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

An open letter to the Secretary of the Indian Dental Association

Dear Dr Dhoble,

First, let us affirm that this letter is not ad hominem and it should not be taken personally. At the end of our careers, we have no interest or ambitions to any post or privilege in IDA. But as members or past office bearers of the association we have deep concern about the way the Indian Dental Association ( IDA) is being run.  We have brought this matter to your attention in a personal note and have not received a credible reply or explanation about several issues being raised. We also wish to assert that we are not being influenced by any group as is being perceived by some of your friends.

Therefore this open letter. While we acknowledge the fact that you have made the IDA into a gleaming corporate structure, we are also concerned about the meagre benefits the contributing dentist members around the country are getting out of their association. The matters of immediate concern are ( but not limited to)

1. The concentration of power in the hands of a few. The Hon. Secretary's post is a time bound one as per the constitution but we have seen just 2 secretaries in the last 36 years. By the end of the present term in 2022, the secretary would have served 20 years. The general body meetings for election of the HGS are somehow arranged to always be in the incumbent secretary's home city or at least state. This seems more than a coincidence as it has happened two times and we will not be surprised if it is scheduled again in Mumbai / Maharashtra in 2022 for the next election.

2. The IDA Head office is run like a corporate office at enormous cost to the association. We see from the balance sheet/ statement of accounts that the HO spends about ₹6-8 crores a year ( 4 previous year statements available to us). The rent for running the office and salaries run way beyond 1 crore each. In your communications you have claimed to have 80 employees. The annual electricity bill is ₹ 15 lakh , there are humongous expenses for travel in India and abroad amongst other things. This does not seem to be helping the contributing dentist from various parts of India in any meaningful manner. Today's offices, nationally and internationally, are run with paperless administration and e- governance. Major International Associations with larger memberships and handling greater logistics are run at far lower costs and manpower ( calculated on purchasing power parity). More over, this is not a permanent office and it is meant to be rotated from time to time. Can this kind of expenditure on resources be justified, particularly when the members do not even get a quality journal free of cost. What does a dentist shelling out ₹1400 a year in these hard times get for their contribution?

3. The sponsorships from toothpaste and other companies, received and disbursed through the HO, seems to be too centralised. Current government and statutory regulations frown on corporate sponsorships and the money received itself is questionable. Let us assume that it is a 'corporate social responsibility' ( CSR) and there fore justified because the profession and public has after all benefitted in some small ways by their schemes. However the centralised receipt and disbursement of these sponsorships call into question the manner in which the finances are being spread across the branches. If at all sponsorship as CSR can be received, the dentists are concerned about transparency and fairness in its distribution for conduct of continuing education or knowledge dissemination programmes. In fact the ethical conflicts raised by such sponsorships itself should be scrutinised.

3. A recent development suggests that the IDA is being turned into a professional service provider for a statutory body, namely the Maharashtra State Dental Council. This is being viewed sceptically by many members. We understand that the IDA is providing logistic and data management support to the Maharashtra Dental Council for a fee of ₹45,000 a month and ₹5 lakhs as development fees. We have reservations on this matter for 4 reasons

a. Whether the General Body of IDA was consulted before involving the IDA as a business service provider. Business outsourcing is not a function described in the IDA constitution.

b. Whether it is correct to use the services of employees of the IDA head office for business purposes as they have been employed ( at enormous cost) for administration of the association.

c. Whether the company Dentsoft, which developed the software, belongs to any office bearer of the IDA. 

d. We understand that the Hon.secretary general of IDA is canvassing for the post of DCI member under 3 (a). Since the IDA secretary will have access to the data of the prospective voters for 3(a) in the State Dental Council elections, there seems to be a conflict of interest and an unfair advantage to the Secretary? This model will be misused across the country if we allow this to happen. 

There are several other issues pertaining to the democratic running of the organisation. We strongly feel that the association would be better run by employing a highly qualified executive secretary ( as is done by several international associations) with adequate pay and perks rather than have a professional dental practitioner running the affairs of office as Hon. Secretary General with no pay.  Alternately, the term of of the secretary should be limited to one term. The association should be run by a President and executives elected by the members for a fixed term and preferably in a centralised city where the real estate is not so high and the human resources are more rational. We need an association that can work towards the welfare of the dentists who are going through a rough patch, rather than build plush corporate offices and initiate programmes that have no impact on the practising dentist for whom the association was created in the first place.

As a beginning, I hope the members will strongly gather together and bring change in the constitution so that we can have a more democratic and decentralised organisation working towards the welfare of the dentist, his profession and the public. Despite the requirement that the constitution and amendments be circulated, there is no public access to it.

We do not want World Dental Shows and pomp. We need welfare for the members at a time when dentistry is going through some bad times. We need representation in the Clinical Establishment Act. We need social security and indemnity. We need free continuing education, not just in Mumbai but in the remotest parts of the country. Mostly, we need absolute transparency and free and fair elections.

We need change! It can only come with new and younger faces of a bright new generation. As a secretary, you can still make it happen and salvage your position by engineering change and passing on the baton after serving for 20 years. The gray beards must retire gracefully. 

This letter in its authentic original format is available on the blog site www.maxfaxgp.blogspot.com . Any variation in its dissemination is not the responsibility of the authors. It is being published in the interest and welfare of the profession.

George Paul- Member IDA, past Hon. Gen. Secretary and President AOMSI, TN State Legal Cell Convenor

Viswanath V- past State IDA president, Kerala State and CC member.

Murali Venkataswamy- Member IDA, past TN State Legal Cell convenor.

 

SOCIAL MEDIA AND THE MEDICAL PROFESSION

There is a message circulating on the social media that is a cause of great concern and brings into focus the dark side of this new media phenomenon. I am trying to make a balanced statement on why the social media should not and cannot be used to settle personal scores between doctors and patients, especially when it can do unjustified harm to the reputation of the other.

The issue in question refers to the travails of a retired army officer living in coimbatore who claims to be the victim of medical negligence. The message expresses with angst his sufferings with an implant supported denture, done and redone, by two dentists in Coimbatore for which he spent a large some of money. I had the opportunity to see the letter written by the patient on several Whatsapp groups, expressing his angst. I also received a copy of an X-ray ostensibly of this patient's jaws. As a dentist who has been in Maxillofacial surgery for the last 36 years and as a qualified lawyer and ethicist I have a few comments to make. This does not purport to defend or vilify anybody.

1. I do not wish to comment on the treatment per se because I am not an implantologist although I have a working familiarity with the process. Implants are done by another specialist in our practice. However, I can say that the patient's claim about the cost is irrelevant. Implant dentures are costly fixtures and I am sure the patient was informed  about the same. The number of implants and how it is engineered are purely technical details and can be justified based on the prevailing situation of bone and nature of prosthesis. There is no such thing as an exorbitant professional fee unless it is sprung on people without notice. That does not seem to be the case.

2. I fully empathise with the patient who is obviously frustrated because some of the teeth on the denture where constantly chipping off. If I had paid 6.5 lacs for a treatment, I too would be frustrated. I am close, in age, to the patient and can fully understand the despair one feels as we grow old with multiple medical problems. However, one cannot justify the act of using social media to name and blame the medical/ dental care giver based on personal opinions.

3. For the lay persons benefit, let me explain what an implant supported denture is. Implants are titanium devices that are planted surgically into bone. They can fail if improperly placed or if the bone condition is unfavourable or due to various other situations. These days, 95- 98% of implants  do not fail. 

This is followed by loading the implants with a functional denture after 3 to 6 months or sometimes even immediately. These dentures are fabricated in dental laboratories and the teeth on them is made of a costly material which is expected to bear normal bite forces.

4. Having seen the X Ray and CT scans, it is obvious that in this instance the implants have remained intact after 2 years. However, the patient's teeth on the denture were supposedly getting chipped. It cannot be seen on a radiograph but it is a possibility. This can happen due to improper fabrication or by sub standard material used by the laboratory etc. Since the patient complains that it has occurred twice with two different dentists and labs it is unlikely to be due to the laboratory procedure. This can also happen if there are excessive forces acting on the dentures. These forces maybe due to para functional activity of jaws, due to movement disorders like Oro facial dyskinesia, bruxism ( night grinding) or simply hyper function. I cannot comment on what the cause for the chipping of teeth was or on the engineering principles that required the number of implants he had. This is because of my limited knowledge on the nuances of implantology and full mouth rehabilitation. However, I can comment on the line of action the patient chose to publicise this issue, either because of ignorance or despair or both.

5. If the patient assumed that there was negligence on the part of the dentist, he may well be right or wrong. That needs to be decided by experts on the direction of a legal or statutory authority and should be based on evidence based science. There are several provisions within the legal and statutory system to get relief and a due process of law to ascertain medical negligence. I, as the author of a book on medical law and having written several articles on the subject of medical negligence, feel strongly that the gentleman has used the social media as a tool to defame the dentist on the basis of his personal opinion. Medical negligence can only be decided based on evidence that a practitioner has caused injury by failing to meet the standards of care prescribed by evidence based medicine. The Supreme Court has repeatedly reiterated that mere dissatisfaction or the development of a complication does not constitute medical negligence. 

6. Under these circumstances the decision to take the matter to the public without any technical input and premised purely on the basis of personal experience or dissatisfaction amounts to subverting the provisions of law pertaining to medical negligence. Directly putting up complaints on the social media drawing attention to the professional abilities of their doctors and imputing motives to their actions amounts to civil and criminal defamation. This is particularly so because the nature of the post appears to be ad hominem ( personal).

My comments are a reaction to an increasing tendency of people to express their angst and targeting medical professionals in a way that affects their profession and standing in society. To do so, if they are indeed found negligent by a court of law, is different from making unqualified judgment based on personal experiences. 

The patient, in the above situation, can always go to court or approach the relevant statutory body to obtain relief. It must also be remembered that the doctor who has been vilified has the option of going to court for civil and criminal defamation against the patient for using the social media with the obvious intention of causing loss of face and reputation which the professional might have built up over several decades. This amounts to extra judicial vigilantism in the name of warning the public. 

Both doctors and patients must act within their remit, realising that both have rights, duties and responsibilities.

George Paul

Oral and Maxillofacial Surgeon

Consultant in Medical Law and Ethics

Attention members of DCI

AN OPEN LETTER TO THE PRESIDENT AND EC MEMBERS OF THE EXECUTIVE  COUNCIL OF THE DCI

Respected sirs and madams,

I happened to see a memo from the office of the DCI restricting the conduct of any kind of course not pre approved by the Dental Council of India ( No De-110(186)(complaint)-2018/457. This obviously sponsored notice, coming as it does at this point of time, seems to suggest that all programmes aimed at providing knowledge or refreshing skills must have the approval of the Dental Council of India. 

Respected president and members, I beg to differ, like thousands of others, because the DCI has no such powers to curtail the improvement or renewal of knowledge and skills from qualified persons with or without the sanction of the DCI. The notice cites sections 10, 10A, 10B, 51 and 52 to make the fallacious argument that the DCI is the custodian of all clinical learning or updating. It has freely and wrongly interpreted the meaning of the term ' qualification' to mean competence or acquisition of knowledge and skills. I hope the statutory body had spent a little more time taking a legal and grammatical opinion before coming out with such an ambiguously framed memo hindering the fundamental right to learn and benefit society.

Sirs and madams, the heading of section 10 of the Dentist Act refers to registrable qualification. I am sure that you are aware that the medical and dental statutory bodies regulate only registrable degrees which indeed are qualifications. The prime registrable degree in dentistry is BDS . A registered dentist with a BDS is allowed to practice dentistry including all specialties depending on their interest, ability and training. The postgraduate qualification is only an additional or add on registration. Add on Registration for post graduation essentially permits one to become a teacher in a college approved or recognised by the DCI. It does not provide exclusivity of clinical practice in a specialty, as India ' DOES NOT HAVE' a separate specialty register.

In other words, the members of the statutory body must understand, that a qualified BDS graduate can do Endodontics, Oral surgery, periodontics or orthodontics according to his expertise which is achieved through experience, practice and skill enhancing programmes. Where they obtain these additional skills within the purview of dentistry is not the business of the DCI . This is made clear in the definition of 'recognised dental qualification' in chapter1 (j) which includes only 'qualification in the schedule'. In which part of the schedule are there references to refresher courses recognised by DCI, sir??? 

Section 10(2) requires all these qualifications to be entered in the schedule. Which courses other than those offered by recognised dental colleges are included sirs? Are the courses conducted by IDA or Specialty associations part of the schedule? Does the DCI have powers and guidelines to include them? NO! Quoting section 51 and 52 in the aforesaid  memorandum/ notice is at best a wrong interpretation and at worst an attempt to mislead. These sections only refer to practice of registered dentists and has nothing to do with acquisition of further skills and knowledge by them. 

In fact the code of ethics regulation ( of which I was one of the draftees) encourages the acquisition of knowledge without conditions. It exhorts dentists to continuously upgrade skills in Chapter I, 3.2 and subsections. Nowhere does it say that imparting knowledge and giving a certificate of experience is unethical as implied in your notice.

Let me try to cite an example. Several hospitals provide Basic and Advanced life support training for a fee. The same with Trauma Life Support. Does the DCI have to whet every certificate programme in every hospital or institution in India and abroad to have a current training record in BLS, which you will agree is an essential part of safe practice. Skill renewal and enhancement can be provided in formal and informal settings with and without certification from a person with established skills. Dental practitioners get trained by other practitioners in the use of new techniques and materials. They attend courses conducted by industry pioneers and manufacturers of new devices and equipment. What has DCI to do with these?

Medical science has advanced only because of these courses which cannot be or has not been provided in teaching institutions during their limited course of study. In fact the need has arisen because many recognised dental colleges have not been able to provide the knowledge and skills as prescribed in the curriculum.

Sirs and madams, I request you to withdraw the memorandum which was issued in haste. If indeed the Dental Council wishes to bring in regulation for accreditation of providers of knowledge and skills, please create terms of reference, guidelines and make amendments to the constitution rather than issue fiats which retard the continuous enhancement of knowledge and skills by imposing unreasonable and unconstitutional bars on the dissemination of information.

Thanking you,

Your sincerely

George Paul

Reg No 10285 ( TNSDC)

Past President AOMSI