Sunday, September 9, 2012

Medical education in India: Time to encourage cross-talk between different streams


India is a country where medical pluralism is officially recognized and encouraged. Currently India recognizes six different healthcare systems along with the conventional medicine (Allopathy or Biomedicine). India follows a ‘parallel’ kind of policy model where the conventional medicine and other indigenous systems of medicine (referred collectively as ASU- Ayurveda, Siddha and Unani or, ISM-Indian Systems of Medicine), are placed ‘parallel to each other’. Because of such a policy, however, there is no official provision for cross-talk between the professionals belonging to these different streams during medical education, research and practice. This has in fact given rise to mutual misgivings among these healthcare professionals regarding the strengths and weaknesses of each other.

In this write-up, I argue that it is the right time to encourage some kind of cross-talk among the professionals of different streams of healthcare systems in the Indian context to enable our country to take care of its varied healthcare needs effectively. I further suggest that introducing an ASU module in the current MBBS curriculum would be one such concrete step that would help in building an atmosphere of mutual trust and mutual respect among the healthcare professionals of various streams, which would improve the healthcare delivery system of the country. Encouraging ASU institutions to hire biomedicine experts to give instructions in the areas of their expertise is another suggestion that will be discussed.

The current scenario of ASU education in India:

According to a recent report, there are currently more than 300 undergraduate colleges and more than 50 postgraduate colleges that produce graduates in ASU streams of medicine in India. The syllabi of these programs contain a huge number of topics related to conventional biomedicine. However, the number of ASU institutions asking the biomedicine experts to teach these topics to their students is extremely low. The governing body CCIM too doesn’t make it compulsory for such topics to be taught by the experts in the relevant fields. Therefore, the teachers teaching some ASU subjects also teach the relevant biomedical subjects such as anatomy, biochemistry, pathology, physiology, surgery. Therefore, it can be assumed that the quality of instruction in these topics that ASU students receive is possibly inferior.

The scenario is different in the medical colleges, because, the governing council, MCI does not think it necessary to include even the essentials of ASU related topics in the undergraduate or post graduate curricula. Therefore, there exists a perceivable gap between ASU and conventional healthcare professionals when it comes to ‘awareness about the domain knowledge of each other’.

Problems with the existing system of medical education and practice:

1. MBBS graduates don’t know what interventions their patients might have been subjected to

It is estimated that about 60-70% of the population in India resorts to one or the other ASU modalities of interventions for their healthcare needs. ASU systems employ various kinds of interventions like Panchakarma, dietetics, herbal preparations, herbo-mineral preparations and so on. Graduates in conventional medicine, however, are not aware of these interventions. They are neither exposed to the theoretical constructs of ASU systems, nor to their possible health benefits. They are not even exposed to their possible adverse effects. There is increasingly available literature on herb-drug interactions, food-drug interaction and drug-drug interactions, and therefore, in all possibilities, these are being overlooked by the medical practitioners currently. This not only creates hindrances in the anticipated outcome, but also puts patients at increased health risks.

2. MBBS graduates don’t know when to refer their patients to ASU practitioners

While there are several reports highlighting the positive outcome associated with ASU interventions in several health conditions, especially those related with chronic non infectious diseases, graduates in conventional medicine don’t know what kind of cases can be referred to ASU hospitals. Conditions like fistula in ano, for example, are better treated with Ksharasutra therapy than with many other conventional methods. However, the referral taking place even in such cases is only marginal. Similarly, several studies on the effect of Ayurveda interventions in conditions like rheumatoid arthritis have been published, to which, conventional medical graduates are not introduced.

3. MBBS graduates are not introduced to ASU modalities that can complement and enhance the clinical outcome

There are several studies indicating the possible beneficial role of ASU interventions when administered as ‘adjuvant’ or ‘complementary’ to the conventional therapies. Dietary interventions, Panchakarma and lifestyle modifications as per ASU modalities, for instance, can at least be supplemented along with many biomedicine interventions to enhance the clinical outcome.

4. MBBS graduates are not introduced to the recent advances that are taking place in ASU systems.

Several interesting research findings related to ASU interventions are being reported widely in recent years in peer-reviewed scholarly journals. Graduates in conventional medicine need to know some of these key advances so as to help their patients.

5. MBBS graduates are not introduced to the medical heritage of their own country

ASU systems are historically integrated into social and cultural domains of commoner’s life in India. Certain terms such as ‘heat’, and ‘gas’ that are commonly expressed by patients, have got their roots situated in such cultural connections. Similarly, Sushruta’s practice of rhinoplasty was a milestone in the evolution of surgical practices. Therefore, having some knowledge in the history and heritage of one’s own country definitely adds value to the medical practice. 

6. ASU graduates don’t receive instructions from qualified experts in the topics related to conventional medicine

In one of our earlier studies, we have noticed that Ayurveda students are not trained well in the essentials of physiology, pathology and clinical diagnosis in general, and this possibly holds true for Siddha and Unani students as well. The reason for this situation in all probability is that ASU students don’t receive these instructions from the experts in these fields. 

7. Inadequate involvement of Biomedicine experts in ASU research

An ideal research protocol for ASU streams needs the involvement of biomedicine experts, however, only a few biomedicine experts are currently interested and involved in pursuing research related to ASU systems. This is because they are not routinely exposed to these systems during their formal education. It is to be noted that ASU systems can still guide many areas of current sciences because they provide a larger fundamental conceptual framework that is in alignment with ‘systems thinking’.

Suggested solutions:

1.      Introduce ASU module in MBBS curriculum

Introducing an ASU module in MBBS curriculum that contains the essential introduction to these systems would help in solving most of these problems. This module ideally must cover the following components:

a. Fundamental principles and theories on the basis of which ASU systems are practiced

b. Historical evolution of ASU systems in India and the important contributions of these systems to the current sciences

c. Introduction to the essentials of commonly practiced ASU interventions like Panchakarma 

d. Essentials of ASU pharmaceutics: common methods of preparation of ASU formulations, their key ingredients 

e. Recent advances (fundamental and clinical) that have taken place in ASU streams

f. Essential information regarding herb-drug / food-drug/ drug-drug interactions related to commonly used herbs/drugs/dietary compounds.

g. Pharmaco-vigilance program of ASU and the major centers coordinating it

2.   Encourage instructions by bio-medicine experts to ASU students in the relevant topics

Institutions like Banaras Hindu University have since long introduced such a practice. During their postgraduate years of study, Ayurveda students receive instructions by experts in Anatomy, Physiology, Pharmacology, Pathology, Microbiology, Biochemistry and Medicinal Chemistry. However, such a practice needs to be encouraged everywhere so that ASU students receive standard instructions.

Suggested Road-map:

a.  The government of India may identify a few institutions where ASU module could be introduced on an experimental basis. These institutions should preferably have a medical college and an A/S/U college under the same management, preferably in the same campus. Institutions such as Banaras Hindu University, where three faculties (Medicine, Ayurveda and Dental sciences) work under the same umbrella of IMS (Institute of Medical Sciences) are ideal for such a venture to begin with. A few other institutions with a similar set up could be identified.

b.  A group of experts may be asked to frame a module. This group should consist of experts from ASU, pharmacology, clinical research and sociology. This group may be asked to come up with a course module containing the essential information in the form of an e-book. This should also include the links and addresses of important organizations and institutions that can facilitate the acquisition of the required information on the issues addressed.

c.  This module may be introduced either during final MBBS or during the internship period. Initially, fifty hours of contact lectures may be allotted and feedback from the instructors and students can be obtained. Alternatively, during every semester of MBBS ten hours of contact lectures can be introduced to lessen the burden.

d.  Governing bodies like CCIM should come up with norms making it essential for biomedicine experts to be recruited in ASU colleges to give instructions in their area of expertise. 

e.  As a long-term measure, a 10-year integrated MBBS/MD/PhD ‘triple degree program’ in integrative medicine might be introduced, wherein the essentials of all major streams of healthcare systems can be incorporated along with a research project. This would certainly encourage more researchers to involve themselves with ASU systems.

(I thank Dr.Madan Thangavelu from Cambridge, for his suggestion to include a 10-year integrated triple degree program under the list of "suggested road-map".)

9 comments:

Unknown said...

Dear Sir,

Your article emphasized a useful suggestion to improve the health education by incorporating the three essentials of Ayurved viz Diet, Panchkarma and Lifestyle modification as per ASU modalities in MBBS curriculum. I fully agree with it. This would also complement in fulfilling the missing links and answering the unsolved puzzles of modern Dietetics. Moreover this would certainly be very suitable for our medicos because India is a country of at least four different seasons, so why follow the guidelines and researches done abroad, why not follow the system that has developed in the same soil.
At the same time, on the matter of developing a 10 year long integrated course, I regret to express a difference of opinion. In the present arena when studies are directly linked to livelihood or vocation, Medical Science whether conventional or ASU is losing its charm over other branches due to a simple reason of having a long training duration of 5 to 5.5 yrs or so. Many medicos after their UG do not even wait for PG and change their field which is a big drain of the skills they acquired. Remaining start their private practice. So I would like to put a humble submission that if you simply incorporate the three essentials that you mentioned in your article to the M.B;B.S. curriculum, I think that itself would suffice the underlying objective. I also doubt that there could be only a few candidates in the present scenario of chasing a ludicrous job who shall be seriously interested in research and that too a ten year long one. I think a workable alternative could be to promote interdisciplinary research among faculty who are dedicated and have an unbiased mind. Thank you.Yours faithfully Deepak Gautam, IMS BHU.

Unknown said...

Respected sir,
Your article impressed me very much because i too was of the same opinion but in different way.Even layman is of the opinion that these alternative medicines are nothing but "Jadibhuti"
No one is aware about our fundamentals or its importance in maintaining the health or to free from diseases. I think ayurvedic community too lacking in these concepts.We are always "Kuppa Manduk" sir i feel very sad about it .For this i think teachers like you should guide the students to present our basic fundamentals in simpler way in the national and international conferences of modern medicine. Because till today they dont know our samhitas had explained these many disorders in detail. My self doing Ph.d in shalakya tantra myself or my teacher should present various anatomical physiological pathological and surgical aspects explained in your sastras in detail For eg. Dry eye syndrome and shuskakshipaka are same, in what way ,how treatment modalities of ayruveda can help, with the knowledge of modern if i present this in ophthalmic modern conference. By this they will be aware the need of knowing ayurvedic system, which can help in health care and disease management. This way we can easily add the concepts in M.B.B.S curiculum and at the same time they feel interested in learning too. So each and every modern conference should have one or two presentation of ayurvedic topic starting from basic.I think it is not a very big job.Second there is no public demand for these system. I had never seen AYUSH which is considered to be the whole and sole of development of these medicinal system had given advertisement of any health care promotion in media or any endemic disease mangement by ayurvedic approach. For eg we can give an add of particular drug combination for dhupan and kwatha preapartion in malarial endemic areas. Publicity in media really attracts the public in particular system. AYUSH , Institute like BHU, Jamnagar and NIA if possible all government colleges should promote ayurveda in local media. What ayurveda can do in so and so clinical condition.This generates public interest and this in turn generate the government which helps in understanding the need of cross -talk between different streams.. Jai Ayurveda Thanking you sir Gopinathan Jamnagar

Unknown said...

Respected Sir,
If integration of multiple health disciplines has to commence in any way, then it has to be undoubtedly at the curriculum level. The pointers that you have raised are pertinent and long overdue.The current Public Health scenario of our nation calls for a concerted multi-disciplinary approach. The futility of grooming Public Health professionals from Allied streams would lay exposed when they would find themselves incompetent to understand linkages that could be developed for a broader, holistic approach. This can be accrued to their weak foundations in their own system and a clear lack of apt understanding of the foundations of other systems. Curriculum revisions are the way forward and I truly hope that they do translate into reality.

shweta mishra said...

sir an all india survey was done for for unani and ayurvedic medicine and the inference drawn is indicative towards merger of unani and ayurveda

we first of all need a govt which thinks and feel for ayurveda the way we do
and rather than adding this in mbbs it would be great to incorporate it in p.g medicine first and gradually when it picks up should be added to u.g cours because mbbs in itself is having a bulky syllabus which they read as cut paste in such case who will take ayurveda seriously,

2nd most important thing is to teach ayurveda to (bams)student in such a way so that they gain enough confidence to practice it IF WE SHOW STRENTH AND PROSPERITY IN OUR SUBJECT PEOPLE WILL ALREDY FALL TOWARDS US TO KNOW US WELL

a general awreness programme for all the medical college in form of wrkshops will not be that burdemsome and can be easily incorporated with some points in c.v. for preference in future govt jobs

Unknown said...

This is really a wonderful piece of advice by Sweta Mishra Ji. The second last paragraph is very true and workable. It reminds us of those famous lines - "Khudi ko kar buland itna ke har taqdir se pahle Khuda bande se ye poochhe bata teri raza kya hai"

Kishor Patwardhan said...

Thank you all for your productive comments.I would like to state here that this proposal is non-judgmental:it does not address the question as to which system is better or which one is inferior. My only concern is that, for a healthcare delivery system to be effective, all the healthcare providers should have some basic understanding regarding the streams other than their own. Effective education is definitely important, not only for Ayurveda, even for Allopathy. This proposal does not address that question.

kumari said...


Wonderful blog & good post.Its really helpful for me, awaiting for more new post. Keep Blogging!










Healthcare in India

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