Dental Phobia by Chan Joon Yee
My friend – let’s call him C, had a problem. Actually it’s not really his problem, but his teenage daughter got pregnant – which kind of made it his predicament since he is a highly respected person with a solid reputation in his community. C’s daughter ended up flying off to a European country for an abortion cum holiday before returning to Singapore to attend school. The reason C took the trouble to do that had something to do with this piece of news.
The finer details are still being finalised, but the new Healthcare Services Bill is intended to better “safeguard the safety and well-being of patients” in the changing healthcare environment while enabling the development of new and innovative services that benefit patients. It is also supposed to strengthen governance and regulatory clarity for better continuity of care to patients. It is further assumed that HCS Bill – and the National Electronic Health Record (NEHR) that it mandates – address wider issues of “patient welfare”.
The obvious advantage of this system is that inaccurate or incomplete medical history will be a thing of the past. An unconscious patient brought into A&E will have all his drug allergies and current medical condition clearly displayed for the convenience of the attending physician – assuming he is correctly identified. The core data accessible to future attending physicians include 1) Patient Profile; 2) Events; 3) Diagnosis; 4) Operating Theatre Notes/Procedures/Treatments; 5) Discharge Summary; 6) Medications; 7) Laboratory Reports; 8) Radiology Reports; 9) Immunisation; and 10) Allergies.
The scheme will be implemented in 3 phases. By December 2020, all private medical and dental clinics must comply. Below are some answers to FAQ provided by MOH.
1. Who will be able to access my health records?
Only doctors who are caring for you will be able to access your records.
2. What kind of health information will be captured in the NEHR?
It will include your diagnosis, medications, allergies, and vaccination records. In addition, the system will capture operating theatre notes and procedures, as well as laboratory and radiology reports. It will not, however, include doctors’ personal case notes of each consultation. Yes, every liposuction and fat transfer to the butt that you had will be made known to the doctor giving you a flu shot in the arm.
3. Can my insurance company or employer look up my records through the company doctors?
If anyone wants to look up your records for purposes other than caring for your health, they will have to get explicit consent from you.
4. What if I don’t want anybody to look up my health records?
You can opt out of the NEHR. When you do so, your medical records will still be uploaded into the system, although doctors or other healthcare professionals will not be able to access them. The authorities have said that this will not change for now, although they are open to feedback on the issue.
5. Will all my old health records be uploaded into the NEHR system?
No, there will be no backdating of old health records. And of course, for some procedures, you don’t need to see the medical records to know that they have been performed.
6. What cybersecurity measures will be taken to make sure that all this sensitive information will be protected?
The authorities have said they will take measures similar to what the Inland Revenue Authority of Singapore uses to protect its tax database from hackers and other cybersecurity threats.
My friend C has many friends and colleagues who are doctors. We may assume that every one of them is professional in his/her approach, but we also happen to be one of the most judgemental societies in the world. Will C’s friends and colleagues not look at C’s daughter differently if they know that she had an abortion in her teens? Just look at the way we dis-incentivise single parenthood. I would think that “Victorian” is already a very kind word to use for the total lack of graciousness, compassion and flexibility in granting a faultless child his citizenship.
I seriously think that we need to fix such social stigmas and narrow-mindedness before we even think of implementing something as progressive as the NEHR. But given all the “safeguards” mentioned, does C have any reason to worry that the record of his teenage daughter’s abortion is going to follow her for life, visible to every future doctor that she sees? Maybe not, but would you take the risk if you were in C’s shoes? Wouldn’t it be safer to be totally off the record here? What all this point to, besides better continuity of care to patients as purported, is a boost to outbound medical tourism for procedures ranging from abortion to plastic surgery or treatment for psychiatric conditions and sexually transmitted diseases. The Bill works perfectly for a bunch of hogs, but fails miserably to take human weaknesses and social stigmas into consideration.
There is another issue. The elephant in the room, is that doctors will have to spend a good amount of money just plugging into the NEHR. Clinics whose patients don’t mind the tattered cushions in the waiting area and mouldy walls in the toilet must now fork out money for a business broadband account. It’s no longer optional.
Entering data also takes up time. All this will add to the administrative workload of doctors who are supposed to be clinicians. 30-year-old clinics which have not gone digital estimate that they need to fork out almost $17,000 for software/hardware and put in many hours of familiarisation trials to get started. All this will inevitably translate into higher medical costs. Another boost for outbound medical tourism.
Meanwhile, the policymakers who sit in trendy offices and hold trendy meetings (courtesy of our compliant taxpayers) go about their daily chore of generating more and more work for people whose response can only fall between voluntary acceptance or involuntary compliance.
Dental Phobia by Chan Joon Yee
Dentists have a very simple reason for advising their patients not to consume alcohol after an extraction. Alcohol causes vasodilatation and this may prolong bleeding. There are very few experienced dentists who haven’t had patients showing up at their clinics one day after extraction with a blood-stained pillow (sometimes only the pillow case), livid with fear (not with the loss of blood).
Even in such situations, blood loss is usually quite minimal. Actually, we should be more worried if blood does not reach the wound. Healing gets delayed and a condition called dry socket may occur. It is very painful and takes a while to recover; definitely not something you would rather have over slightly prolonged bleeding.
Dental Phobia by Chan Joon Yee
2017 has not been a good year for me. Business is down and it’s not just in one clinic or two, but practically every dentist I have talked to has complained about a fall in income this year. And it’s the same with my friends who are in the retail and construction business.
Usually, such “perceptions” are not taken seriously. Where are the numbers, the data obtained through surveys or the tracking of “loyalty points”? Not backed by big data and/or a string of abbreviations behind our names, our ideas can only be labelled as perceptions or opinions. Meanwhile, official media sing a very different tune.
Very few dentists who have to deal with the realities on the ground can agree with that headline. Shortage of dentists? They’ve got to be kidding, right? But they’re not. Predictably, this article and many others like it talks about aging population. It seems like common sense that an aging population would lead to a demand for more dentists. Well, yes and no. I’ll come to that in a moment.
Some years ago, I attended a lecture where the speaker showed graphs with dentist to population ratios as evidence that we in Singapore don’t have enough dentists. But the professor failed to mention that in some of those countries with a “healthy” dentist to population ratio, it could be a two-hour drive between two dentists and some practitioners even operate from the backyard of their homes.
In Singapore, how many dentists are there between two MRT stations? How many are there in one neighbourhood shopping mall or town centre? Dozens if not scores of them! There are two adjoining HDB blocks in Toa Payoh where there are three dental clinics and only two medical clinics. The uninitiated may think that folks in that estate must so dentally paranoid that they see the dentist a few times every month just to make sure that their fillings are still in place and their gingivitis scores are good. In reality, the clinics are barely able to make ends meet.
Make no mistake, it’s extremely challenging and competitive out there. So why is there a mismatch between what the big data tells the policy makers and the realty on the ground? The answer is hidden between the lines. The article above goes on to say that “In Singapore, this situation (shortage of dentists) is presently a lived reality in the dental profession. Here, foreign-trained dentists already made up the majority of new dentists registered in recent years.”
Is that even a fair indication that we don’t have enough dentists? The need for a majority of foreign dentists implies that there has been an exponential increase in demand for dental services and our local dentists can’t cope? You guessed it, it’s something else.
With the successful public listing of a chain of dental practices in Singapore, almost half a dozen wannabes have emerged in recent years. As you may have guessed again, most of these IPO hopefuls are backed by foreign investors. For a successful IPO, these dental practices need to demonstrate growth. The result? Dental clinics spawned throughout the island; sometimes even in the most unlikely places! In the past, a practitioner would nurture a practice for years before nurturing another. These days, they toss a bunch of seeds and hope they’ll grow by virtue of branding. If you plan to set up 100 clinics, of course you will need at least 100 dentists. If you don’t have 100 dentists, then of course there is a “shortage”. But is your aging population enough to sustain the 100 dental clinics that have been set up at today’s prohibitive costs?
Dentists without such lofty ambitions don’t care if foreigners want to flush their money down the drain. But this denied or ignored oversupply of dentists and dental services in the private sector is super-saturating the market, promoting vicious competition, desperate measures and even unhealthy practices like backstabbing and badmouthing within the profession.
There is another qualitative issue that increasing the number of dentists does not address. It is an irony that when the population was aging far slower decades ago, dentists then were more acquainted with extractions, dentures and other unsophisticated, quick fix treatment that the elderly would normally ask for. Today’s dentists are more into implants and orthodontics. A recent seminar on geriatric dentistry saw a pathetic number of participants. What do you expect? Clinic operating costs are high. A dental education is very expensive, so naturally the young and virile dentists go where the money is. So is there a mismatch between what dentists want to do and what the aging population needs? If there is, then training more dentists, setting up more clinics and importing more foreign talent simply won’t work. Does the argument for more dentists based on an aging population hold any water?
It really saddens people in the know to see the stark realities on the ground while policy makers continue to inflate the bubble based on some imaginary problem treated with the wrong medicine. Of course, all this cannot last forever. The sooner those foreign investors and academic experts can come to their senses, the better. I wish I could get out of the way when the bubble bursts.
Dental Phobia by Chan Joon Yee
Many people are under the impression that dentists earn a lot of money. Hence, whenever there’s any news that dentists may suffer a huge loss of income from some disruptive technology, the public would appear to have reason to celebrate. Here’s one. Researchers at King’s College London found that the drug Tideglusib stimulates the stem cells contained in the pulp of teeth so that they generate new dentine – the mineralised material under the enamel. This new drug has been touted as something that will end restorative dentistry with filling materials.
The Telegraph has the details here.
Not surprisingly, the article went viral, but exactly what was it trying to say when it suggested that “Teeth already have the capability of regenerating dentine if the pulp inside the tooth becomes exposed through a trauma or infection”
Any person with a basic knowledge of tooth development would know that this statement is untrue. First of all, the pulp forms secondary dentine all the time. However, the pulp does not push outwards as it forms the secondary dentine. It pushes inwards, painting itself into a corner if you will. That’s why young teeth have comparatively large pulp chambers while older teeth have smaller ones. As the tooth grows older, the pulp shrinks and becomes smaller and smaller. Meanwhile, the external surface of the tooth continues to wear out. No actual “regeneration” occurs.
A young, healthy tooth has a relatively large pulp chamber. The growth of new dentine forces the pulp inwards. There can be no change in the external dimensions of the tooth.
A young, healthy tooth has a relatively large pulp chamber.
The process of secondary dentine formation can be sped up when the pulp senses decay and mild irritation coming from the surface of the tooth. This is a protective measure and not a very ingenious one if you ask me. However, if the highly sensitive and fragile pulp tissue becomes exposed through trauma or infection, it almost always becomes non-vital. It is simply untrue that exposed, infected or injured pulp can still generate dentine as suggested by the article. Once the pulp has been exposed due to caries or trauma, root canal treatment is seldom avoidable.
Unless the evolution of human cell biology has taken a drastic turn, I don’t see how inserting a collagen sponge impregnated with some miracle drug can cause the pulp to build dentine outwards and fill up the cavity.
Dental Phobia by Chan Joon Yee
Long before the age of the internet in 1971, political scientist Herbert Simon said “….information consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention.”
So how big is the internet now? Have you been keeping count? There are 60 trillion websites out there and two million new books (mostly digital) are launched every year. Let’s not forget the 16,000 new films and 30 billion blog posts. It’s mind-boggling to say the least. How does one get noticed if one is running an inconspicuous dental practice in the heartlands? It was easy back in the early 2000s when few dentists advertised on Google or knew how to generate buzz and traffic on their sites. That was when I capitalised on my knowledge and brought my practice to the next level.
But within a few years, clueless folks running “generic” internet marketing services came into the scene. They didn’t manage to make dental websites more interesting, but they certainly managed to bid Google ad rates to stratospheric heights. As early as 2006, I had to find ways to avoid bidding against the fools. A keyword like “dental implants” was going at $50 per click at one time. I could have run a Google Adsense on a site to earn money from clicks on my competitors’ ads, but these sites would compete for eyeballs with my own clinic website. A bit counter-productive there.
I decided to rely on my writing and creativity to attract hits while avoiding the trappings of Google ads which would burn a hole in the dentist’s pocket. And many a teething dental practice must have wasted a ton of money paying the “professionals” to promote their sites.
The 10/2016 issue of Dental Tribune recommended 9 tips for dentists to make their sites more visible to the public. Let me evaluate them from a Singaporean point of view.
Short for search engine optimisation and make no mistake, though SEO is free if you DIY, there is an enormous amount of competition in this area and for the shopper, finding your site is only the beginning. Does your website impress him/her without giving your competitors an excuse to complain to the authorities?
2. Google review
Few people will do it unless the rewards are substantial. It may also get you into trouble if a competitor complains that you are paying people to give reviews. Some dental practices sponsor bloggers and get them to give positive reviews on their blogs. This works, but it’s not a magic bullet and may lie in the “grey area” as far as regulations are concerned. I have not heard of anyone getting into trouble for getting bloggers to post positive reviews.
3. Connect with patients
Would anyone want to connect with you unless you are offering some spectacularly different treatment (which you can’t advertise to that effect) or have some interesting non-dental content? And if you generate content which are considered “unbecoming of the profession”, you’ll also get into trouble when a competitor complains.
4. Engage through video
If you’re not into YouTube, forget it. Testimonials are not allowed on your site and the Dental Council states specifically that you cannot initiate contact with potential patients online.
5. Collect email addresses by sponsoring free wi-fi
That’s a good one, but I doubt it’s cost effective. Users may just unsubscribe once they don’t need your wi-fi.
6. Publishing newsletters.
Yao mo gao chor ah? I don’t mind writing the newsletter for you for a fee, but honestly, I don’t think anyone would read it. I can write in such a way that people will read it, but then, that will certainly get you into trouble if your competitor complains.
7. Deal with online enquiries in a polished manner.
Of course, but make sure you have the time outside clinical sessions to do that. You can’t expect your assistant to be able to do it in a “polished manner”.
8. Create memorable new patient experience.
Definitely, but then, it’s a bit off topic as far as marketing and getting noticed is concerned.
9. Employ a strict end-of-treatment protocol to collect reviews, feedback and testimonials.
Again, you can’t publicise these reviews or else you’ll get into trouble if a competitor complains.
To sum up, most of the “tips” given in Dental Tribune is quite useless. Marketing dental practices online with cool and engaging content will still draw the eyeballs and give you superior traffic over your competitors, but the authorities in Singapore may jump on you if someone complains about the kind of content you use to generate traffic. This leaves you the expensive options of using Google or Facebook ads (which the article discourages) or the even more expensive option of holding public seminars. What to do? Our hands are tied.
Dental Phobia by Chan Joon Yee