|CONTROVERSIES IN MEDICINE
|Year : 2021 | Volume
| Issue : 1 | Page : 66-70
Do we need more AIIMS type institutions? Yes!
National President, Academy of Family Physicians of, India
|Date of Submission||09-Mar-2021|
|Date of Acceptance||20-Mar-2021|
|Date of Web Publication||25-Apr-2021|
Dr. Raman Kumar
National President, Academy of Family Physicians of India, 049. Crema Tower, Mahagun Mascot, Crossing Republic, Ghaziabad - 201 016, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar R. Do we need more AIIMS type institutions? Yes!. J Med Evid 2021;2:66-70
AIIMS was created in 1956 to serve as a nucleus for nurturing excellence in all aspects of health care. The Bhore committee had in 1946 already recommended the establishment of a national medical centre which would concentrate on meeting the need for a highly qualified workforce to look after the nation's expanding health-care activities. The AIIMS project was initiated with the support of a generous grant from New Zealand under the Colombo Plan. Given the objects and functions of the AIIMS Act 1956, institute's impact can only be judged on the basis impact on India's underdeveloped states with regard to patient care, medical education and research. AIIMS was one of the first institutions to be designated as an institute of national importance. The objects of the institute as defined in the act were (a) to develop patterns of teaching in undergraduate and postgraduate medical education in all its branches so as to demonstrate a high standard of medical education to all medical colleges and other allied institutions in India; (b) to bring together in one place educational facilities of the highest order for the training of personnel in all important branches of health activity and (c) to attain self-sufficiency in postgraduate medical education.
Further, AIIMS New Delhi's defined functions are following (a) undergraduate and postgraduate teaching in medical and related physical biological sciences, (b) nursing and dental education, (c) innovations in education, (d) producing medical teachers for the country, (e) research in medical and related sciences, (f) health care: Preventive, promotive and curative; primary, secondary and tertiary and (g) community-based teaching and research. While many Indian Institute of technology and Indian Institute of Management were opened in different parts of India, AIIMS evolved into the sole lighthouse of health care in the national capital over several decades, attracting patients from all over India, especially from the northern part. AIIMS epitomises the public sector academic tertiary care centre in India.
Could a single AIIMS New Delhi cater to the patient care of the whole country or at least the catchment area? Could a single AIIMS provide enough medical teachers for India? Could a single AIIMS inspire research culture amongst other medical institutions of India?
India runs the largest medical education system in the world. However, matching the education system with the pressing needs of the population remains a challenge. Three-fourth of the medical colleges are located in the southern part of India. More than 50% of the medical colleges are governed by private management.
Until recently, the regulation of medical qualifications and medical institutions has primarily rested with the erstwhile MCI (Medical Council of India). The major focus of MCI regulations was on the staffing pattern, their qualification and facilities; and the recognition of institutions for various courses rather than the regulation of a standard curriculum. AIIMS New Delhi had no role in setting curriculum or standards care at various medical colleges across India. Major postgraduate qualifications of diverse quality were being awarded until recently without any formal curriculum document. The universities and institutions are primarily preoccupied with conducting examinations and appointing examiners for thesis and final university examinations, apart from awarding degrees. Many AIIMS graduates have chosen to immigrate abroad rather than staying back in India and contribute to the health system. Of late, AIIMS, Delhi had been overburdened with patient care rendering it unable to meet its primary objectives.
At other medical colleges in India, trainee doctors are often left to themselves to learn and acquire competencies, skills and knowledge in most situations. Most of this self-directed learning is based on peer's experience and work culture specific the institution. There is more focus on entrance examinations than on imparting curriculum or objective skill-based exit assessment. Entrance to a course guarantees a license to practice in a discipline. Despite best intentions, medical education in India has mostly remained challenged. The impact of dissolving MCI and enactment of the National Medical Commission is yet to be seen. From the first impression, it appears that except for the control and power structure, nothing much has changed. Old regulations of the earstwhile MCI are being adopted with cosmetic changes. Primary care doctors and family physicians who form the majority of the medical doctors in India, have no representation on NMC as well like MCI. The earstwhile MCI used to be a specialist monopoly.
| General Status of Medical Education System in India: Influence of AIIMS|| |
In the late nineties, the population of undivided Bihar was more than eight crores. At that time, AIIMS, New Delhi had completed five decades of existence. There were only nine medical colleges in the undivided Bihar with 544 MBBS seats; Jharkhand separated from Bihar in the 2000 with three medical colleges and 190 MBBS seats. There were two private medical colleges and students of both of these medical colleges were waiting for MCI recognition for decades. The annual intake capacity of the majority of these medical colleges was only fifty MBBS seats. Only three of these nine medical colleges were running any postgraduate programmes. There was not a single DM/or MCh-subspecialty seats available in the entire Bihar state. The MCI did not recognize many PG seats in Bihar due to inadequate infrastructure or lack of eligible faculty. Due to PG seats' paucity, medical students, after completing MBBS, would migrate outside Bihar for employment and career progression. A state with the poorest health performance could not hold back its fewer numbers of trained doctors.
Overall situation of the medical education system in the state was very poor; The MCI would often issue a warning of derecognition to the medical colleges of Bihar, citing lack of faculty and poor infrastructure. An interesting phenomenon observed was the resignation of faculty from government medical colleges and migration to private institutions. The most common allurement for this trend was the admission of their children to the MBBS course. There was a persistent deficiency of medical teachers in both government, as well as the private medical colleges; perhaps a universal phenomenon across India. More than buildings and infrastructure, a deficiency of eligible faculty would risk the medical college's existence. Medical teachers would be transferred from one medical college to another, temporarily during MCI inspections, to meet the headcount in front of the visiting teams.
| Perspectives from an Underdeveloped State of INDIA (Bihar): Late Nineties|| |
The combined MBBS and BDS entrance examination was called MDAT (Medical and Dental Admission Test) which was considered immensely tough due to a fewer number of MBBS seats. Every year thousands of medical aspirant students would move from the districts to the state capital Patna to be able to attend coaching classes. Only the luckiest one would succeed after slogging many years. The private coaching classes were one of the most flourishing businesses and continue to be so till date. Patna remains the coaching hub for medical and engineering courses.
Medical aspirants were also eligible for the all-India CBSE quota of 15% seats across country. However, the success rate for the CBSE all-India quota was minimal due to the difference in the Bihar intermediate council's syllabus and CBSE's schooling. Rarely would few of the well-off parents send their children to the expensive private medical colleges of South India – popularly known as donation colleges. Nagpur was a popular destination for engineering students from Bihar for private donation colleges. However, no such option was available for medical students, and private MBBS colleges were considered very expensive. Although there were 54 districts in the undivided Bihar, the school students from Patna, Bokaro, Jamshedpur and Ranchi fared better at the entrance examinations due to access to a better schooling system as compared to other districts and rural areas of the state. As an outcome, a vast rural habitat remained underserved. Due to the state government's limited capacity to start and run medical colleges or to increase seats at the existing medical colleges, there were limited training opportunities for the local high school students.
| Medical Entrance Examination and Opportunities for Local School Students|| |
Patna, the state capital of Bihar, has remained the medical treatment hub, but the health facilities remain mostly unorganised. IGIMS Patna (Indira Gandhi Institute of Medical Sciences) was established on the pattern of SGPGI Lucknow; however, it was not functioning optimally and was running without any UG or PG courses. It was not a popular destination for treatment in Patna either. PMCH (Patna Medical College Hospital) remained the most sought-after place for treatment for the entire Bihar and Jharkhand leading to an overburden of patient care at outpatient, emergency and inpatient facilities. Super speciality care was almost non-existent in Bihar at that time. Once upon a time, Patna Medical College carried reputation; however, education training and research were gradually declining. Any treatment related to heart, kidney, liver and cancer would require persons and families to travel to Delhi, Kolkata, Mumbai, Chennai and Vellore. Unfortunately, the situation was more challenging for people from outside Patna. They had to travel by road or train for 5–6 h to Patna and further referred further to Delhi. AIIMS, Vellore, Escorts, and Apollo are popular names; even known in remote and rural parts of in Bihar.
| Patient CARE in Bihar: Late Nineties|| |
AIIMS, New Delhi has remained the most popular destination for the treatment for people of Bihar since its inception, especially for the economically weaker section of the society. People from other states of India also visit AIIMS, New Delhi, for treatment. Getting treatment at AIIMS was never easy due to long queues for OPD (out patient department) appointments, investigations, beds, and procedures or surgeries. Due to overcrowding, some patients spill over to other Delhi hospitals such as RML (Ram Manohar Lohia) Hospital and Safdarjung Hospital. Many more would visit the private hospitals of Delhi.
One of the essential responsibilities of the MPs (Members of Parliament) from Bihar and other underdeveloped states is to help their voters and constituency get medical relief at AIIMS, Delhi and other hospitals of Delhi. It is common for patients to carry recommendation letters from their political leaders (MPs/MLAs and Ministers) to hospitals while visiting medical consultants for treatment. Official political recommendation (letters/phone calls) for patients' medical treatment is a unique phenomenon, probably exclusively observed in India. Such political rationing of medical facilities, disregarding the medical, scientifc and humanitarian triaging demonstrates the public health deficiency/inefficiency of many states and India as a country.
”Come after 2 years, AIIMS Delhi tells heart patients who need surgery,” read one of the headlines in a new paper in 2019. It is a no secret that the people with networks and connections have better access to public health facilities in India. Journalists, bureaucrats and political workers are better placed to get free medical relief. Getting medical relief from publicly funded healthcare institutions is difficult and often insulting for ordinary citizens. Ruckus and violence at hospital emergencies have become a common occurrence due to overcrowding and mismatched resources. Interestingly, there was only one AIIMS for the whole of India for decades.
| Political Recommendation for Medical Treatment-AIIMS Delhi: Patient Experience|| |
Amongst the nine medical colleges of Bihar controlled by the government, the 9th one, Patliputra Medical College Dhanbad, was perhaps the most unique. The college was derecognised in the late eighties due to an unfinished medical college hospital building. It was said that the funds allocated for construction of the hospital building were transferred to Bhagalpur Medical College. Since then, the incomplete building remained a hurdle to full recognition by the MCI. However, the government of Bihar continued the admission of students to this college. It was arranged to transfer these medical college students to the other medical colleges of Bihar after the third year. Temporary arrangements for clinical postings were made available at the Dhanbad district hospital, Central Hospital of Bharat Coking Coal Limited, and SSLNT Trust hospital. For ten long years, no funds were allocated for the building construction of the medical college. There was a deficiency of faculty for the academic departments also.
Finally, MCI banned the practice of transfer of student of this medical college to the other medical colleges. An agitation of students broke out. Furthermore, legal proceedings started in the Patna High Court. The medical education department of Bihar started efforts for full recognition of the institute. Local political leaders were also given representations. At that time the sitting MP from Dhanbad, Dr (Mrs) Rita Verma was holding the post of State Minister for Health and Family Welfare in the NDA Government. During a student-faculty meeting, it was suggested to get funds for constructing a medical college hospital building on the patterns of AIIMS New Delhi, which was constructed with the help of a financial grant from the New Zealand government under the Colombo plan. The matter was raised with Dr. Rita Verma, the Member of Parliament from Dhanbad. The Union Health Minister Dr. CP Thakur, was also from Patna, Bihar during that period. The demand for constructing AIIMS like institute in Dhanbad was submitted to the Dr Rita Verma in the presence of the Health Minister of Bihar Mr. Shakuni Chaudhary. At a college function, the minister publically assured to convert PMCH Dhanbad into AIIMS. We do not know how it was taken further. However, a couple of years later, Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) was established for the construction of six new AIIMS in the different parts of India [Figure 1] and [Figure 2].
| Dhanbad-Bihar/Jharkhand-Demand for a Local AIIMS (1999)|| |
|Figure 1: Lack of faculty and infrastructure at government owned state medical colleges is the key reason for disruption in the academic environment (Credit the Telegraph)|
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|Figure 2: Demand for more AIIMS in the under developed states of India was raised in Dhanbad, Bihar in 1999 (Photo Credit Hindustan Times)|
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The PMSSY scheme was announced on the 15th of August 2003 to correct the imbalances in the availability of affordable or reliable tertiary level health care and also for improving facilities for quality medical education in the States. In pursuance of the said scheme, initially six All-India Institute of Medical Sciences (in addition to the AIIMS, New Delhi established under the AIIMS Act) one each in the States of Bihar (Patna), Chhattisgarh (Raipur), Madhya Pradesh (Bhopal), Odisha (Bhubaneswar), Rajasthan (Jodhpur) and Uttarakhand (Rishikesh) were set up, broadly similar to the existing AIIMS, New Delhi. Recently, a second AIIMS has been announced in the Darbhanga district of Bihar.
| Pradhan Mantri Swasthya Suraksha Yojana: 2003|| |
It is evident from the above discussion that a single AIIMS located in the national capital was failing its objectives. Opening new AIIMS institutions was a wise decision of the government, especially for India's economically backward states and areas. Following are the benefits of many new AIIMS institutes across India.
| Conclusion|| |
Note: The author has completed his MBBS education in Bihar.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
- Patient care – people from all over India can access the same standards of care without traveling long distances. The burden on AIIMS Delhi will decrease, and faculty can do quality patient care and research
- Availability of medical teachers: The government has decided to open and convert all district hospitals into medical colleges. Lack of eligible faculty is a key bottleneck to quality medical education in India. A local AIIMS within the state will facilitate training and availability of medical teachers within the state
- Quality research: Central funding for research will stimulate quality research among state medical colleges through local AIIMS. State governments often cannot allocate sufficient funds for medical research
- Clinical Practice Guidelines and Standards – Despite having vast clinical experience, Indian institutions have not been able to formulate standards and local practice guidelines; therefore, mostly unsuitable international guidelines are followed. Hopefully, more AIIMS will have a better capacity to formulate practice standards suitable for local populations
- More opportunities for local students: Though students compete from all over India for AIIMS, it is essential to recruit a percentage of students from the host state and the local community. Rural and local background of the students are the most vital determinants of physicians' retainment for serving the local community
- The pursuit of Excellence: A single AIIMS in Delhi had an inbuilt reputation but no competition. More AIIMS will fuel competition and result in better patient care and research outcomes.
- Support the concept of Family Physicians in India: Contarary to the mandate and objects of AIIMS Act 1956, the Delhi based AIIMS failed to support excellence in all discipline of medical sciences and community based medical education. Continuous exclusion of the concept of family physicians and general practice; and non existance of family medicine department at AIIMS New Delhi till date is an example of tertiary care hospitalist bias; inspite of the repeated calls by the respective National Health Policies (NHP 2002 & NHP 2017) of the government of India. AIIMS New Delhi is also guilty of promoting sub specialty based fragmentation of care in India. The gradual extinction of 'family doctor' concept is not inadvertant occurance. However all newly eastablished AIIMS institutes across India have mandatory department of family medicine, which is likely to strengthen the concepts of 'medical generalism', 'whole person care', 'life cycle care', 'comprehensive care', 'person and family centered care' 'continuity of care', ' woumb to tomb care', 'effective referral system' and 'cost effective quality primary care'. Exclusion and discrimination Family Physicians from the mainstream medical education system is also likely to end. Practicing Family Physicians are legally not eligible to become medical teachers in India till date.
[Figure 1], [Figure 2]