Medicine, Mixopathy and the Indian Middle Class
An unpopular opinion
Where we stand depends on where we sit – Miles Rufus
Mixopathy has been in the public discourse ever since the Maharashtra government rolled out a notice saying that it would register BHMS doctors under the Maharashtra Medical Council (MMC) on completion of a one year Certificate Course in Modern Pharmacology (CCMP). The decision, although currently stayed by the Supreme Court, has sparked a heated debate in the medical community. The IMA has been a vocal adversary of the policy and doctors all over the internet have unanimously condemned the proposal. As a doctor, I cannot insist more on how disconcerting the issue is. The degree that we worked so hard to achieve, holds less and less value. But after doing some preliminary research, I can see why, in all its indignity and hopelessness, this story too has two sides. In this blog I will talk about the inevitability of the status quo and raise some important policy questions about cross-pathy. For anyone who's interested in the chronology of the events and recent developments, I’ve created a table for reference, which can be found at the end of the article. The first mention of such a bridge course was in 2014 and since then it has followed a sluggish go-stop-go trajectory.
Two of my grand uncles with a BAMS degree were medical officers with the M.P. government in the 80s. As a kid my dad would accompany his uncle on his routine village tours. It used to be the highlight of his summer vacations – local villagers welcoming his uncle with the vernacular “Dr. Saab” and showering him with delicacies and farm produce for his visits. He was treated like a demigod, who could cure any ailment with the prick of an injection. The locals could not tell BAMS and MBBS apart. For them the title Dr. entailed enormous healing powers. Although ayurvedic doctors weren't formally allowed to practice allopathy but for the lack of MBBS graduates, the government employed them and implicitly permitted delivery of primary care by them. They had an array of drugs on them: paracetamol, antibiotics, pain killers, antacids, steroids and the likes. They administered parenteral drugs in the PHCs, ran OPDs and carried out various health programs and schemes. Just fresh out of BAMS, he was more confident while managing real world problems than I or most of my MBBS batchmates would be.
When Homeopathic doctors announced a three day hunger strike following a stay on the earlier decision, it seemed preposterous in the face of it. Just like everyone else, I strongly believed that it reeked of entitlement. Do they see BHMS as a gateway into modern medicine, some sort of a shortcut? Well, Yes. Nine out of ten (if I'm being open-minded) students enroll in BAMS/BHMS because they could not bag an MBBS seat. Then they maneuver their way into the mainstream healthcare market. Smaller private hospitals and nursing homes also employ these graduates, often at a much lower compensation. So naturally this tantrum of a hunger strike to blackmail the authorities into legalizing crosspathy, seemed extremely outrageous. I often wondered if they even knew how any of these drugs actually worked, their side effects, were they a go or no go in pregnancy, the pathology behind diseases or the systematic approach towards diagnosing a condition? So I decided to double down on the BHMS curriculum. And it revealed an entirely different story. Although I couldn’t get my hands on the older data, when I looked up the current BHMS curricula (1), I was aghast at how closely they resembled the MBBS syllabus on paper...
Broadly, BHMS students study 11 out of the 19 MBBS subjects but if you dig deeper into the syllabus, it turns out that Surgery is further broken down into General surgery, E.N.T and Ophthalmology; psychiatry and psychology too are a part of the course and allied subjects like orthopedics and radiology are also integrated with the main subjects. Except pediatrics, every subject is taught in some capacity. So, it is safe to assume that they have a working knowledge of clinical medicine. Below is a snapshot of one of the competencies designed for surgery. Any MBBS student will testify the semblance to the surgery that we study.
A recurring argument against CCMP, which I earlier concurred with, is that a one year bridge course cannot equip AYUSH doctors with the knowledge needed to practice allopathy. But I stand corrected. The course is tailored in such a way, at least on paper, that the kind of understanding that BHMS students develop of the human physiology and disease pathology is almost at par with their MBBS counterparts. Once they have a framework of clinical medicine in mind with a preliminary knowledge of modern pharmacology, a one year long bridge course should make them eligible to deliver primary care. So, perhaps the lobby behind CCMP is not entirely unjustified. Although, I would like to reiterate that this is “on paper”, I don’t know how well it is taught in reality. But the question that we should be asking is: Why is the government hell bent on bridging the gap between the two curricula? In fact, JIPMER has gone so far as to propose an integrated BAMS-MBBS program, wherein students will be offered a dual degree in both ayurveda and modern medicine. I thought the motto of the Ministry of AYUSH is to embolden traditional medicine; I did not know that they are planning to achieve this by piling on to allopathy.
If you go out for a walk in your neighborhood and count the number of private clinics run by BAMS/BHMS practitioners, their pervasiveness in the market will become clear as day. Up until I started preparing for the medical entrance exam, every time someone ran a fever in my family, we would consult a local ayurvedic doctor. He either wrote a prescription or dispensed loose drugs (a mix bag of allopathic and ayurvedic medicines) and we would religiously abide by it without an iota of doubt. It's not like we never bothered consulting more qualified allopathic doctors but either the fee was too high for a 10 minute consultation about a cold or the waiting period was too long. So, as long as it was a fever, cold, allergies or diarrhea, we were more than comfortable seeing the ayurvedic doc. When my cousin recently took ill, my uncle proudly presented a prescription of a CCMP certified doctor to me. He’d gone against my advice and consulted him anyway, so naturally I was dismissive of him. But he said, “this doctor did a video consultation for my son for 400 bucks and prescribed the same tests that any other doctor would.” His reports came back positive for typhoid fever, for which the doctor put him on standard antibiotics and my brother recovered in a week. It's probably an overgeneralization but this is the story of the majority of the Indian middle class. Since many conditions are self-resolving and need only symptomatic management or standard drugs, affordable consultation and comparable treatment outcomes incentivize lay people to see AYUSH doctors. In a market economy, we cannot prevent this from happening. With or without CCMP, practitioners of alternative medicine are going to encroach into allopathy. Period.
Going forward, there I want to throw light on some important questions –
By introducing CCMP and registering BHMS doctors under the MMC, is the government is enabling mixopathy and undermining the status of MBBS doctors? This accusation has my unbridled support. MBBS and BHMS doctors should not be registered under the same board whatsoever.
If mixopathy is inevitable, isn't it a sign of good strategic planning to formalize and regulate this sector? Yes. Perhaps a bridge course and formal training in pharmacology will prevent medical negligence in the hands of these doctors. An analogy comes to mind– If you know that your kid is going to engage in sexual activities whether or not you allow it, isn't it better to teach them about protection?
How do we cap the scope of cross-pathy? I think while preparing the SOP, the officials must tread with caution and impose stricter laws to regulate the extent to which AYUSH doctors can encroach into allopathy. But this isn’t going to be a cakewalk; there will always be a grey area.
The rationale behind introducing CCMP is to foster primary healthcare in the rural areas. The policy makers are hoping that this will miraculously attract AYUSH practitioners to the villages. Well, they couldn't be more delusional. With this law in place, wouldn't BHMS doctors want to settle in the cities and monetize this new skill set? Estimates based on National Sample Survey data suggest that the density of AYUSH practitioners is already 7 times higher in urban areas compared to rural areas (2). Why not create infrastructure to attract existing MBBS doctors and specialists to the villages since India already meets the prescribed doctor patient ratio (they are just concentrated in the cities)? In absolute terms, we do not have a scarcity of MBBS graduates. So, wouldn't it be better to mobilize them instead of fueling competition by creating a new breed of CCMP doctors?
“Allopathy and AYUSH systems complement each other; they are not competitors.” said the Union Minister of State, ministry of AYUSH a few days ago. “To give Ayurveda global recognition, India is placing special emphasis on evidence-based research and high-quality clinical trials through the Central Council for Research in Ayurvedic Sciences (CCRAS) and other institutions.” He added (3).
By formalizing cross-practice, are we not discouraging research and evidence based practice of AYUSH? By giving alternative systems of medicine legal backing to prescribe allopathic medications, the government is in fact telling them, “It’s okay to not build a robust R&D based bedrock for AYUSH. You can just piggy back on allopathy and carry on.” The purpose of creating a Ministry for AYUSH was to promote research and peer review in Indian knowledge systems and traditional medicine so that it can be elevated to international standards. But the approach that the government seems to be taking is an antithesis of what it set out to achieve.
Governments throughout the history of independent India have relied on BAMS and BHMS doctors to fill the gaps in healthcare delivery. Mainstreaming AYUSH as a part of the National Rural Health Mission – (now NHM) was started in 2005 and is currently under expansion(2). But the present government, since 2014, has gone to great lengths to promote the legitimacy of AYUSH, albeit without scientific evidence. On one hand they want to portray Ayurveda as a system of medicine in its own right and on the other hand they want hand holding with modern medicine. The homeopathic doctors who threatened to go on a hunger strike are not entirely to blame for their actions, they’re only asking for what was promised. It is those who made the promise who should be held accountable.
P.S.- I'm going out on a limb here but I think the reason why MBBS doctors are so deeply threatened by the idea of legitimising mixopathy is not just that it's unfair but also because the system hasn't prepared us to be a better breed of doctors (better at providing quality primary care). The skills that we've learnt throughout MBBS are subpar and inadequate to deal with real world problems. If the quality of services provided by general physicians were leaps and bounds ahead of AYUSH doctors, we wouldn't have to worry about competition. Unfortunately, MBBS has been reduced to a prerequisite for post-graduate training. The government is doing many things to improve primary healthcare but they are shooting in the dark and hitting all the wrong spots.
Chronology of national policies
Chronology of Maharashtra Policy
