Corporate Hospitals - A Boon?

By god’s grace, I do not have much experience of the corporate hospitals which are supposed to be the shining (literally) symbols of India’s advancement in health care. I have visited them a few times for consultations, the outcome of which, have been very satisfactory. The fact is that the hospitals had nothing to do with the outcome. What mattered was the doctors whom we consulted. Had we consulted the same doctors in places other than these hospitals, I would have saved a hundred or two on consultation fees but I will not grudge that. The hospital provided comfortable parking space, waiting space and most importantly, clean toilets, and I consider these facilities worth the extra money spent.

Quite a number of my friends and relatives have visited these hospitals for surgeries and other procedures and have expressed satisfaction. At the same time almost all of them have mentioned the fact that they have found the hospitals very expensive. Some of them have complained about unnecessary investigations and procedures but that is part of the ‘health care business’. I have no idea about the economics of these establishments but even as a layman I can see that maintenance of these establishments must be quite expensive. Obviously, to recover their cost plus profit, the hospitals must charge the patients a lot. And since they have to maximize profits they find different ways of charging the patient. Recently I heard about the changes in functioning of the dental clinic in one of the corporate hospitals in Goa and if that is how the other departments are also run, one need not wonder why they are so expensive.

This hospital had a dental clinic and had appointed a dentist on a monthly salary. But for the fact that the clinic is located in a swanky building with a big name, the dental set up is the same as any of the hundreds of dental clinics run by individual dentists in any city. For some of the procedures beyond the capabilities of the ‘in house’ dentist, the hospital called a specialist, who was paid on 'per case' basis.

Let us consider a surgical extraction for which the specialist is called. The procedure done in an ordinary dental clinic, by a visiting specialist, would cost the patient about Rs 1500 - 2000. The same procedure performed by the same specialist in this hospital was being charged Rs 3500. The specialist would get Rs 1500 and the rest went to the hospital.

Now, the hospital decided to outsource dental services. A company which is in the business of running dental clinics in corporate hospitals all over the country has taken the contract. The company sets up its own equipment, maintains it and also appoints a dentist. The hospital gets a fabulous rent - 3 lakh if what I hear is right - for the space provided for the dental clinic. The company has retained the same specialist who used to attend the hospital earlier, but, it now charges Rs 7000 for the procedure which was being charged Rs 3500. The specialist gets the same Rs1500, the company keeps Rs 2500 and the hospital gets its share of Rs 3000! This is apart from the rent.   

The company running the clinic banks on the name of the hospital and the volumes generated by running such clinics all over the country. The hospital provides its name to the clinic but has nothing to do with the quality of service. It just collects a tidy rent as well as a share of the fee. The hospital exploits the company and the company exploits both the dentist and the patient.  

If you ask me what is that I am trying to convey here, I have no answer. I am just placing here a fact that came to my notice. 

Pleasing The Planets

Tulsi - Holy Basil

I got up earlier than usual and since it felt very pleasant outside, decided to go out and water the plants. I stood there watering the plants and enjoying the fragrance of jasmine when my neighbour’s gate opened with a clatter and his wife came out.

“May I take some ‘Tulsi’ (holy basil) from your yard?”

I have plenty of Tulsi around my house and I asked her to help herself. She came in. Usually I see her in the compound around six in the morning but now it was not even five. I was wondering why she is up so early when she spoke “We are doing a pooja today and it has to be done at the right time to be effective. The ‘muhurt’ is very early.” She paused and answered the question that was forming in my mind. “You see, our daughter is in twelfth standard and she is not getting good percentage. Maths was bringing the percentage down. So she stopped maths and opted for psychology. Still there is no improvement. So we have had her ‘patrika’ (horoscope) examined and ‘Bhatji’ said that some of the planets are not favouring her studies. He suggested this pooja and we hope that she will do well after this. Let us see. Twelfth standard is the turning point no? We have to do all we can.” She collected enough Tulsi to satisfy all the gods and planets and left.

Now, some of you may say that it is all nonsense. Don’t say that. The planets are really helpful if only you know what to do with them. They have helped ‘Bhatji’ and others like him a lot. If you have any doubt just switch on ETV Kannada or Udaya TV  between eight and nine in the morning and count the number of diamond rings on ‘Guruji’s fingers!   

Disclaimer: I have only stated facts and do not intend hurting anybody’s sentiments. Religious, planetary, monetary or otherwise!

Fooled By the Fruit Bat

Whenever I find the half eaten guava fruits lying on the ground under the guava tree, I look up hoping to find more fruits up there. I usually find some small fruits yet to ripen and make it a point to keep watching them and get at them as soon as they ripen. Before the fruit bat. But the bat almost always beats me.  

I was watering the plants under the tree last evening and casually looked up. I found two fruits just right on one of the upper branches. 

I tried to reach them with the hook like contraption that I have made for the purpose (using a stick, discarded copper pipes, electric wire tags and ‘duck’ tape) but they were beyond my reach.

If I can’t reach them from the ground, I usually can reach them from above, from the balcony. I eagerly ran upstairs, happy to have beaten the fruit bat this time. I bent down from the balcony, much beyond the limit,  risking losing my balance and falling down, and parted the leaves. This is what I found.

The other fruit was still green, not ripe. I heard someone laughing. But the bat was not to be seen.

Not A Medicine At All !!

Mr Venkateshan came to the clinic to get his tooth removed. He is around eighty. Whenever he comes, he invariably mentions his son, whom he says is the best ‘Heart Transplant Surgeon’ in Melbourne. And he also mentions the fact that his son has kept an old pair of his (Mr Venkareshan’s) footwear with him and that he goes to work only after paying respects to them every morning. Mr Venkateshan is obviously very proud of his son and justifiably so. “I told my son that I am getting my tooth removed today. He wanted to know whom I am going to. I told him that I have one of the best dentists right here in Ponda and not to worry”. Needless to say my ego leaped up three steps. I examined the tooth, thought that it might not be very difficult to pull it out and prepared for the extraction. Then I asked him the usual set of questions.

“How is your general health sir?”

“I am fine doctor. See I am eighty but I don’t have any trouble. I drive the  car myself”

“So, you do not have any of the common ailments? Diabetes, blood pressure, heart conditions?”

“Nothing doctor. I am fine. My son arranged for a detailed check up when I went to Australia six months back. They certified me perfect.”

“Oh, that’s very good to hear. Did they suggest any preventive medications?”

“No doctor”

“So, you don’t take any medicines on a daily basis?”

“Nothing doctor. I told you. Why do you want me to take medicines? God has kept me in good health and please let me remain like that”

“I hope you remain so for ever sir, I just wanted to make sure. That’s all”

I did the extraction. It was a bit difficult. The tooth was very long and very firm. But it was OK. I made him sit in the clinic for nearly half an hour, checked for bleeding, confirmed that he was fine and sent him off with few painkillers.

Around five in the evening I received a call from him.

“Doctor I am sorry to disturb you but you see there was some trouble”

“What happened?”

“There was no bleeding when I left your clinic but it started bleeding afterwards. I had a very difficult time”

My heart missed a beat. It always does. Whenever a patient complaints of bleeding after extraction. I have removed may be seventy or eighty thousand teeth and have handled hundreds of bleeding cases but this complaint always makes me anxious and nervous. And if a close relative is a doctor, I am likely to face a court martial for even minor complications.

Once it so happened that a lady who had a heart condition fainted after injection of the local anaesthetic. It was a case of ‘Vaso vagal syncope’, meaning a short spell of fainting triggered by fear (of injection or extraction), or a stimulus like an injection pain or such other ‘trigger’. It had nothing to do with the heart condition and I had taken all the precautions. She recovered and the tooth was removed. But the next day I had to face an inquiry from her brother who called from US.

“Doctor did you check her blood pressure before injecting?”

“What Local anaesthetic was used? Did it contain adrenaline?”

“Had you prescribed antibiotics before extraction?”

“Do you use disposable syringes?”

So on and so forth. So, I was concerned on hearing about the bleeding. About Mr Venkateshan and also about myself. I enquired anxiously,

“How are you now sir?”

“Now it is better” He drawled “I called you just to inform about it.” My heart slowed down a bit. “You see it was my fault. I should have told you that I am taking Warfarin tablets every day” (‘blood thinners’ - medicines which prevent clotting of blood)

“But sir, I did ask you if you take any medicines on a daily basis”

“Of course you did doctor. I told you it was my fault. You see I am taking this tablet for more than twenty years and it has become natural for me like my morning cup of tea. I don’t consider that to be a medicine at all” !!!

This time I was lucky. There was no complication and no court martial. I have come across this tendency a few times in the past. One tablet for cholesterol or half a tablet for blood pressure taken daily is not considered ‘Medicine’. I will have to learn to rephrase my questions in future. 

Give Up 'Ghutka' ? - Truely Dental Diary

Mr Virani owns a small industrial unit in our city. He manufactures metal furniture. He has a number of people working for him and I often receive calls from him requesting favour of ‘instant treatment - without appointment’ for his workers. He seems to be a nice man no doubt, but this request is not an indication of his concern towards the well being of his employees. It is because he does not want them to avoid work giving the reason of a tooth ache. Anyway, I am not here to analyse Mr Virani’s attitude towards his employees. My job is to treat the patients and I try to do my best. And the employees get the benefit of getting Mr Virani’s vehicle for the trip to my clinic and the visit is considered ‘on duty’.

Yesterday I received a call from him and within half an hour one of his workers was in the clinic.  Mr Virani firmly believes that if a tooth is causing pain, the best thing to do is to pull it out. No medications, temporary fillings, RCTs and such other nonsense for him. Go to the dentist, wait for an hour if necessary, get the tooth out and get back to work. That is what he wants for himself as well as his employees. “Doctor saab daat dard kar raha hai. Abhi aataa hoon. Nikaal dena.” And “Doctor saab unko phirse mat bulao. Abhi daat nikaalke bhejo” (Doctor, tooth is paining. I am coming now. Please remove it” And “Doctor, don’t call him again and again. Pull out his tooth right now and send him back"). What is good for him must be good for his employees too. It is not always possible to oblige Mr Virani and help him maintain his production schedule. I go by my assessment of the case and not by Mr Virani’s insistence. But sometimes I can oblige him. This seemed to be one such. The fellow who was in the clinic, said that one of his teeth was shaking and was very painful.

I put him on the chair and examined him. The tooth was mobile and tender ( Patients complaint - in our language). The best thing would be to remove it then and there and he would not even need a pain killer. Two minutes flat. Thirty seconds for the injection, one minute for the injection to take effect. Thirty seconds to pull the tooth out.  Over.  All are happy. Patient, because the pain is gone like magic. Virani, because his worker is back to work in fifteen minutes flat. And me, because my appointment schedule is not at all affected and I get a bit of extra money without any effort. But it was not like that. There was something disturbing here. Take a look at the picture.

The fellow is little over twenty years in age and already has a shaky tooth. Not good. I am sure you can guess which is the tooth I am talking about. Yes, the third grinder from the back. You can see something black below the tooth. That is the root of the tooth, which, in normal case should not be exposed. And it is black. The result of the tooth being in constant contact with tobacco. A wad of ‘Ghutka’ to be precise. Ghutka has not just destroyed his gums, it has affected the inside ‘skin’ of his cheek. What we call as the 'buccal mucous membrane'. It is not difficult to notice a sort of elevated or thickened, off white or yellowish patch next to the tooth, easily differentiated from the pink mucous membrane around. That patch is a ‘precancerous lesion’. Meaning something that has the potential to turn into full blown oral cancer. At an age little over twenty.

I see many ‘Ghutka’ chewers in my clinic, who mostly visit me to have their tobacco stained teeth cleaned. I hate that job but cannot evade it. More than my hatred towards this cleaning job is my hatred towards these tobacco chewers in general. Every nerve end in my body burns with irritation when I see these people spitting tobacco juice everywhere - once every minute - without any concern, as if they own the world. I can’t do anything and I just allow my stomach lining to get burnt. But when they are in the chair it is a different situation. I treat them alright but I also deliver a sermon which lasts through the session. And sometimes it will be quite a fiery one. I also try to put all sorts of fears, real of course - though a bit exaggerated, in their mind to make them give up ‘Ghutka’. I know it is not of much use but I try.

As I injected, I started my sermon for the benefit of the fellow who was in the chair. I told him that his case was much more serious than the ones that I usually see and if he persists with the addiction he may end up with cancer. I gave him five years, ten at the most. I finished the extraction asking him what prevents him from giving up this dirty habit? I put a pack in his mouth and sent him off. He went out sheepishly.

 After I finished the next case he entered again and stood silently in a corner. I asked him what was the matter

“You see Doctor saab” he said (in hindi) “I don’t like to chew this stuff all the time but I need it to carry me through the day. I work for nearly ten hours at a stretch with a break of half an hour and it is an exacting job. To do this work for ten hours, I need to eat a lot. But the salary I get is barely enough for two meals and if I don’t work I do not get even that. I am always hungry. A cup of tea costs five rupees and it is almost water. If I put one packet of Ghutka in my mouth it kills my hunger and I can easily carry on for two to three hours.Three packets of Ghutka costing six rupees see me through the day. You say that I will not live more than ten years if I keep eating Ghutka. If I don't, I will die of hunger, much earlier. How am I going to manage if I stop chewing Ghutka?”

I did not know what to say. Look at the fellow, observe his cloths and you can appreciate his words better. Now what am I going to do? Ask his employer to raise his salary? Provide him other employment which is more paying? Suggest that he find an easier job? Suggest him any other remedy?  Write to the labour department?           

I do not have an answer. If you have, please let me know.