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

 

What is wrong with the the continuing education point system as a mandatory requirement for registration.

Let me be very clear. Continuing education is a necessity for professional upgradation and public safety. So when I ask "what is wrong..." it is immediately construed as being negative. No! But the system must be implemented in a rationale and beneficial manner causing the least inconvenience to those involved. The issues that require review include

1. The CME/ CDE is not a requirement for registration as a dentist according to the Dentist Act. While there is a gazetted regulation making it mandatory, it cannot be legally binding as the Dentist Act 1948 ( along with amendments) which lays down the criteria for registration as a dentist in India does not have such a requirement. If challenged in a court of law the Act will prevail over the regulation. Therefore the Act will need to be amended to make the CDE points binding.

2. The cost of earning CDE points is very high, at the present. To earn 20 points a year a person will need to spend an amount that is not affordable by a newly minted dentist, thousands of whom do not even have a job. Medical doctors need to earn only 30 hours in 5 years whereas dentists require 100 hours in 5 years ( the calculation of credit per educational hour is of course more stringent for medical doctors). The Dental Council of India or the State Dental Council should therefore offer free programmes to help practitioners, if it is to be made mandatory. At a time when webinars and  online learning and even assessment is possible at a very minimal cost, the necessity to travel and attend costly programmes must be eliminated. Online attendance can even be monitored better. The current system of points for attendance at conferences is a farce with most attendees standing around in corridors and foyers when lectures are delivered to near empty halls. The Kerala state IDA has just announced a free state CDE in Oral Surgery. As one of the speakers, I have waived all reimbursements for travel and stay, which is normally extended for outstation lecturers. I am sure that several senior experts and teachers are willing to do so. If the IDA, a private association, can do it, then the Government statutory bodies should be able to do so with government subsidies. It is after all meant to provide public safety.

3. Some categories of professionals are exempt from continuing education. This seems to be scripted to benefit selected segments. Let me deal with each of these exemptions.

A. Section 8.1 says all dentists above 65 are exempt from CDE. I should be celebrating the exemption because I will be 65 in 5 years and therefore exempt when the first evaluation takes place. But no! If the principle of CDE is based on the ethics of being currently updated there is no rationale in exempting a 65 year old, unless he is not practising, in which case he has no need for those points anyway. How does a 65 year old become safe for practice without CDE when a 55 or 60 year old is deemed unsafe if not updated. It is purely arbitrary.

B. Section 8.2 exempts all MDS staff with 15 years experience and currently teaching post graduate students. This is quite ridiculous as the CDE points is for the sake of safe practice of dentistry. Not just one specialty. The exemption is acceptable if these professors are not practising, as in central or state government institutions which do not permit private practice ( e.g. AIIMS, JIPMER or states like Kerala Government etc). It is even applicable to specialists who only practice their specialty, which is difficult to determine in the absence of a specialty register. However it is unfair to exempt teaching dentists who practice general dentistry after their college commitments. Thousands do so and they mostly do general practice outside of their specialty. For example, how can a professor of oral pathology be provided exemption of CDE points when he/she does endodontics, orthodontics or oral surgery in his/ her private practice. The whole notion is facetious and poorly thought out.

C. Section 8.5 says that if one is 'seriously' sick, it is necessary to get a certificate from a Government doctor. It means if one has a CABG it is not enough to get it from your private cardiac surgeon or hospital. You need a certificate from a joint director of health service or some person.Why? Because Government doctors are honest!!!

There are several other issues. Can a person working abroad retain his/her registration. If so how? Are foreign CDE programmes accredited. What will happen if you don't fulfil the CDE point requirement? Will your registration be cancelled? Since one requires 20 points minimum a year, does it mean one can be considered as ineligible in the first year itself?  How do you get your registration back? 

Does the DCI need to go back to the drafting table?!!!

New CDE regulations- another avenue for institutions to make money??

Continuing dental education- will be it another avenue for profiteering by institutions??

In 2007, the Dental Council of India came out with an ambitious but poorly drafted, half hearted and ambiguous attempt to make continuing education compulsory for practising dentistry. In 2011, a new regime, struck it down as non implementable due to several reasons. Five years later it has now emerged again as a rehashed version of the original regulation, by the same dispensation that struck down the earlier version.

There are two things that strike me.

1. Why is it that the already beleaguered and over produced specialty of dentistry alone require such compulsory updation as a pre requisite for renewal of registration when critical health bodies like MCI, AYUSH and other bodies have not imposed such compulsions?

2. Why has the onus of providing such updation been placed almost exclusively with Dental Colleges which have been variously described as ranging from very good to very bad. In other words, why are other private organisations and skill providers been excluded from accreditation?

Before anybody gets me wrong, let me explain that I am in full support of doctors and dentists being fully updated on advancement in their science as a matter of public safety and quality treatment. However, there are too many glaring holes in the structure of the current regulation, though most of us will concede that it is a significant improvement over the last attempt, a decade ago. My position on the matter is simple. Make learning a more open process where people can gain knowledge in less expensive ways provided by modern communication technology. We do not need another regulatory body breathing down the backs of the poor struggling dentist who has to reckon with one more 'bully' in the form of the state dental council. Here are some of the objections

1. The primary task of providing continuing education has been offered to the teaching institutions. Are we looking at a bail out package for Dental Colleges that are sinking for want of students taking up dentistry? Going by the new regulation, it seems that the statutory bodies are providing them with another opportunity to make money. It is completely presumptuous to think that teachers in dental colleges are better placed to provide skills and knowledge. On the other hand the need for continuing education and updation is precisely because many of the sub standard colleges have failed to provide good training in the first place.

2. Even more presumptuous is the fact that teachers do not need continuing education. They are exempt!! This could be true, if they were pure teachers who did not do private practice and their work is restricted to the dental colleges. Let me give you an example. How can a teacher in Oral Pathology, who neither sees nor treats dental patients in a dental college be allowed to practice dentistry after college hours without the mandated CDE points?  Does teaching Oral Pathology give the person knowledge about Infection control, Ethics, Crown and Bridge preparation or Oral Surgery. Absolutely not!!! The only way that this major anomaly can be addressed is by preventing dental college staff from private practice or by making it compulsory for them to undergo CDE like every body else, if they wish to practice after their working hours.

3. By introducing a self assessment protocol we are giving too much of discretionary powers to the regulators. They can pick and choose their victims. Most of us see the enormous possibility of some of these powerful persons venting animosity by targeting those they have professional or personal rivalry with. If made compulsory, CDE as a compulsory requirement, should be used universally against all those who do not comply by a process of due diligence exercised by the regulatory bodies. Any attempt by regulators to exempt anybody from statutory action for non compliance, should be considered as a corrupt practice and criminal action should be initiated against the regulators. This is the only way to prevent selective harassment.

4. There is a discord in the rules for obtaining CDE points. It says one should have 100 points in 5 years but not less than 20 points in a single year. Going by this rule, a person who gets less than 20 points in the first year, already faces disqualification. Why wait for 5 years to take action? Another clause also says ' not more than 25 points in a year'. What will the DCI do? Punish those who learn more? We will ignore that as oversight or stupidity!!

5. The notification says it comes into effect immediately. Does this mean that a dentist cannot register on the 1st January 2019, if they do not have 20 points? Are all the oversight mechanisms in place or is it going to be arbitrary. Is my next CDE programme this weekend valid? Is the next National Conference of my specialty valid? Too many gaps, if you ask me.

There are several more vacuous discrepancies in this incomplete regulation. 

My bottom line is that while the DCI has the powers to make sub ordinate legislations, it cannot legally refuse re -registration on the grounds of this new regulation. The Dentist Act only requires a recognised qualification and a prescribed fee for registration. In any conflict between the Act and regulation, the Act will prevail. I hope the DCI is prepared for litigation, unless they amend the Act and even then it cannot be used retrospectively. It cannot be used for those who are already registered.

The DCI should remove draconian consequences for not updating and encourage CDE as a positive way to remain relevant in the profession. In as much as that is concerned, I appreciate the provision in the new regulation for certifying those who achieve the recommended CDE points. That alone should be an incentive. Not punitive action!

George Paul

Oral and Maxillofacial Surgeon

Salem