Governments, Central Government and the DCI have completely ignored this issue in giving ‘essentiality’ and ‘No Objection’ certificates. This is true for Government and Private Dental Colleges.
2.       There must be a complete review of all dental colleges by an independent body similar to the Anil Dev Singh Commission and a complete weeding out of improperly functioning institutions must be effected. In fact the Ministry of Health can undertake an exercise similar to the Flexner Committee report in the early 1900’s in the USA where medical education was rationalized and almost 50% of existing medical institutions were shut down or merged. The existing DCI inspections are unlikely to fulfill such a drastic exercise. Where is the Anil Dev Commission report (2004) by the way? An RTI by one of us indicates the Health Ministry does not even posses a copy of it after spending crores of rupees!!
3.       We understand that several institutions are scheduled for getting PG seats (new or increased). As per procedure the DCI has to recommend the names of these institutions to the Health Ministry for them to grant permission. However, we understand that the word ‘Council’ as defined in Section 3 of the Dentist’s Act 1948 refers to all categories of members in the General Body (GB) of the DCI. The powers and responsibilities of the EC are mentioned in several sections of the DCI separately and distinctly from that of the ‘Council’. They obviously cannot be interpreted as the same.  We have learnt that the recommendations under item no 8 of the agenda for this meeting seeks to approve new courses or seats in various institutions. The recommendations for these institutions were sent by the EC (not Council) to the Health ministry.  Do the 5 or 6 persons in the EC represent the will of the whole Council? The Health Ministry has apparently given permission based on this questionable reference. The ratification by the GB therefore appears to be a mere formality and is obviously ‘post facto’. We see a major procedural lapse in this sequence. The GB ratification appears to be eyewash and the whole exercise raises questions on the enormous powers being asserted by the handful of persons in the EC. We request the DCI to rethink on the recommendation particularly because there are institutions in this list who are under investigation for precisely the same issue- grant of PG. How did they get the permission now?
We need greater transparency in the functioning of regulatory bodies! The role of the GB has been reduced to a superfluous one. Justice should not only be done, it should also be seen to be done!
George Paul- Salem
V. Viswanathan- Calicut
Murali Venkataswami- Chennai
Varghese Mani- Thrissur
Raveendranath M- Kannur

CC- To Hon Minister of Health and Family Welfare

Sunday, June 1, 2014

An open Letter to Ms Smriti Irani- HRD Minister



Dear Ms Smriti Irani,
Let me first congratulate you on your conferment as the guardian of one of the most watched ministries in the new Government. No! I was not rooting for the BJP. I was not cheering for any party for that matter. They have all disappointed us for several decades- some more than others. I hope you prove my skepticism wrong, at least as far as the HRD ministry is concerned.  It was however a pleasant surprise when you were named the HRD minister. Much noise has been made about your qualification for the post. Degrees, in my opinion, are of no concern. You seem to have enthusiasm. And in Ralph Waldo Emerson’s words “Nothing great was ever achieved without enthusiasm”. I think that alone will suffice.
For several years I have written about and petitioned the HRD department on the functioning of some Deemed Universities in this country. To understand the angst of the student community, one must go back into its history. The Radhakrisnan Commission (1948) had mooted Deemed Universities as a means of making innovative higher education available to meritorious students. Private sector participation was sought as a means of corporate social responsibility- not profit making ventures. Until the mid 90’s Deemed status was given to only the best institutions. Suddenly, the flood gates opened and a slew of institutions were accorded the ‘Deemed to be University’ status. The reason is obvious. The objectives of Deemed Universities were turned on its head. The autonomy vested in them became a means of cheating the system. Institutions, mostly medical and engineering colleges, wanted greater autonomy in their admissions, to by- pass the state merit quotas. The HRD ministries in those days were headed by highly qualified professionals. It is surprising that they saw nothing amiss when medical and engineering seats in some of these institutions were being auctioned off for crores of rupees. It goes on unhindered. This is why many of us feel that the HRD ministry does not need doctorates to head it. We need honest persons who can empathize with the plight of disadvantaged meritorious students who have been systematically sidelined in the last decade and a half. Ms Irani, you may be in a position to do what your ‘highly educated’ predecessors failed to do!
The decision to grant Deemed Status in most of these institutions was not in keeping with the established guidelines and norms which required that these institutions strive for a policy ‘leading to excellence and innovations’. In fact the Deemed University objectives specifically exclude routine courses like BA, MA, MBBS, BDS,B Pharm etc. Clause 3.2 in the extraordinary gazette dated 21st May 2010 says that one of its objectives is “To engage in areas of specialization with proven ability to make distinctive contributions to the University Education system that is- academic engagement clearly distinguishable from that of an ordinary nature that lead to conventional degrees in arts, science, engineering, medicine, dentistry, pharmacy, management etc routinely offered by conventional institutions.”
Thankfully, the Government has not sanctioned any new Universities after 2009. On the contrary, in 2010, the Government moved the Supreme Court to withdraw the Deemed Status from 44 Universities based on the recommendations of a high powered committee. The fact that these Universities continue to brazenly admit students after collecting huge capitation fees and conducting fake entrance examinations, is an indication that there are powerful political forces behind them. The Chancellors are often the owners of the institution. Vice- Chancellors are often handpicked and appointed from within the family or close inner circles.
The least that the HRD Ministry and the UGC can do is to regulate and oversee the entrance and exit examinations.  In fact the first step would be for the UGC to conduct a common entrance examination to ensure merit at least for the Medical and Engineering courses (UG and PG) in all these institutions. Deemed Universities certainly cannot claim exclusivity in the award of routine MBBS, BDS, BE and their post graduate courses. The Supreme Court, in several judgments has clearly stated that all professional and higher education admissions should be governed by the triple test which is based on an examination that is fair, transparent and non- exploitative. An entrance examination can be fair, transparent and non-exploitative only if it can be accessed by everyone and a rational fee structure for the course is clearly announced in their admission brochure. Many authentic Deemed Universities conform to these norms. They should have no objection to a common entrance test.
Ms Smriti Irani, as the honourable minister for HRD, this should not be a tough act. It will vindicate your claim that you should be judged by your actions and not your qualification. You will also earn the everlasting respect from generations of meritorious students for restoring their trust in the system.
George Paul
June 2nd 2014

Saturday, April 26, 2014

Twenty Seven Years of tolerance- a tribute to a loving wife!


I was being very honest when I said steamy. Anybody who has spent a summer in Salem will vouch for that. I do not know why we had the wedding that punishing summer, when we could have done it in salubrious Bangalore. But then there are some customs amongst the Syrian Christians. Unfortunately Salem had no Syrian Christian Church and naturally no priest. Unlike the Catholics, the average Syrian Christian goes through the business of confessing to a priest only at the time of their wedding and if lucky just before they die. With great reluctance I decided to confess my sins of bachelorhood to an imported father (from Kerala), in a rented Church, on the morning of the day. The priest was a merciful man. He asked me to just think of all the sins I might have committed over the last 28 years and ask God for forgiveness. Now! That can be a laborious process- recalling the indiscretions of more than two decades. I did some rewinds and fast forwards on what I perceived could be construed as sins by the Orthodox Syrian Church. Unlike several other priests, he was not interested in the salacious details of my adolescence- it saved me the blushes.  And thus I was rendered ‘pure’ and in a state of grace, ready to accept my communion and my new bride. At 400 centigrade the normal 3 hour wedding service seemed like eternity. It was truly an act of contrition for my bachelor days! If you were waiting to hear about my first night, you will be surprised to know that we spent most of it looking for my missing father in law in the Hotel we were staying in. He had crept into one of the several rooms that were booked for the bride’s family and went to sleep- while everybody searched high and low. My worried wife and I sat outside our honeymoon suite awaiting news. They found him snoring in a room at dawn!
Bini spent the first two years of our married life in Bangalore completing her studies and I taught and practiced in Salem. We met over the weekends keeping alive a marriage that remained fresh by virtue of distance. She later joined me in our practice and became my father’s protégé and inheritor of his dental practice. I taught, traveled and limited my clinical work to my specialty, maxillofacial surgery- which was convenient. It has been a good 27 years with Bini. She took control of things. The loving mother of our two wonderful girls. The new daughter to my parents. The purse strings of our modest resources. Our cheer leader. My critic and conscience keeper. Our occasional cook (thankfully!). The spiritual motivator who left me to my own beliefs. Our social manager. Our accountant and fiscal planner. My designated driver (after parties). Our public relations expert. Our holiday planner and side seat driver. My confidant and hand holder. My writing censor.
She allowed me my privileges. The TV remote. The weekend binges.  To call a spade a spade. To fight my battles. To lick my own wounds without rubbing it in.
The shy and reticent Bangalore girl who transformed into a street smart, multi-tasking small town house wife and professional was exactly what the doctor ordered.  She balanced life with great grace, taking care to always make me feel like the boss. She became the friend of my friends. She reformed me in the limited ways that wild guys can be reformed. She has made my life a worthy one. She was always there for me through good times and some bad patches. She is the love of my life. She is the wind under my wings.
She has approved this message!
George
26th April, Wedding Anniversary and day of marital recollections!

Thursday, February 13, 2014

Science or Surgery- an unnecessary debate!



I recently encountered a raging controversy on the semantics of a dentist's degree. Simply put, the question was whether a 'master of science' degree should be considered inferior to a 'master of dental surgery'. To explain the background, one must understand that in the USA, a master of science is designated with the acronym MS, whereas in India ( and all commonwealth countries) the same is designated as MSc. For the record I might add that MS in India generally refers to Master of Surgery and by logic the MDS is called a Master of Dental Surgery. The case in question refers to a gentleman with  MS in Orthodontics ( as it is referred to in the USA) is today being challenged by one of his colleagues because he has a 'science' degree and not a 'surgery' degree and therefore ineligible to call himself an Orthodontist. Orthodontics, strictly speaking, is not a surgical persuasion. It is an important specialty that deals with non surgical correction of dental and facial deformities. The surgical corrections are done by another specialty. Notwithstanding any of these, in India they are all designated as Master of Dental Surgery. For instance Oral Medicine, Preventive Dentistry and Oral pathology (which are all obviously non surgical specialties) are also designated as MDS. It is just a nomenclature to which we have not appended much thought. It certainly does not matter too! All specialties are important.
To me, the whole controversy about the expansion of a degree ( MS or Msc) appears  puerile and immature because the course content and structure of the syllabus are exactly the same and the regulatory body in India (DCI) has clearly recognized the MS from the particular US University as being equivalent to the MDS. So you can see that the bone of contention is in the expansion of the acronym after the dentist's name!
Science is perhaps the greatest persuasion in human endeavor and surgery is just a part of this great ocean of collective knowledge. Then why do we consider science to be somehow inferior to surgery. It is unfortunately an uninformed world view that makes people clamor after a title that incorporates the word 'surgeon', not realizing how limiting that term can be. I am a Maxillofacial surgeon (a surgical specialty of dentistry) but I would feel more pampered to be called a scientist rather than a surgeon. This is because it would be an acknowledgement that my professional abilities extend beyond the realm of purely using a knife to cure people. In fact until the last century, surgeons were looked down upon because they achieved much less in health care than the other health professionals. In fact even today the surgeons in the UK are called 'Mr' and not 'Dr'. Have you ever wondered why the AIIMS is called the All India Institute of Medical Sciences. Does the word ‘science’ seem inferior for this institute? The same applies to NIMHANS and several other national institutes of higher medical training.
Surgery is just a small aspect of the higher calling of science which encompasses a greater understanding and application of knowledge. We must remember that to become a surgeon, one must first embrace science. Surgery is just minuscule arm of the broader subject of science.
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