Understanding the Context

On the 20th of November 2020, The Central Council of Indian Medicine (CCIM) issued a notification in its gazette that allowed post-graduate (PG) Ayurvedic practitioners to receive formal training for performing 39 general surgical procedures and 19 procedures involving the eye, ear, nose and throat. Postgraduate education in Ayurveda is guided by the Indian Medical Central Council (Post Graduate Education) Regulations, 2016, which has been amended to confer the title of MS (Ayurved) in Shalya Tantra (general surgery) and MS (Ayurved) in Shalakya Tantra (diseases of ear, nose, throat, eye, head, ortho-dentistry) to those doctors “practically trained to acquaint with, as well as to independently perform” 58 specific surgical procedures, which range from skin grafting to root canals. Proponents of the notification argue that there is no new policy being created with this notification. Instead, it ought to be seen as a clarification of legal procedures, and as a part of the larger regulatory ethos that comes with the National Medical Commission.

However, the notification did not fare well with the sentiments of allopathic practitioners across the country, and the Indian Medical Association (IMA) — the representative organisation of doctors from the modern scientific system of medicine — questioned the competence of Ayurveda postgraduates to perform these procedures. Calling it an attempt at “mixopathy”, the IMA declared a nation-wide bandh on December 11th and made an appeal in the Supreme Court for the complete withdrawal of the notification. They fear that the new notification gives off the impression that an Ayurveda surgeon performing a given procedure possesses the competencies as those practicing modern medicine. They argue that the poor and difficult-to-reach Indians are being treated like guinea pigs at the hands of under-qualified Ayurveda surgeons, all in the State’s pursuit of achieving “health for all”.

Several believe that allowing Ayurvedic practitioners to perform surgeries is an encroachment into the jurisdiction and competencies of modern medicine. As per the 2019-20 Economic Survey, the doctor-population ratio in India is 1:1456 against the WHO recommendation of 1:1000. Those living in hilly areas or belonging to tribal communities find themselves heavily dependent on doctors from the Indian systems of medicine. The notification calls into question the infrastructural and training resources that various systems of medicine in India enjoy, and their ability to serve the public. Does it put vulnerable patients at a greater risk of complications, or is the institutionalisation of these 58 procedures a signal of more qualified surgeons, a more reliable regulatory process, and better access to healthcare for all?

Click on a quote to read an opinion

“The stakes of malpractice are heightened when you throw general surgical procedures into the mix. Put simply, through this notification, the government is banking on a sub-par cadre to ensure that every Indian has access to surgical intervention.”

— Dr. Radha Vasan, Senior Consultant, MBBS, MS (Ophthalmology)

“What’s more interesting is that this Amendment may offer some hope for more stringent grievance redressal procedures, a clear regulatory procedure, and a more aware set of patients. The CCIM notification should be seen in the context of a larger process of transforming the entire healthcare system, which is currently unorganised.”

— Dr. Vivek Shenoy 

Performing surgery on the human body takes a lot of preparation; it isn’t a practice that anybody wants to be taken lightly. The Ministry of AYUSH responded to the IMA’s protests saying that surgery was not a term that belonged to ayurvedic or allopathic fields; rather, they argued that “surgery is just a technique.” This is true. But, at the same time, it is a technique that demands perfection. 

Let’s take something as small as the eye, which the Amendment allows PG students to operate upon. Ayurveda is such a broad speciality, just like an MS or MBBS. An MBBS graduate cannot perform surgery, right? They join a specific branch of surgery, say Opthalmology, after having studied the basics of everything else about the human body. There is a reason that an MS in General Surgery cannot perform ophthalmic, ENT (ears, nose and throat), or gynaecology procedures. AYUSH graduates do not spend the same kind of time on any one particular organ.

The specialization factor is critical to this debate because even a small incision in a patient’s eye in the wrong direction can damage its underlying layers and potentially blind a person for the rest of their lives. The margin for error is minute, even for something as commonplace as cataract surgery. 

And so, on the other side of the fence, you have a syllabus for PG in Ayurveda that does not include the technicalities of the intricate layers in the eyes, for example. Only three to six months are spent on the theoretical basics of performing surgery, that too as a sort of observership. With very little hands-on experience, the Ministry now wants to allow students to perform surgery on a human eye? This is a myopic and dangerous notification, and I stand wholeheartedly with the IMA’s discontent.

A Mismatch of Intent and Praxis

Most super-speciality practitioners prefer to ply their trade in the cities, where profit margins are higher. Patients in rural India or even Tier-II cities do not have adequate medical facilities, be it with surgical attention or emergency medicine, when they require it. AYUSH practitioners, therefore, are willing to plug this shortage by treating patients in rural areas, but this poses a huge danger: there is an underlying ethos of invincibility in their practice. AYUSH practitioners can prescribe treatment as they wish because patients in rural areas are not in a strong position to call out their wrongdoings. 

The stakes of malpractice are heightened when you throw general surgical procedures into the mix. I have dealt with such experiences even at a hospital as famous as Madurai’s Aravind Eye Hospital. Here, the training for eye specialties like cataract surgery is open to foreign students. The Greeks, Italians, Brits, Americans, and even South Americans from Uruguay and Paraguay, who partake in this year-long training have sparse experience with general surgery or ophthalmology. They are akin to MBBS graduates. Aravind allows these students to practice procedures on the eyes of poor and rural patients at health camps. Whatever complications may occur thereafter, the more experienced surgeons among us would be asked to tide over it, but the damage has already been done. It is an example of misplaced priorities leading to botched procedures; this is what will happen when we leave the door open for other practitioners who are non-MBBS or non-specialised. Put simply, through this notification, the government is banking on a sub-par cadre to ensure that every Indian has access to surgical intervention.

Finding Synergy Between the Two

All systems of medicine serve humanity. Ayurvedic practitioners take pride in the historical practice of their surgical procedures and treatment methods, and rightly so. Ayurvedic treatment is known to have lesser side effects, at least when compared to allopathic medicine, but it is a long-term mode of treatment. Allopathy is more instantaneous. As a practitioner, I see the synergy between modern medicine and AYUSH disciplines like naturopathy, and they can serve the public hand-in-hand.

Human beings need what we call “holistic treatment”. AYUSH practitioners have proven their ability to prevent ailments and improve resilience over time, and they bring lots to the table. But let us not get confused with modern medicine’s expertise, especially with regard to the domain of performing surgery.

The President of the IMA, Dr. Rajan Sharma, declared that an integrative system of medicine would create a “Khichdi medical system” which produced hybrid doctors. The truth is that most dissenters to the CCIM notification are completely unaware that these surgical procedures have been performed since several years. Ayurveda doctors already use allopathic treatment, right from prescribing medicines to performing general surgical procedures. It isn’t even “mixopathy”, as the IMA calls it. What is happening in India is downright “crossopathy”. Recognising this, the government has merely notified 58 specific procedures to be legitimately conducted, so that ayurvedic practitioners know what to focus on, how to train and what to train for.

For one, all super-specialisations are left out of ayurvedic training; the 58 procedures listed do not include neurosurgery, pediatric surgery, neurology, cancer surgery and the like. I am familiar with several ayurvedic surgeons who undertake a limited set of surgeries within their abilities. They request an MS in general surgery to perform laparoscopies or other such procedures that they cannot handle alone. This is what being a responsible surgeon entails. Few surgeons will perform procedures that they are incapable of executing with proficiency. Like any other profession, surgeons have their own reputations to maintain.

A Move Towards Standardisation

What’s more interesting is that this Amendment may offer some hope for more stringent grievance redressal procedures, a clear regulatory procedure and a more aware set of patients. The CCIM notification should be seen in the context of a larger process of transforming the entire healthcare system, which is currently unorganised.

Consider someone who undergoes surgery and experiences complications afterward. The patient goes on to file a complaint to the IMA, which realises that the said surgery was performed by an ayurvedic surgeon who is not qualified in accordance with extant rules. Typically, the IMA would throw their hands in the air and respond saying that this matter falls outside of its jurisdiction. This leaves the patient out in the cold, regardless of whether they are in cities or in rural India.

Unlike allopathy, there are no similar grievance mechanisms or regulatory bodies that govern the ayurvedic practice. The National Medical Commission (NMC) is a step in the right direction, to make sure everybody falls under the same rules.

To be fair, students of Ayurveda also study anatomy, physiology, biochemistry, pharmacology, and pathology, like MBBS graduates do. The same amount of time and effort is put into obtaining both qualifications, and both start on an even playing field. When it comes to PG courses, medical colleges demand huge investments, from at least 25 acres of land, 750-1000 beds, and equipped professors and lab facilities. Ayurvedic surgeons are not as qualified as someone with an MS in terms of their learning experience, and this Amendment lays a framework for their situation to improve.

The government can now enforce that any college giving an PG seat to a BAMS graduate must, say, a 500-bedded hospital with at least five operating theatres. A minimum number of surgeries will have to be performed before obtaining the degree. These requirements are clearly stated for the three-year MS syllabus, and it should be equalised for AYUSH too. Perhaps this aspect should have been addressed before legitimizing these 58 procedures.

In the Interest of Public health

The IMA or allopathic practitioners have nothing to feel threatened by at all. Being relatively better equipped, qualified and trained, it is impossible for allopathy to be replaced. Instead, this amendment should be seen as a stepping stone, of sorts. It is a manifestation of the huge role that manpower plays in healthcare systems.

India does not have enough MBBS graduates to serve the needs for immunisation, safe pregnancies, and children’s healthcare. In countries like the UK, nurse practitioners are so well-trained that they can perform a wide range of tasks that doctors do. Many of India’s national health mission goals can be reached by utilising the untrained and unaccountable manpower which already exists within the healthcare system. We need to make efforts to improve their contributions. Bringing AYUSH practitioners into the mainstream, giving them requisite training, and incorporating them into primary healthcare provision is a necessary step.

Six months ago, someone who needed surgery would probably go to a fancy hospital and be treated by any doctor with the title of “surgeon”. I think the most beneficial knock-on-effect of this controversy is that patients will now look up when they go to the clinic, to check their doctors’ qualifications. They will now make more informed choices, aware of whether they have received ayurvedic or allopathic treatment, and whether their doctor is equipped to perform a certain surgical procedure or not.

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