m John Connolly’s Seminal Contribution to Psychiatric Practice

Need to Brace Ourselves for Major Mental Health Is-Need to Brace Ourselves for Major Mental Health IsColumn sues Post COVID-19 Pandemic sues Post COVID-19 Pandemic John Connolly’s Seminal Contribution to Psychiatric Practice *Dr. Ashoka Jahnavi Prasad *Dr. Ashoka Jahnavi Prasad

Dr. Ashoka Jahnavi Prasad

We are battling a pandemic of unprecedented proportions. Healthcare professionals are working We are battling a pandemic of unprecedented proportions. Healthcare professionals are working round the clock to curtail this global menace. It is very round the clock to curtail this global menace. It is very likely that we would soon be able to slow down the likely that we would soon be able to slow down the alarming rate at which the illness is spreading and from alarming rate at which the illness is spreading and from the reports in the medical journals that I have been pe-the reports in the medical journals that I have been perusing, we would be able to procure a vaccine in due course. The price that the entire humankind has had to pay is huge by any reckoning and everyone is looking forward to the day when we would not approach the newspapers with the degree of trepidation that we are doing so today. rusing, we would be able to procure a vaccine in due course. The price that the entire humankind has had to pay is huge by any reckoning and everyone is looking forward to the day when we would not approach the newspapers with the degree of trepidation that we are doing so today. If there is a general consensus that the mentally ill should be extended humane treatment without any transgression of their human dignity, the entire world owes a huge debt of gratitude to the two pioneers: Philippe Pinel and John Connolly. But I worry that we are more or less completely unprepared for the psychiatric sequalae of this COVID 19 which we would have to confront very soon. As a member of several international medical relief missions, I have myself noticed the major mental health issues that emerge in nearly every major epidemic - and it is a fair bet that this episode would not be any different. But I worry that we are more or less completely unprepared for the psychiatric sequalae of this COVID 19 which we would have to confront very soon. As a member of several international medical relief missions, I have myself noticed the major mental health issues that emerge in nearly every major epidemic - and it is a fair bet that this episode would not be any different. Pinel was a French psychiatrist who had very strong humanistic instincts. He departed from the conventional psychiatric practice during his time and took a very strong stand against any coercion of the mentally ill. I intend to write about him in a future column. Most of the present-day psychiatrists would agree that John Connolly’s pioneering contributions were far more groundbreaking. Providing psychiatric care to survivors and health-Providing psychiatric care to survivors and healthThe name also has a personal significance for me. care workers in the aftermath of a pandemic outbreak is a complicated, but crucial, imperative in the service of reducing the burden of human suffering. Challenges will abound on multiple levels, but there is no substitute for preparedness. Knowledge of assessment, differential diagnosis, medical complications, and treatment will aid the psychiatric care provider in developing a treatment approach for these patients who are most vulnerable during their greatest time of need. One must first consider the psychiatric sequelae of surviving the illness, its complications, and the complications of its treatments. In the acute phase of illness, even small foci care workers in the aftermath of a pandemic outbreak is a complicated, but crucial, imperative in the service of reducing the burden of human suffering. Challenges will abound on multiple levels, but there is no substitute for preparedness. Knowledge of assessment, differential diagnosis, medical complications, and treatment will aid the psychiatric care provider in developing a treatment approach for these patients who are most vulnerable during their greatest time of need. One must first consider the psychiatric sequelae of surviving the illness, its complications, and the complications of its treatments. In the acute phase of illness, even small foci Before relocating to Edinburgh, I had worked in the Republic of Ireland. My very first supervisor in psychiatry was one Dr John Connolly. Although he was born more than a hundred years after the legendary Dr Connolly, he shared many of his namesake’s philosophies, and through his innovative approach, he succeeded in making a phenomenal contribution to Irish psychiatry. We often used to make puns on the uncanny similarities between the two namesakes. But it is the iconic Dr John Connolly, whom I shall attempt to acquaint the readers to. of infection can produce psychiatric symptoms ranging of infection can produce psychiatric symptoms ranging John Connolly’s lifework in the field of psychiafrom mood changes and irritability to cognitive dys-from mood changes and irritability to cognitive dystry began properly in 1839 with his appointment as function to psychosis. Neuropsychiatric manifestations function to psychosis. Neuropsychiatric manifestations Physician Superintendent of the Middlesex County may even present as the first signs of infection in an oth-may even present as the first signs of infection in an othLunatic Asylum at Hanwell, and it was there that he erwise well-appearing patient. Hematogenous spread erwise well-appearing patient. Hematogenous spread made his historic contribution to the care and treatof bacteria or virus to the central nervous system can of bacteria or virus to the central nervous system can ment of the insane in the asylum, as well as providing

Dr. Ashoka Jahnavi Prasad is identified as the most ed-Dr. Ashoka Jahnavi Prasad is identified as the most educationally qualified person in the world by The Polymath. ucationally qualified person in the world by The Polymath. He has a dynamic resume with a PhD in history of med-He has a dynamic resume with a PhD in history of medicine from Cambridge, LLM from Harvard among other icine from Cambridge, LLM from Harvard among other notable qualifications. Dr. Prasad has also worked as notable qualifications. Dr. Prasad has also worked as a consultant to the World Health Organization (WHO) a consultant to the World Health Organization (WHO) and helped prepare two of their reports. and helped prepare two of their reports. produce meningitis associated with significant mor-produce meningitis associated with significant morbidity and mortality, presenting symptoms including bidity and mortality, presenting symptoms including headache, nausea, nuchal rigidity, confusion, lethargy, headache, nausea, nuchal rigidity, confusion, lethargy, and apathy to be confirmed by the examination of CSF. and apathy to be confirmed by the examination of CSF. Bacterial meningitis may also result in brain abscess, Bacterial meningitis may also result in brain abscess, with seizures and various psychiatric symptoms pre-with seizures and various psychiatric symptoms prevailing depending on the size and location of the abscess. Successful treatment with empirical antibiotics and primary excision of the abscess may still result in persistent psychiatric symptoms. In cases of viral encephalitis, psychiatric symptoms are very common in the acute phase and recovery, especially mood disorvailing depending on the size and location of the abscess. Successful treatment with empirical antibiotics and primary excision of the abscess may still result in persistent psychiatric symptoms. In cases of viral encephalitis, psychiatric symptoms are very common in the acute phase and recovery, especially mood disorclinical psychiatry masterly descriptions of the various forms of insanity. But prior to that, his interests lay primarily in this field, long before opportunities arose to devote himself to it, and the subject of his inaugural dissertation for the Edinburgh MD (Destatu mentis ders. Major disability can result, including symptoms ders. Major disability can result, including symptoms in insania et melancholia, 1821) for which, almost with a of depression, amnestic disorders, hypomania, irritabil-of depression, amnestic disorders, hypomania, irritabilpresentiment of his future, he chose a motto from the ity, and disinhibition (sexual, aggressive, and rageful) ity, and disinhibition (sexual, aggressive, and rageful) great Pinel. In it, he made an important, but little apeven months after recovery. Psychosis may also rarely even months after recovery. Psychosis may also rarely preciated point that, “just as the changes brought about result. Standard treatments with antidepressants, stim-result. Standard treatments with antidepressants, stimby a disease cannot be understood without knowlulants, mood stabilizers, neuroleptics, and electrocon-ulants, mood stabilizers, neuroleptics, and electroconedge of the healthy body, so it is essential to study the vulsive therapy should be applied [1] .vulsive therapy should be applied [1] . healthy mind in order to understand the sick.” After obtaining his MD, he functioned as a general practitioIndividuals may suffer potentially permanent cog-Individuals may suffer potentially permanent cogner for many years, including five years at Stratford on nitive deficits secondary to illness or its treatments nitive deficits secondary to illness or its treatments Avon, where he gained experience on the insane, not that will require cognitive rehabilitation. In cases of that will require cognitive rehabilitation. In cases of only in his capacity as a physician, but also through his delirium, if the resultant encephalopathy is severe or delirium, if the resultant encephalopathy is severe or appointment as ‘Inspecting Physician to the Lunatic persistent, pharmacologic interventions with antipsy-persistent, pharmacologic interventions with antipsyHouses for the County of Warwick’, the duties of chotics (such as haloperidol 0.5–20 mg/ day) and mood chotics (such as haloperidol 0.5–20 mg/ day) and mood which entailed accompanying the magistrates on their stabilizers (such as valproic acid up to 60 mg/kg/ day) stabilizers (such as valproic acid up to 60 mg/kg/ day) annual tour of inspection to the three private madshould be considered. Also, psychosocial interventions should be considered. Also, psychosocial interventions houses in the County. In 1830, during his tenure of the will need to be implemented to maintain safety and will need to be implemented to maintain safety and first chair of medicine in the newly founded University care for someone who may no longer be able to care for care for someone who may no longer be able to care for of London, he followed his original bent with the first themselves. themselves. book, which attempted to link normal and abnormal In the wake of an infectious disease outbreak, the In the wake of an infectious disease outbreak, the states of mind “to render the recognition of insanity a loss of functioning imparted by illness may leave sur-loss of functioning imparted by illness may leave surlittle less difficult, by showing in what it differs from vivors feeling demoralized, helpless, and in a state of vivors feeling demoralized, helpless, and in a state of those varieties of mind which approach nearest to it.” mourning over the loss of the person, they used to be. mourning over the loss of the person, they used to be. “The medical men have sought for, and imagined, If the patient experiences marked distress or significant If the patient experiences marked distress or significant a sound and definable boundary between sanity and impairment in social or occupational functioning, they impairment in social or occupational functioning, they insanity, which has not only been imaginary and armay meet DSM-V criteria for adjustment disorder. Ther-may meet DSM-V criteria for adjustment disorder. Therbitrarily placed, but by being supposed to separate apeutic interventions in those instances should focus apeutic interventions in those instances should focus all who were of unsound mind from the rest of the on helping individuals regain a sense of autonomy and on helping individuals regain a sense of autonomy and men, has unfortunately been considered a justification mastery through rehabilitation. It is helpful to focus on mastery through rehabilitation. It is helpful to focus on of certain measures against the portion condemned, gaining immediate control over some specific aspects of gaining immediate control over some specific aspects of which in the case of the majority, were unnecessary their lives, as well as helping the persons identify and their lives, as well as helping the persons identify and and afflicting.” link with agencies and supports in the community link with agencies and supports in the community [2] . [2] . Psychotherapy, both individual and group therapy, if Psychotherapy, both individual and group therapy, if To remedy this evil, he suggested that doctors available, can help survivors come to terms with the available, can help survivors come to terms with the should be taught to be “as familiar with the disorders loss of functioning. loss of functioning. of mind as with other disorders”, and that to end this, every lunatic asylum should become a “clinical school” If the patient is left with significant depressive If the patient is left with significant depressive in which medical students might prepare themselves

34 The Indian Practitioner d Vol.75 No.8 August 2022 The Indian Practitioner qVol.73. No.4. April 2020The Indian Practitioner qVol.73. No.4. April 2020

53 53

for their future duties. However, this was not achieved for another dozen years.

Connolly also made the first suggestion for the mental health service based on the local mental hospital, [1] which was to not only provide in patient accommodation for the area, but also a domiciliary service supervised by a rotating panel of doctors and nurses from its staff. In this way, he hoped that it would be possible to treat in their own homes a large number of patients, who would have otherwise had to be admitted, and hence focusing attention and facilities on the smaller number of patients for whom hospital in patient services would still be required. Training in Psychiatry [1]

The interest of the public greatly requires that the medical men, to whom alone the insane can ever be properly entrusted, should have opportunities of studying the forms of insanity, and for preparing themselves for its treatment in the same manner in which they prepare themselves for the treatment of other disorders. They have, at present, no such opportunities. During the term allotted for medical studies, the student never sees a case of insanity, except by some rare accident. While every hospital is open, every lunatic asylum is closed to him. He can study all diseases, but those affecting the understanding of all diseases and the one which is the most calamitous. The first occurrence, consequently, of a case of insanity in his own practice alarms him. He is unable to make those distinctions, which the rights and happiness of the individual and his family requires; and has recourse to indiscriminate, generally to violent or unnecessary means; or to get rid of his anxiety and his patients together, by signing a certificate which commits the unfortunate person to a mad house.

Let no one imagine, that even now it is impossible or difficult to effect the seclusion of an eccentric man; or easy for him, when once confined to regain his liberty. The timidity or the ignorance, or it may be a dishonest motive of relatives, which leads to exaggerated representations. When men’s interests depend upon an opinion, it is too much to expect from the opinion to be cautiously formed, or even in all cases honesty. Once confined, the very confinement is admitted as the strongest of all proofs that a man must be mad. When, after suffering so much wrong, he has the opportunity of speaking to the appointed visitors of the house, supposing him to be confined where he can be visited, and supposing him not to give way into his feelings but to control them, his entreaties, his anxious representations, his prayers for liberty, what do they avail! The keeper of the asylum is accustomed to all these things. He knows that the truly and dangerously insane can act in the same way. And from ignorance, in the absence of any bad intention, he does away with all the effect of the patient’s words. The visitors, knowing nothing of the shades of the patient’s minds, and not reflecting upon them, are told that they see ‘the best of him’. That it is one of his ‘good days’ that he is often ‘dreadfully violent’, or, that if left to himself, he would ‘commit suicide’. They shrink from the responsibility of deciding- where they know it is possible and that they may be wrong. Besides this, there is ready and indisputable certificate signed by a medical man- physician, surgeon or apothecary- stating that the man is mad and must be confined in a lunatic asylum. It does not matter that the certificate is probably signed by those who know little about madness or the patient. A visitor fears to avow, in the face of such a document, what may be set down as mere want of penetration in a manner wherein nobody seems in doubt but himself. Or that he may even be tempted to affect to perceive those signs of madness that do not exist.

On these matters, the public is not altogether inauspicious, and hence, there arises an evil of an opposite description: for the occasional detection of mistakes, and the dread of committing a beloved relative to a lunatic asylum. The opinion, that to pronounce an individual insane is equivalent to pronouncing a sentence of separation from every friend, and an abandonment of all the care for him unto strangers, does prevent, in some instances, the interference of professionals in the interest and comfort of the family’s requirement. And those, to whom temporary superintendence and slight restraint would be salutary, are allowed to ruin their fortunes, or to make the whole family wretched, because restraint, once determined, is seldom apportioned to the individual case, but is indiscriminate, excessive and uncertain in its termination. No provision of the legislature can prevent the occurrence of these grievous mistakes, unless opportunities arise at the same given time. To make medical men as familiar with disorders of the mind as with other disorders, and thus rescuing lunatics from those in whose interest it is to represent such maladies, as more obscure and more difficulties arise to manage than any other. It would be some compensation for the unavoidable evils of public lunatic asylums, if such establishments of that kind become a clinical school, in which under certain restrictions, medical students might prepare themselves for their future duties to the insane.

Suggestions for the Better Protection and Care of

the Insane: A Domiciliary Service [1]

What’s required is:

1. That no person who is not insane should be treated as an insane person 2. That all who are insane should be properly taken care of 3. That the friends of individuals who are insane should be able to procure such immediate aid as the case requires

To accomplish all these objectives, it would be desirable

1. That all persons of unsound mind should be under the care of the state; and should continue so until recovery 2. Every lunatic asylum should be the property of the state and must be controlled by public officers 3. Every lunatic asylum should be a school of instruction for medical students and a place of education for male and female keepers 4. No patient should be confined in a lunatic asylum, except on the particular representation of the relative or friend that he could not receive proper care and attention from 5. All the officers and the keepers of each asylum should be appointed by the secretary of state 6. There should be attached to every asylum a certain number of medical officers and keepers (residing in the house or not) ready at all times to attend to insane patients at their own house. The medical associations, out of the house, should not be exclusively practitioners in case of the insane 7. As soon as signs of insanity appear in any individual, notice of it should be given at the public asylum for the district, and the individual should immediately be visited by a medical officer connected with the establishment, either by a medical assistant residing within the house or by a medical associate out of the house 8. If it is represented that a keeper is required, a keeper should also be immediately sent from the establishment. But in this case, representation should generally be made by the medical attendant of the family requiring aid, and always confirmed by the medical officer of the establishment, or by the medical associate visiting the patient 9. A register of all the patients, in and out of the asylum, should be kept in the central establishment of each district or county. And all persons on the in-

sane list should be visited by a medical officer associated with the asylum, at least once in 15 days in chronic cases, and at least once in 7 days in recent cases, it being understood that the regular medical attendant had the general management of the case 10.The patients out of asylum being the majority and consisting of all whose circumstances would ensure them proper attendance- better arrangements might be made for the smaller number in public asylums, or central houses of reception, of which there might be one in each county, two in London, and one in any considerable town. There should be smaller houses in the neighbourhood of the asylums for the reception of one or two lunatics, such houses should be governed by the general regulations of the larger establishments. Such patients should be sent or removed from home as required.

These were regarded as revolutionary ideas in those times. John Connolly indeed succeeded in giving the field of psychiatry a new direction.

And his son-in-law, Henry Maudsley, who has a very famous hospital known after him, and was made the Superintendent of the Bethlem Hospital in his 20’s, incorporated his father-in-law’s ideas in the treatment modalities.

Acknowledgement

My very sincere gratitude to late Professor Kenneth Rawnsley, former president of the Royal College of Psychiatrists, who helped me procure access to the Connolly’s papers.

References

1. Connolly J. Indications of Insanity. Dawsons of Pall

Mall, London. 1964.

We are Moving Forward Towards Providing Access to Affordable and Modern Medical Facilities:

Dr. Surekha Kishore, Executive Director, AIIMS, Gorakhpur

All India Institute of Medical Sciences (AIIMS), Gorakhpur is unique in many ways, and has a number of achievements to its credits since it was set up. It has over 15 broad specialty OPDs and 12 specialty clinics and brings health care within the reach of the population in the city, as well as the surrounding rural areas. AIIMS is known for accomplishments in providing affordable health care, in medical education and in research, and collaborations with international universities for improving health outcomes. In this free-wheeling email interview, Dr. Surekha Kishore, Executive Director, elaborates on the key health care areas and facilities of the institute, the education and re-education programmes for health care workers, diagnostic facilities and services, telemedicine services to provide consultation to underserved areas around Gorakhpur, and on incorporation of AYUSH, amongst other developments.

The Indian Practitioner (TIP): You have been with AIIMS Gorakhpur as its Executive Director since 2020. How do you see the evolving role of AIIMS as a premier medical institution in the country and what are the competencies now and being built into the future to serve India’s public health challenges?

Dr. Surekha Kishore (Dr SK): AIIMS, Gorakhpur has been evolving day by day and we are moving forward towards providing access to affordable and modern medical facilities which will create balance in the regional health sector and serve the country’s aspirations.

Teaching: Our institute follows a competency-based curriculum for Medical & Nursing courses which reflects the high-quality standards in this institution of national importance. We started with 50 MBBS seats in 2019 and from 2020, we are having 125 MBBS seats per year. We started our 1st batch of B.Sc. Nursing in the year 2022 with 60 students per year. We are in the process of initiating various certificate and postgraduate courses along with Ph.D.

Training: We have a Medical Education Committee to train health personnel, doctors, nursing officers and students related to the principles of medical education technology. Besides these training, we conduct various other training programs like fire safety and training on biomedical waste and hygiene practices. We conduct collaborative training with international bodies like the Alive and Thrive (A&T) initiative, John Hopkins University, Global Health Advocacy Incubator, etc.

Research: We have a dedicated cell for research and a registered Institutional Ethics Committee which is approved by CDSCO for regulatory clinical trials and the Department of Health Research, MoHFW, Govt of India since 2020. Till now 110 extramural and intramural research studies have been approved by the research cell which includes 3 clinical trials. Our institute’s proposal for establishing multi-disciplinary research units has been accepted by the Department of Health Research, Ministry of Health & Family Welfare, Government of India. This will encourage and strengthen an environment of research in our Institute and improve the health research and health services. We are focusing on conducting community-based studies to improve the overall health status of the population by creating evidence-based applications of health promotion, prevention, diagnostic and treatment procedures/ processes/methods.

Patient care: We have currently 15 broad specialty OPDs and 12 specialty clinics. We are a premier 750 bedded hospital in the heart of Gorakhpur. Our facility in Gorakhpur brings multi-specialty care within the reach of a vast region of the population. From the day of its inception, AIIMS Gorakhpur has been having one of the busiest OPDs with a turnout of approximately 2500 patients every day. It caters to patients from Gorakhpur, Deoria, Kushinagar, Basti, Mahrajganj districts, and nearby states like Bihar and across the border from Nepal, the adjoining demographic regions of the country that encounter wide variety of diseases.

The Institute has diagnostic services including

Biochemistry, Microbiology, Pathology, and Radiology to augment clinical services provided to the patients. We have recently inaugurated the Modular Operation Theatre complex, delivery services and Labor, Delivery, and Recovery (LDR) complex of the institute. We have to ensure that the benefits of these facilities reach not only the cities but also the people in the remote villages of our region. We have e-Sanjeevani, the national telemedicine service of the Government of India to enable remote doctor consultations and doctors to seek consultation with subject experts and specialists through the hub-spoke model with Basti, Sant Kabir Nagar, Deoria and Maharaganj district hospitals.

Outreach activities: We give our outpatient services at Rural Health Training Centres at Dumri Khas and Shivpur, Gorakhpur. Besides regular classroom teaching the students have also visited the rural field practice area adopted by the Department of Community Medicine & Family Medicine. In recent times we have organized various public health activities in the domain of health and well being. We are also involved in the field-level monitoring of the various community-level activities in District Gorakhpur and District Sidharth Nagar like monitoring of Village Health & Nutrition Day sessions and hands-on training to ASHA and ANM on every Saturday in the RHTC area.

TIP: AIIMS Gorakhpur is said to be hosting some unique courses/ services which are not available elsewhere in the country. Could you tell us something about these? How would they impact and shape the medical education and healthcare sector?

Dr SK: Under Ayushman Bharat, the transformation of 1.5 lakh subcentre’s into Health and Wellness Centers is being done through the incremental addition of Community Health Officers (CHOs). Many trained nurses are produced meeting the target of CHOs as required. In order to fulfil the demand of country’s high demand of CHOs, we are integrating the CCCH curriculum into the existing B.Sc. nursing curriculum. In this way, our graduated nurses will be already skilled to provide quality comprehensive primary health care at the community. AIIMS Gorakhpur is the first institute to include yoga in the foundation course of medical and nursing courses before NMC announced it. The National Medical Commission (NMC) has now introduced compulsory yoga training in the MBBS foundation course. Stress and anxiety are quite prevalent among medical students. Practices such as yoga and meditation for medical students have been found to improve feelings of peace, focus, and patience, while simultaneously reducing stress levels and fatigue. We conduct Shramdaan activities which include cleaning of office areas, residential colonies, and public places including cleaning drains, public toilets, waste collection drives, and awareness campaigns. Our faculty members, medical and nursing students actively participate every week which is unique in medical institutions. On 15th March 2022, we inaugurated Cardio- Pulmonary Exercise Test (CPET) & Video bronchoscopy Lab Services & Modular Operation Theatre complex which is again unique service in the state of Uttar Pradesh.

TIP: Could you tell us about your Institute’s association with overseas institutions, such as Bloomberg School of Public Health and John Hopkins University Global Health Centre? What is your vision about the scope and potential of such partnerships?

Dr SK: AIIMS Gorakhpur and John Hopkins University (JHU) signed an MOU to collaborate towards supporting ongoing efforts in Eastern Uttar Pradesh aimed at improving overall health outcomes toward achieving the health-related sustainable development goals, reducing the prevalence/incidence of infectious diseases (e.g., vector borne diseases, vaccinepreventable diseases), and building performance-oriented equitable health systems.

We both agreed to develop and expand health science, research, training, education programs, and organizational development at AIIMS, Gorakhpur. JHU is going to support ongoing efforts to increase health science and research training capacities of other institutions in Eastern Uttar Pradesh. We are going to engage in collaborations on analytic, scientific, and programmatic developments towards improving the implementation of various health programs in Eastern Uttar Pradesh. We are going to pursue collaborative health research, including community-based research, health needs assessments, and implementation of science projects.

We agreed to exchange scientific materials and collaboration on academic publications relevant to the interests of both parties. JHU agreed to provide support and engage in collaborative academic programs, including academic exchanges, jointly executed courses, conferences, seminars, and/or lectures. Our nursing courses will be admitted by them. In the future, we may develop student or faculty exchange programs under this MOU.

Apart from this, we have collaborated with various other organizations like PATH, Global Health Advocacy Incubator, Alive and Thrive (A&T) initiative and World food program in India for training and research.

TIP: With the AYUSH ministry signing a pact with WHO to establish a Global Health Centre for traditional medicines research, there has been a push from the government to bring AYUSH research in limelight. Is your Institute doing any work on this? What is your view on promoting Ayurveda and other traditional systems of medicine in India?

Dr SK: We have been working on traditional research with the establishment of AYUSH in our institution. We have recently signed a memorandum with Maha Yogi Sri Gorakhnath AYUSH University. The western system of medicine is looking towards Complementary and Alternative systems of medicine (CAMs) for the management of many alarming problems. In this endeavour, Ayurveda, the age-old indigenous system of health care that primarily focuses on prevention of diseases through lifestyle modifications and interventions (based on the fundamental concepts) can play an important role in prevention, control and treatment of NCDs (Diabetes and its complications, Hypertension etc) and management of risk factors like high lipid levels etc. As per the NPCDCS programme, integration of AYUSH (Ayurveda, Yoga, Unani, Siddha & Homoeopathy) for prevention and health promotion is one of its mandates. Moreover, integration of Ayurveda can also provide cost-effective management of NCDs, as these conditions require lifelong management and strengthen the primary healthcare network in order to ensure the success of its action plan.

TIP: To serve the larger interests of healthcare in the country, many suggest that we should promote and bring back the family physician. What are your thoughts on this? Does this fit somewhere in the vision for your Institute?

Dr SK: Family Medicine is a clinical discipline based on a synthesis of knowledge and skills from other clinical disciplines, public health sciences, and behavioural sciences including anthropology and psychology. It is unique in the integration and application of these disciplines to the individual patient, family and community in the clinical setting. Family practice is a patient-centred and community-based clinical method. Patient–doctor relationship is the key in family practice. The Family Physician (FP) is often more than a “doctor” to the patient and family. A FP provides continuing care to patients and families. Development of a bond helps in understanding the person and the illness better. A FP can provide quality affordable care. FPs provide solutions to common illnesses. They win the trust of the patients and families. We at AIIMS Gorakhpur have had Family Medicine OPD since 2021 and daily on average 100 patients availing the services. The main strength of FM in India is that the concept has a wide public acceptance as the “Family Doctor” has been an integral part of health-care culture of the nation. FM has the potential to integrate well with the Public Health Care system in India. Staffing in all the public health centres is as per the Indian Public Health Services standards and a FM specialist could efficiently fit in at each echelon of this model.

Moreover, we at AIIMS, Gorakhpur are in the process of initiating Family Adoption Program (FAP) as part of the MBBS training curriculum. Each medical student will be required to adopt five families to monitor their health conditions regularly and advise them accordingly. This will help in getting the undergraduate student to get exposed to the family and environment and he /she will be able to appreciate and comprehend a holistic approach to health and disease. We would be able to create a FIVE STAR Doctor as per WHO i.e. a doctor possessing a combination of the following attributes: 1) Care provider 2) Decision maker

3) Communicator 4) Community leader 5) Manager. TIP: A recent report has highlighted that some of the premier AIIMS Centres in the country are facing faculty and non-faculty shortages with several post lying vacant. What is the situation at your Institute? What is being done to tackle this?

Dr SK: All new AIIMS are facing the problem of a shortage of faculty. AIIMS-like institutions require sincere, dedicated faculty, and this takes time. Currently, we have 73 faculty members, and our recruitment cell is conducting interviews biannually in order to fill the vacancies. We recently advertised 108 vacancies of faculties in different departments. It is a continuous process, and we are on it. Various measures are being taken to attract quality faculty. We are in the process of engaging Adjunct Faculty/visiting faculty to enrich the medical education and guidance till the time regular posts are filled up.

A parliamentary committee has also strongly recommended the government to take necessary measures to treat the new All India Institutes of Medical Sciences at par with the premier facility in New Delhi and explore the feasibility of rotation and transfer of faculties to maintain similar quality of education as well as services. The Committee has recommended that the Ministry should explore the feasibility to have the provision of rotation/transfer of faculties from one AIIMS to another AIIMS so that the quality of education, as well as services in all the new AIIMS, will be at par with AIIMS New Delhi.

TIP: According to media reports, India is facing a dearth of doctors among other categories of healthcare professionals. What kind of

strategies could be adopted to address this problem? What reforms could be brought about in the medical education and healthcare sector to tackle these challenges successfully?

Dr SK: The Indian healthcare industry has made great progress over the last decade with the government’s goal of achieving the 3As of healthcare- affordability, accessibility, and availability. We have sufficient MBBS seats in our country, but PG seats are insufficient to fulfil the shortage. The COVID-19 virus has caused pressure on the healthcare system around the world, and India has not been exempted. To ensure that the country keeps producing trained doctors and healthcare workers, it must expand its healthcare infrastructure and enhance medical colleges in India. The Mudaliar Committee, also known as the ‘Health Survey and Planning Committee, 1962,’ planned 1 medical college for 50 lakh people, with a doctor-population ratio of 1:3000. Yet, as indicated by the World Health Organization (WHO), a doctor-to-population ratio of 1:1000 is urgently required.

The PMSSY initiative, which was proposed in 2003, intends to address regional imbalances in low cost and reliable healthcare while also improving infrastructure to provide good medical education in deprived areas. 22 new All India Institutes of Medical Sciences (AIIMS) were developed under this initiative, and MBBS classes have already commenced at 18 of the new AIIMS. Several states have shown their support for the plan and have expressed intention to launch it.

Shri Yogi Adityanath, the Chief Minister of Uttar Pradesh, inaugurated seven new independent medical colleges recently.

In the last 6 years, reorganized medical education strategies have addressed several challenges, including soaring tuition costs and ambiguity in college frameworks, growing medical seats, improving the educational system, facilitating the gap between rural and urban medical colleges, and making the process of opening medical colleges easier.