IS YOUR DENTIST REALLY RIPPING YOU OFF??

No one says that going to the dentist is fun. Having someone intensely examine inside one’s mouth, picking at the teeth is very uncomfortable. But that does not mean one should avoid the dentist at all costs either. The mouth is one of the most important parts of the body. It’s here that one eats, breathes and talks to other people, so it’s important to keep it healthy. But what about the expense? After all, dental work is considered to be super expensive, and those who have visited a dentist, or considered it, know that even the most basic dental procedures can be quite costly, with people often landing up in the hands of quacks to avoid the expenditure, leading up to numerous complications.

While it is very easy to see how expensive it is, it’s wrong to assume that the dentist keeps all of the money one pays. Dentistry has very high overhead costs. Dentists have to pay for equipment costs, dental materials, personnel, educational loans, and for new technology, and these costs quickly add up. These are just a few of the expenses any dental office has.

There are a number of reasons why dental procedures are so expensive. First, services are performed by trained professionals. Dentists go through many years of studying and training (priced in lakhs of rupees). Like many other professionals, dental services are priced accordingly. Dentistry is not a commodity. It is a professional service that's both art and a science. Yes, there are excellent dentists and not-so-great dentists or quacks, not at all caring for the patient’s health, providing services at dirt-cheap rates. Often, one gets what one pays for.

Dental services are not mass produced.  While a patient may have been in the dental clinic for 60 minutes for a crown preparation, the dental team spends additional time working on the impressions, making models, disinfecting the impressions, preparing them for transport to the lab and communicating with the lab. Sometimes dentists might also spend an additional hour or two, working on a case long after the patient leaves the office. This attention to detail takes time and costs money.

Dentists have far more equipment than most medical physicians have. The tools on hand, at a general dentistry practice, include highly specialized equipment that is not only pricey to purchase, but also to maintain. X-ray machines and dental chairs with the necessary light, trays and hookups, are really expensive. These alone cost as much as some cars do. This, of course, doesn't take into account the costs of the instruments, as well as the materials and other medications used in procedures.

A good, competent dentist would always invest in the best equipment. Dental equipment costs have skyrocketed with the increase in technologies used in dentistry today. It is not uncommon for an average size office equipped with latest technology to have lakhs of rupees invested in the equipment alone. What the patient pays helps pay for the equipment dentists use to make their visit quick and comfortable.

Every piece of equipment in a dental clinic is maintained to strict standards so as to minimize the risk of any infection. The water that comes out of the dental units is first treated to prevent any bacteria or viruses from forming a film in the water lines.  Instruments are cleaned in ultrasonic cleaners, packaged and autoclaved between each use.  Suction machines are disinfected and treated to prevent the spread of infection. The autoclaves are monitored by an outside agency to verify and document their effectiveness.  X-ray machines are calibrated and tested by the appropriate regulatory agencies annually.  Dental chairs are disinfected daily. All of this attention to patient health and safety takes employee time and costs money.

The education costs in becoming a dentist (much like the costs of becoming a lawyer) are astronomical. A big difference in the lawyer, though, is the above-mentioned equipment that the dental facilities have.

Dentists often turn to third-party labs for things like crowns and dentures, which are really expensive- the material cost of a crown is probably more than half the total fee of the dentist. Various dental labs differ in the quality of the products they produce. People want their dentists to be using high-quality labs for things like crowns and dentures, which, in turn, cost more. Dentists also always want to use a good lab, because if the crown breaks, they are the one stuck redoing the thing for another hour for free. It doesn't make them look good, the patients get angry, and it's a waste of time. All this can also drive up the costs of certain procedures.

Almost all dentists have an assistant on staff. And, unlike many other medical professions, there are almost always TWO people working on patients at all times- the dentist, and his or her assistant.

In all of the above, there is no mention of the normal expenses that any office has, like rent, electricity, advertising, etc. There's also continued education (again, very expensive).

Anywhere from 60% to 80% of what a patient pays goes toward the expense of running a modern dental practice. Dentists pay for rent on their clinic space, payroll for assistants and receptionists, taxes, and material supplies- just to name a few. People would be surprised to know how tight the profit margins are.

Add the entire cost up, and there is an overhead number that is simply amazing in how large it is. Most people won't believe this, but nobody becomes a dentist to get rich, especially a general dentist. When dentists charge for a root canal / crown combo that they spend an hour and a half on, they are making less than many accountants or lawyers.

Teeth are a crucial part of health and appearance. Untreated gum disease, for instance, is linked to heart disease (would one choose a cardiologist based on price?). The realization is important that shopping price is a minor concern when it comes to health. Any minor cost differences calculated over a lifetime becomes insignificant.

Dentists love their profession, and it does afford them a solid middle-class lifestyle, and allows them to put something away for later as well. But dentists are hardly getting rich here. They have also done their share of free work (meaning they don't get paid), and they'll always try and make themselves affordable to anyone who wants to visit them.

Every dentist works hard to balance the expense in providing quality care with the need to keep fees under control. So the next time a thought comes in one’s mind that the dentists are charging too much, maybe they are just doing it just right.

TERMINAL SEDATION: HARD CHOICE FOR A COMFORTABLE DEATH

“In almost every room people are sleeping, but not like babies. This is not the carefree sleep that would restore them to rise and shine for another day. It is the sleep before, and sometimes until, ‘DEATH’.” They are sleeping because their organs are shutting down, the natural process of death by disease. But they have been rendered unconscious by strong drugs.

Their life would end not with a bang, but with the drip, drip, drip of an I.V. drug that has put them into a slumber from which they would never awaken. The drugs are strong sedatives and opioid analgesics, to kill pain. This combination can slow breathing and heart rate, and may make it impossible for the patients to eat or drink. In so doing, it can hasten death.

These patients are receiving what doctors call “Terminal or Palliative Sedation”, a treatment that is already widely being used, even as it displeases many individuals and a profession whose paramount rule is to do no harm.  Terminal sedation is a treatment administered when other treatments are not sufficiently effective, and which aims at keeping a severely suffering patient unconscious in the proximity of death. Relevant indications are agitation, fear of suffocating, sleeplessness, and states of severe pain.

It is based on carefully thought-out ethical principles in which the goal is never to end someone’s life, but only to make the patient more comfortable. But the possibility that the process might speed death has some people contending that the practice is a form of “slow euthanasia  (intentionally ending life in order to relieve pain and suffering),” and that doctors who say otherwise, are fooling themselves and their patients.

There is little information about how many patients are terminally sedated, and under what circumstances. Estimates have ranged from 2 percent of terminal patients to more than 50 percent (doctors are often reluctant to discuss particular cases out of fear that their intentions will be misunderstood).

While there are universally accepted protocols for treating conditions like flu and diabetes, this is not true for the management of a person’s last days. Indeed, a review of a decade of medical literature on terminal sedation and interviews with doctors suggest that there is less than unanimity on which drugs are appropriate to use or even on the precise definition of terminal sedation.

The most pointed question is that is it possible that a person under deep sedation could still be feeling pain, and how would the doctors know? There is no way to know when is a patient’s last day, and under normal circumstances, he might outlive many “healthy” individuals. Whether the patients would have lived a few days longer is one of the more prickly unknowns in palliative medicine. It is a difficult subject to discuss. But there is one ethical guidepost for all the protocols: Terminal sedation should not become so routine that the end of life is scheduled like elective surgery, for the convenience of the doctor or the family, or because the patient’s care is no longer economically viable.

Palliative care includes treatment “furnished for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death.” Relatives of a patient who is suffering from a terminal illness and who is experiencing great pain, should have no legal barriers, and be free to decide whether they want their dear one to obtain medication, from qualified physicians, to alleviate that suffering, even to the point of causing unconsciousness and hastening death.

The main distinction between terminal sedation and euthanasia is time. Terminal sedation leads inexorably to death, but “not too quickly” Terminal sedation is a selfless act, because the relatives might be giving up an extra day or two of communication with the person they love. Even when many people agree that terminal sedation is a humane response to unyielding suffering, many doctors seem to feel a prick of conscience.

Doctors should not “forsake” patients by telling them they can do nothing for them. If there is no cure, they can at least offer comfort. Doctors are not gods who can cure everything, and at some point in time they have to accept that. It is the mark of an honest doctor who understands when that time has come.

DOCTORS: GODS OR SOMETHING ELSE?? (PART III)

Take the brightest youngsters and put them through rigorous, expensive and prolonged 5 year training program. Once graduated, tell them there are no government jobs for them. Tell them no campus placements by private enterprise for them either. Make them work on stipends as residents, trainees while exploiting them to the maximum, simultaneously charging them in lakhs for the "training". After post-graduations and super-specializations, with no resources of their own and having depleted their parental resources, tell them to buy land of prescribed area in commercial location to start private enterprise at commercial rates. If not, then work in some corporate hospital after deleting own conscience and do as told. Even as self employed, do not earn more than subsistence money. Charge rates as decided by government even in private "commercial setups" while paying commercial water , electricity, complying with labour laws, register with shops and commercial establishment act provisions, while using drugs which are the cheapest available, but be prepared to pay in crores as compensation after failing to guarantee cure in a very sick person. See emergency patients and stabilize them at minimal or free of cost. Be prepared to be beaten, abused, equipment and property vandalized besides being arrested.

Doctors today are threatened, victimized, beaten up, hauled up to courts on flimsy grounds, and harassed by various officials under various Acts and Laws. There are reports of doctors been killed by irate patient relatives, who are beaten up on duty by policemen and relatives. This is despite the fact that our work is the noblest of all and our intention is always good. Government does not give any encouragement or subsidy to health sector (specially small and medium healthcare establishments) and despite all this nearly 70% of healthcare of this nation is in hands of small private clinics and nursing homes who do their job professionally within their limitations. Lopsided policies of the Government favor corporate healthcare instead.

Doctors today are unemployed and underpaid. Medical degrees have been devalued by being officially equated with a 3 year B.Sc. Community Health Graduate and Ayush Practitioners. Defeating its doctors in this unilateral undeclared war that the government is waging cannot be good for the country.

Doctors have recently become targets for all and sundry and are blamed for all that ails the society. Their very working is made suspect by repeated televised TRP seeking programs. Wish doctors could speak so freely of the judicial corruption or of paid news programs or of organized corporate rip off or of political loot.

Quality is not what people want. Their concern here is only TRPs and political mileage. If anything is wrong in medical profession it is the blatant and state sponsored quackery supported by advertisement revenue rich press. What is deplorable are nauseating TV programs and advertisements promoting "Tabeez" to cure AIDS, cancer, asthma in clear contravention of Drugs and Magic Remedies Act. The unfortunate habit among Indian patients for over the counter purchase of even schedule-X drugs and repeat self medication from prescription once taken years ago from their doctor, are issues which need to be tackled urgently.

It is strange that despite all the “so-called” organized loot being done by doctors, they are nowhere among the top 100 or 500 richest persons in any city. Only less than 3% doctors earn more than rupees 5 lakh per month total income from all sources, including their so-called cuts and commissions, despite long years of hard toil. Doctors find working in other countries as labour and working as taxi drivers and carpenters better than working as a doctor in India.

The day still seems far-off when doctors will have powers of "Contempt of Doctor" or the gumption to sue a TV channel for slander.

DOCTORS: GODS OR SOMETHING ELSE?? (PART II)

As with anyone else, doctors also have only one life, which they choose to spend helping others. In the modern era, it is a crime to be living for others. Doctors are next to God, very respectable, yet their mistakes become villainous immediately when something goes wrong.

As for the other side, like in every field, there are greedy among doctors. They ruin the reputation of the profession. But a single doctor cannot do anything. Those who try to change the system are boycotted, thrown away or maligned. Every doctor cannot afford to start a hospital of his own. He has to choose a specialty hospital which has all the facilities to practice his specialty. These come at a price. There is heavy money to be paid for the machines, acquiring the skills, manpower, and the maintenance required to make these facilities available. Hospitals have their systems. A single doctor cannot change them. Also, not all hospitals are corrupt.

The Medical councils do not have any protocol / system to protect a doctor who faces vindictive attitude from hospitals if he / she want to argue. Many specialists have already left India, never to return back due to this one reason. Because specialist practice is based upon referrals, and where most of the referral system itself is corrupt, one has little hope of survival especially in a decent city / town.

Doctors are a weak vote bank, hence not on priority of any party. It is more practical for the politicians to openly criticize the doctor / profession in hope of gaining public sympathy / attention. No one wants to attend to their problems, which are many.

The medical council never protects any doctor against court cases or a hospital victimizing them for fighting against corruption. The regulations made are primitive. It is not that the medical council does not know about the prevalent corruption, but it opts to fit in some screws when the whole building needs extensive repairs.

One’s degree and education of many years becomes meaningless in the eyes of medical council just because there is delay in renewal of licenses. While many people practice without degrees or knowledge, the councils choose to target the qualified for not renewing their licenses. It includes a process that involves acquiring points by attending conferences. The money for most such events, travel etc. comes from pharmaceutical companies. They do not have the online option of conferences / license renewal like most western countries, even in this advanced age. So a doctor is expected to leave his town and practice, get involved in events sponsored by pharmaceutical companies, travel with their help, stay in hotels with their money so as to renew his license, but not online. And there is no compulsion that he has to attend the event for his specialty. So a neurologist can attend a gynecology event just for conference points and it is alright for the renewal of his Neurology license. One can even easily get such points without attending the event. There has to be an online option, or a rethinking of this whole business, and an option to do it without involving pharmaceutical companies.

Also, most of the medical insurance companies in India are fraud. They do not pay for OPD consultation / investigations of a patient, even if serious, or patients with genuine illness, if no injectable drugs are used and / or surgery is not performed, or when they do not understand the diagnosis, or the fact that some cases do not have a proper diagnosis, or emergency / critical care / specialist charges etc. Even when they pay, it is their choice how much.

It leads to many wrong practices. In a medical insurance case, no one benefits except the company. The patients, hospitals and doctors, all lose. Still, the medical council does not want to do anything.

Add to these the incessant calls for any enquiries that pop up in the patient’s or relatives (usually the cousin in America) mind at any time of the day or night, and bitter words to follow if reply is delayed. (“That doctor has advised this particular line of treatment, what is your opinion?”) No doctor from the western world gives his mobile phone number to patients.  Then there are many patients whose children stay abroad, but leave their parents back in India. They expect the same care but at a low price, and also a daily update by the treating doctor. They don’t want to come and attend their dying parents, but vent out this guilt in form of anger towards the treating doctor (“Do everything doctor, don’t worry about the money” or “I am unable to come to attend my father because of business meetings/ no tickets / kid’s exams” etc).

A doctor should not be held negligent if the patient does not follow advice as written, or continues doing anything that the doctor has prohibited, does not follow up as directed, does not show the same care towards his own life that the doctor is expected to take, has not given all correct information about himself / herself / his/ her illness, hidden some information from the treating doctor, has lost treatment details, self medication / cross consultation without knowledge of the doctor, resulting in multiple medications, or has had unknown allergies / reactions in the past. There should be a doctor’s board for each specialty which opines about every particular medico-legal case before the court makes its final decision.

If the whole medical system becomes non corrupt, patients will end up paying far higher consultation / surgical fees than what is paid now. This is inevitable. Add the legalities to everything, and many specialists will become non-affordable / non available to most. Many who get free treatment now would be denied the privilege. Else, the next generations will see less and less specialists opting to settle in India.

Doctors love their profession, love their country, and love their patients too. But they also deserve a good life. May God always guide doctors to always do good to their patients.