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Indian Journal of Plastic Surgery
Medknow Publications on behalf of Indian Journal of Plastic Surgery
ISSN: 0970-0358 EISSN: 1998-376x
Vol. 36, Num. 1, 2003, pp. 4-13
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Indian Journal of Plastic Surgery, Vol. 36, No. 1, Jan-June, 2003, pp. 4-13
Oration
Susruta and our heritage
P. S. Chari
Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India.
Delivered on 30th November 2002 at APSICON
2002, Bangalore, India
Code Number: pl03002
Mr. Chairperson, ladies and gentlemen, I am
thankful that the President and the Executive Committee of
our Association nominated my name for the Susruta Oration for the
37th Annual Conference at Bangalore. We, in this country, regard
Susruta as the "Father
of Plastic Surgery." Who was Susruta? When and
where did he live and work? These questions can only
be imperfectly answered like similar questions. In respect
of the lives of our ancient worthies. The Susruta Samhita would have us believe that once upon a
time a number of sages approached Dhanwantari
alias Divodasa, King of Kasi, who received Ayurveda
from divine sources - Brahma via Prajapati, the Aswins
and Indra. Dhanwantari imparts medical knowledge
to these sages, and one of them called Susruta
codified his oral instructions. There is no sure ground
proving the historicity of Susruta, which literally means
"that which is well heard" or "one who has
thoroughly learned by hearing." It is more likely the
anonymously edited manual of a school which had selected
Susruta as patron. It is only safe to assert that Susruta was
of the race of Viswamitra as represented in the Mahabharata- Anushasan Parva,
chapter IV. Divodasa, the preceptor of Susruta, is represented as
an incarnation or descendant of Dhanwantari, the
first propounder of surgical science. The name of
the original work was Shalya Tantra (Skt Sala =
surgical instrument). Beyond this meagre genealogy we
possess no trustworthy information regarding the life
and personality of Susruta.
We have no means of ascertaining what the
Samhita was like as originally written by Susruta, the
present form is a recession or rather a recession of
recessions made by Nagarjuna who opinions identify as
the founder of the Madhyamika or Northern School
of Buddhist philosophy around the second century
B.C. A few quotations from the Vridha (Old) Susruta are
all that are preserved of the original Samhita, but
their genuineness is of a problematic character, and we
are not sure whether they are the production of
lesser lights, or of ancient though less renowned commentators, attributed to the master to invest
them with greater sanctity and authority. The most
renowned commentary on Susruta Samhita is that of
Dalhana (12th century A.D.) called Nabanda Samagraha.
Other notable commentators were Gayadasa (10th
century A.D.) and Candrata (12th century A.D.).
At the time of the Mahabharata which nearly approaches the age of Susruta the number of
sects among the followers of the healing art numbered
five, which were named Rogaharas (physicians), Shaylyaharas (surgeons), Vishaharas (poision
curers), Krityaharas (demon doctors) and
Bhisagatharvans (magic doctors). Susruta's Compendium is
also mentioned in the Bower Manuscript that was found
in 1890 in a ruined Buddhist stupa in Kashgar, on
the western outskirts of the Gobi Desert, and
translated by A.F.R.Hoernle in 1909 at Calcutta. The medical
texts were written in the Pali script of the Gupta
period according to palaeographic criterion which gives
the beginning of the fifth century A.D. as the latest
possible date for the text.
The upshot of these arguments is that in Susruta's
text we have a work the kernel of which probably
started some centuries B.C. in the form of a text mainly
on surgery, but which was then heavily revised and
added to in the centuries before 500 A.D. This is the form
in which we have received the work in the oldest
surviving manuscript today.
Susruta gives us a historical window into a school
of professionalized surgical practice almost two
millennia ago, and which was in its day, almost certainly the
most advanced school of surgery in the world. Many
details in the description could only have been written by
a practising surgeon and it is certain that
elaborate surgical techniques were a reality in Susruta's circle.
The first translation of Susruta Samhita were
ordered by the Caliph Mansur (A.D.753 -774) who had
embassies come from his province of Sind to Baghdad along
with Hindu scholars bringing books. The Caliph
Harun (A.D.786-808) appointed Hindu physicians to
Baghdad hospitals and ordered further translations into
Arabic of books on medicine, pharmacology,
toxicology, astronomy and other subjects. Alberuni who was
a member of the court of Mahmud of Ghazni (A.D.997-1030) mentions the current translation of
Caraka although complaining of its incorrectness. The
centres of Indian learning in his times were Banaras
and Kashmir, both inaccessible to the invading armies
of Mahmud. The first European translation of
Susruta Samhita was published by Hessler in Latin in the
early 19th century. The first complete English translation
was done by Kaviraj Kunja Lal Bhishagratna in three
volumes in 1907 at Calcutta. New sources have been
discovered in Tibetan versions, Tamil sources and Mongol
versions of Tibetan translations. Indian medicine has played
in Asia, the same role as Greek medicine in the West,
for it spread to Indo-China, Tibet, Central Asia, and as
far as Japan.
The contributions regarding Plastic Surgery in
Susruta Samhita are the following:
- Rhinoplasty by cheek flap.
- Classification of mutilated ear lobe defects.
- 15 techniques for repair of torn ear lobes.
- Cheek flap for reconstruction of absent ear lobe.
- Repair of cleft lip.
- Piercing children's ear lobe with a needle or awl.
- Suture materials of bark, tendon, hair and silk.
- Needles of bronze or bone, circular, two
finger-breadths wide and straight, triangular
bodied, three finger - breadths wide.
- Classification of burns into four degrees -
singeing, blister, superficial and deep.
- Different methods of dressings with
various medicaments.
- Wine to dull the pain of surgical incisions.
- 101 types of blunt instruments (yantras) and
20 varieties of sharp instruments. According to Susruta the hand is the
most important
yantra, for without it no operation could be done.
- Surgical demonstration of techniques of
making incisions, probing, extraction of foreign
bodies, cauterization, tooth extraction,
scarification, excisions, trocars for draining abscess, saws
for amputations on various natural fruits, dead
wood, and clay models.
- A system of anatomical dissection of cadavers.
- Operations for lithotomy, intestinal
sutures, couching for cataract, caesarian section to save
a live baby if the mother dies in labour and other surgical procedures
are mentioned. Ligaturing of bleeding vessels was not known, the bleeding
being
checked by
pressure, cautery or boiling oil.
- A code of ethics for teachers as well as students.
There is little historical evidence to show that
these practices persisted beyond the time of the
composition of Susruta's compendium. A few references to
surgery found in Sanskrit literature between the
4th to the 8th century A.D. were collected by P.V. Sharma
(1972),
but the stereotypical nature of most of these
references and the paucity of real detail, suggests that the
practice of surgery was rare in this period. There is
some evidence, however, that although surgery ceased to
be part of the professional practice of the
traditional physicians of the vaidya caste, it migrated to
surgeons of the "barber surgeon" type. As such, it was no
longer supported by the underpinning of Sanskrit
literary tradition, so it became harder to find historical
data about the practice. D.C. Sircar (1987) discusses
some epigraphical evidence for the heritage and
migrations
of the "Ambastha" caste who appears to
have functioned as barber surgeons in South India and
later migrated to Bengal.
By the 17th century, foreign visitors began to
remark on how surgery was virtually non- existent in
India. The French traveller, Travernier for example,
reported in 1684 that once when the King of Golconda had
a headache and his physician prescribed that blood should be let in four places under his tongue,
nobody could be found to do it Col. W.S. Sleeman (1893) in
his "Rambles and Recollections of an Indian
Officer" observed on the same lack of surgeons.
The famous Indian Rhinoplasty method is often
cited as evidence that Susruta's surgery was widely
known in India even up to comparatively modern times.
The operation took place in March 1793 in Poona. A maratha named Cowasjee who had been a
bullock-cart driver with the East India Company Army in the
Third Mysore War of 1792 was captured by the forces of
Tipu Sultan and had his nose and one hand cut off. (A
residual puzzle with this account is that `Cowasjee' in a
Parsi name, not a Maratha one). After an year without a
nose, he and four of his colleagues, who had suffered
the same fate, submitted themselves to treatment by a
man who had a reputation for nose repairs.
Unfortunately, we know little of this man, except that he was said
in one account to be of the brick-maker's caste and
by Cowasjee's commanding officer Lt. Col. Ward as
an `artist' whose residence was 400 miles distant
from Poona. Thomas Cruso and James Findlay, senior
British surgeons in the Bombay Presidency, witnessed
this operation.
They appear to have prepared a description of
what they saw and diagrams of the procedure. The
details and an engraving from the painting were published
at third hand by Barak Longmates a journalist in 1794
in `The Gentleman's Magazine and Historical
Chronicle (66.4 pp.883, 891 and 892). The key innovation
was the transplantation of skin from the site
immediately adjacent to the defect, while keeping the graft
tissue alive and supplied by blood through a connecting
skin bridge. Subsequently, through the publication
by Carpue (1816) describing his successful use of
the
technique this method of nose repair gained
popularity amongst British and European surgeons.
Personal inquiries by Carpue from Cowasjee's
commanding officer Lt. Col. Ward described the understanding
in Poona, at the time of the operation, that this artist
- surgeon was the only one of his kind in India and
that the art was heriditary in the family.
The technique used by Cowasjee's surgeon was
similar, but not identical, to that described in
Susruta's Compendium. Susruta's version has the skin flap
being taken from the cheek; Cowasjee's was taken from
the forehead. The Sanskrit text of Susruta's description
is brief and does not appear to be detailed enough to
be followed without an oral commentary and
practical demonstration, although an experienced
surgeon might be able to discern the technique even so. It
is hard to see how such techniques could have
persisted purely textually. Maybe, the Poona operation is
indeed an extraordinary survival of a technique from
Susruta's time, but in that case it seems to have been
transmitted through channels outside the learned practice
of traditional Indian physicians.
Ayurvedic literature is preserved almost exclusively
in the Sanskrit language, and originally in the form
of manuscripts written on birch bark , palm leaves
or paper. India has, over the millennia, developed
about a dozen different alphabets. The scribe who
copied out the manuscripts would use the script that was
local to the place of work. So it is quite normal to
find Sanskrit medical manuscripts from Kerala in
the Malayalam script, while a manuscript of the very
same text copied in Bengal would be in the Bengali
script. Both manuscripts would still be in the
Sanskrit language and would be virtually indistinguishable
if read aloud.
No systematic effort has been made to collect
together all the known manuscripts of Susruta Samhita, let
alone compare them all, try to classify them, to tease
apart the historical strata in the texts, weed out scribal
errors, and adjust the readings of the texts accordingly.
The printed editions are vulgate texts, that is so say,
they are books printed on the basis of small number
of manuscripts from a local region, normally Bombay
or
Calcutta. And the decisions about what to print
when the manuscripts disagree was made on the basis
of general common sense but without the support
which historical philology and textual criticism can
offer. Criterion for determining what is intrinsic and what
is extrinsic to rationalist medicine in the Susruta
Samhita is based on the observation that medical science
is concerned with specifically four factors: the doctor,
the substance used (drug or diet), the nursing
attendant and the patient. The qualifications essential to
each are also specified. The discussion concerned with
these are intrinsic to medical science. By contrast, any
topic unconnected with these - howsoever may be
their importance in philosophy, religion and
traditional morality - are extrinsic to medicine.
Today, Ayurveda is one of the six medical systems
that are officially recognized by the Indian Government,
the others being allopathy (modern medicine), homeopathy, naturopathy, unani, siddha and
yoga therapy. The practitioners of the six systems
must compete for patients with each other and with
a profusion of practitioners of other medical
skills, including itenerant tonic sellers,
pharmaceutical representatives, village curers, bone setters,
midwives, exorcists, sorcerers, psychics, divines,
priests, astrologers, grandmothers, wandering
religious mendicants and experts in such maladies as
snakebite, hepatitis, infertility and `sexual weakness'.
Indian people talk knowingly or not in the Ayurvedic
idiom. Even the illiterate peasant of a remote village
knows that yoghurt causes phlegm to accumulate in the
chest, and everyone uses simple herbs like vetiver (cus
cus) which remove `heat' from the body and makes
life during the hot summers a little more
bearable. Ayurvedic thought is part of the conceptual
universe of every Indian and has been a part of its
collective consciousness since very early times.
Professor Debiprasad Chattopadhyaya in his book "History of Science and Technology in Ancient
India Vol.II (1986) quotes Gordon Childe's comment
that science and technology only develop during
periods of urbanization. He describes two such periods
in Ancient India, to which we can add two that
developed in the succeeding centuries.
- First Urbanization : Indus Vally
Civilization (about 2300 B.C to 1750 B.C.)
Dark Age from : 1750 B.C to about 700 B.C.
- Second Urbanization : Aryan cities in the
upper and middle Ganges plains
- Third Urbanization : The Industrial
Revolution and British colonization
- Fourth Urbanization : Information
Technology Revolution and Global Village.
Archaelogists in the second and third decades of
the 20th century dug up the outlines of an
imposing civilization with a considerable number of
flourishing cities in the Indus River Valley extending into
Haryana and Lothal, a sea-port, in Gujarat. The
First Urbanization is viewed as resulting from
profound socio-economic transformation from the
neolithic villages to city life in the full sense. An important
trait of city life was the creation of exact and
predictive sciences-mathematics and astronomy - for revenue
and property, inventories, building cities and
calculating the farmer's calender. The farmers surplus could
be taken away for trade and commerce and city
activities. We are still in the dark regarding the nature of
the ruling class as no written material can be used for
the purpose since their script has not been
deciphered. On the analogy of the situation in Egypt
and Mesopotamia it has been suggested that the administration was controlled by priest- groups
who used religion, magic and superstitious beliefs to
control the people. The city centres of the First
Urbanization came to an end about 1750 B.C. for complex
reasons as yet not fully understood. Thereafter followed
a thousand years called the Dark Age.
About the eighth or seventh century B.C. Indian
history started taking a dramatic turn towards the
Second Urbanization. After the conquest by the migrating
Indo-Aryans of the indigenous people, tribal groups
began to settle in towns. Tribal wars led to the
establishment of kings and kingdoms first in the upper Ganges
basin, followed by the middle Ganges plains and
then gradually throughout the sub-continent. There was
a profound intellectual turmoil and thinkers
explored
various alternative avenues to understand nature.
Thus came into being the first Indian scientist with a
superb scientific method, which paved the way for
the revolutionary move forward from
magico-religious medicine to rationalist medicine. His name
comes down to us as Uddalaka Aruni of the Gautama clan.
He was the first to formulate and apply the essentials
of the method of experimental verification. Secondly,
he developed in a rudimentary form a promising
unified theory of man and nature. Both contributed to
the making of the tradition of rationalist medicine in
the Indian subcontinent. Its essence consisted of
the observation of facts (Skt drstanta) and reasoning
or generalizing (Skt. Hetic) based on it.
Without bluntly rejecting the earlier
scriptures embodying mythological beliefs and
religious injunctions, Uddalaka dismisses all these in favor of
a rational search for the ultimate cause of everything
in nature recommending direct observation in the
real sense. By an experimental demonstration he
discovers to his son that which is the finest essence this
whole world has that is its soul. That is Reality. That is
Atman. That art thou, Svetaketu. (Chandogya Upanishad
13.1 1.4 and 6.3.1-15)
Uddalaka deserves to be placed with Thales of
Miletus (640-546B.C.) who is believed by Western scientists
to have initiated the spirit of inquiry and the pioneer
of scientific observation. The main source of our information regarding Uddalaka
Aruni are
the Upanishads, particularly one chapter in the
Chandogya Upanished exclusively recording his discourse
though this needs to be supplemented by some passages
from earlier sources like the Satapatha Brahmana (xi,
4.1-9) which mentions him as a man of considerable
wisdom, willing to acquire that he himself did not possess
from whomsoever possessed it, regardless of caste or
status. The early Buddhist literature contains 550 stories
called Jatakas which orthodox Buddhists believe to
be accounts of Buddha's former births. One of these
(Jataka No. 487) bears the name Uddalaka and mentions
that he studied in Taxila under a renowned teacher
there. He became highly learned and the leader of a group
of roving ascetics in quest of knowledge and purity.
He seemed to repeatedly point out that the only
right method of scientific investigation into the nature
of
reality is that of inference by way of induction. His
basic theme is that of the making (or evolving) of
everything in the universe from the primeval matter. From
this naturally follows the view that in the ultimate
analysis man is nothing but an evolution of it - a view
formulated in the text by the oftrepeated formula, "That thou
art, Svetaketu." There is no scope in this formula for
any divine agency having anything to do with the
making of man. The phenomenon called death was
understood by him as the return of the body to food, water
and heat and therefore ultimately to `sat', or
primeval matter.
The essential core of medical science took
shape already before the time of the Buddha who died
around 485 B.C. or shortly after Uddalaka's time. The
Caraka Samhita admits that various medical systems were
in circulation. Apparently, during the formative period
of rationalist medicine, different authorities were
groping in different ways for determining the most
effective therapeutic principles; various avenues had to
be explored for medical science to be standardized.
What was the status of doctors in our early history
? While steps were being taken by the ancient
physicians and surgeons to move towards remarkable results,
the utmost contempt was shown for them in the
legal literature, the Dharmashastras, when the law
codes were taking distinct shape in the sixth and fifth
century B.C. It was declared that they were so inherently
impure that their very prescence pollutes a place; food
received or given to them was impure, they were not
invited for sacrificial ceremonies, in social status they
were considered no better than whores, hunters and followers of other despicable
professions (Apasthamba 1.6.19; Gautama xvii.7; and Vashistha xiv. 1 - 10,
19). The obvious need of their services to society
was acknowledged of course, as was that of the
followers of other mean professions. Because the healers
were absolutely shorn of respectability it was prescribed
that medical practice should better be restricted to
the Ambastha caste (Manu X.46-47). According to
Manu (X. 116) persons of noble birth are forbidden
learning that is different from the learning of the
Vedas; medicine, logic and poison-removing being
mentioned. The law givers understood that medicine and logic
are closely related. Logic was detested for the reason
that
excessive indulgence in logic encourages heresy or
the tendency to question the scriptures. The Dharmashastras have the primary
purpose of
validating the ideal of the hierarchial society - an ideal of
which the priests were the main theoretical custodians.
P.V. Kane in his monumental "History of the Dharmashastras" shows that
already "dharma"
acquired a sense of "the priveleges, duties and obligations of
a man, his standard of conduct as a member of the
Aryan community, as a member of the caste, as a person in
a particular state of life."
In the translation of Kautilya's "Arthashastra"
(about 300 B.C) by Professor R. Shama Shastri of Mysore
there is chapter on salaries to be paid by the
Mauryan Emperor to his employees. The highest salary
was 64,000 panas and only the Queen Mother, heir apparent, the Chief Minister, the Commander - in -
chief of the Army, the Chief of the Harem, the
Emperor's Purohit or spiritual advisor and the family priest
were entitled to it, possibly because of their proximity
to the Ruler and the fear of assassination. The next
salary slab was halved to 32,000 panas for notable government functionaries and subsequently
halved over and over again. The physician was placed in
the salary slab of 4 panas flanked by the water-carrier
and the horse-groom. The belief got
institutionalized creating formidable difficulties for the progress
of medical science. As late as 1836 when the
Calcutta Medical College was started, when an Orthodox
Hindu got enrolled and actually dissected a cadaver
his courage had to be boosted by the booming guns
of Fort Williams. If, hardly 170 years back, so
much courage was needed to overcome orthodox
opposition to dissection and all this under the protection
and patronage of a powerful Government, it is not
difficult to imagine how much greater courage was required
of the ancient surgeons to prescribe a detailed mode
of dissection as a necessary precondition for
attaining medical proficiency.
Europeans after gaining entry into India built a
series of hospitals but to start with, and for two
centuries thereafter, these hospitals were solely for
Europeans. The first European hospital was founded by
the Portuguese Albuquerque in 1510 at Goa. Its management was handed over to
the Jesuits who made
it one of the best managed hospitals in the world.
For the care of the native poor the British built a
hospital in South Madras called the Native Infirmary which
was named the Stanley Hospital in 1940. The French
built a hospital in Pondicherry in 1701 and when the
French left India the Government of India upgraded it
to JIPMER. In Calcutta a hospital for the native poor
was built in 1792, a precursor of the later Medical
College Hospital. In Bombay the first Britsh hospital was
built in 1676. In 1843 through a munificent donation by
Sir Jamshetji Jeejeebehoy the J.J. Hospital started and
two years later the Grant Medical College was attached
to it. At first no Indians were attached to the
teaching faculty. The Gordhandas Sunderdas Medical College
and the K.E.M. hospital arose as a counter to
British managed hospitals in 1925. The most
important condition of the endowment was that all members
of the teaching faculties should be well qualified
Indians. Dr. Jivraj Mehta was its first dean.
It is commonly believed that proper education in
India was started by the British. Mahatma Gandhi in a
speech at Chatham House, London, in 1931, October 20
said, "I say without fear of my figures being
challenged successfully, that today India is more illiterate than
it was fifty or a hundred years ago, because the
British administrators when they came to India, instead
of taking things as they were, began to root them
out. They scratched the soil and began to look at the
root and left the root like that, and the beautiful
tree perished. The village schools were not good
enough for the British administrator, so he came out with
his programme. Every school must have so much paraphernalia, buildings and so forth. Well, there
were no such schools at all. There are statistics left by
British administrations which show that, in places where
they have carried out a survey, ancient schools have
gone by the board, because they was no recognition for
these schools, and the schools established after the
European pattern were too expensive for the people."
William Adams in his `Report on the State of
Education in Bengal and Bihar in 1835 observed that there
seemed to exist 100,000 village schools in Bengal and
Bihar attached to temples, mosques and dharamsalas. In
the Madras Presidency the Governor, Sir Thomas
Munro, stated that "every village had a school' and for areas
in
the Bombay Presidency around 1820 G.L. Prendergast found "that there is
hardly a village, great or small, throughout our territories, in which there
is not at
least one school, and in larger villages more." Dr. G.
W. Leitner in 1882 showed that the spread of
education in Punjab around 1850 was of the same extent.
Despite the politically unsettled times the most
unscrupulous chief, the avaricious money lender and even the free
- booter vied with the small landowner in making
peace with his conscience by founding schools and
rewarding the learned. Institutions of higher !earning existed
in many districts of Madras Presidency according to
the collector's reports. In Malabar, the Samudrin
Raja (Zamorin) maintained one old institution as a
family trust. Where no colleges existed such learning in
the Vedas, Shastras (Law), Astronomy, Ganeet, Ethics
etc. were imparted in agraharams or usually at home.
The Malabar data mentioned 194 pupils to be
studying medicine.
How was all this education actually organized
and maintained? The village to an extent had all
the semblance of a State; it countrolled revenue
and exercised authority within its sphere.
Notwithstanding all that has been written about empires -
Mauryan, Vijayanagar, Mughal etc. - throughout its history
Indian society and polity has basically been
organized according to non-centrist concepts. The
annual exchequer receipts of the Emperor Jehangir did
not amount to more than five percent of the
computed revenue of the empire, and that of Aurangzeb, with
all his zeal for maximizing such receipts, did not
ever exceed 20 percent. In terms of basic expenses,
both education and medical care, like the expenses of
the local police and the maintenance of irrigation
facilities, had primary claims on revenue. It was this revenue
that maintained not only higher education but also
the system of elementary education. Other recepients
of revenue included those employed in
administrative, economic and accounting activities; religious
and charitable allowances, agraharams, maintenance
of religious places, pundits, poets, joshis,
medical practitioners and others.
The dispossession of the various categories of
revenue assignees started as soon as the British took over
de
facto control of any area. Through various means
like enhanced rates of assessments, revenue
assignments, cash or grain allowance for teachers being
appropriated to the total state revenue, slashing down of
district charges, that is, the amounts traditionally
utilized within the districts. The degeneration of education
is ascribable to the gradual but general
impoverishment of the country, and the means of the
manufacturing classes greatly diminished by the introduction
of European manufactures.
The neglect and uprooting of Indian education,
and its replacement by an alien and rootless system
had several consequences for India. To begin with it led
to an obliteration of literacy and knowledge of
such dimensions that recent attempts at universal
literacy and education have been unable to make an appreciable dent in it. Next it destroyed the
Indian social balance in which traditionally, persons from
all sections of society appear to have been able to
receive an optimum schooling which enabled them to participate openly and appropriately in the social
and cultural life of their locality. And most importantly,
till today, it has kept most educated Indians not
only ignorant of the society they live in , the culture
which sustains this society, but yet more tragically for over
a century it has induced a lack of confidence and loss
of bearing amongst the people of India in general.
Dr. Farouk E. Udwadia noted in his book "Man
and Medicine," medicine does not change in an
isolated milieu or as an isolated phenomenon. It was merely
a part of the change that altered the whole fabric
of human society; and each aspect of life and
living influenced the other.
How does one acquire learning? In the seventh
century A.D. Adi Sankaracharya said, " One fifth is the
inherent qualities of the student; one fifth is by discussion
and study together with his fellow - students. One fifth
by a teacher interested to teach; one fifth by his own
hard work and efforts; and one fifth by experience.
The present scenario in teaching hospitals in bleak.
All departments are understaffed and the
government's policy is to downsize the number of salaried
faculty.
The best talent is no longer attracted by the
offered salaries. The majority opt for private practice and
the problem is to acquire experience, judgment and updating of knowledge and
skills. Holding workshops and C.M.E.s are not enough. We need to evolve a
more dynamic medical education by harnessing the
methods of modern information technology.
Recent decades have seen an explosion in the knowledge base in surgery. The development
of sophisticated operative techniques has demanded subspecialization in surgical training. Individual
faculty members carry this a step further when they
become "superspecialists" with practices confined
to anatomically circumscribed targets. This trend
towards tunnel vision undermines the clinical practice
setting. This phenomenon is ironic. Scientific progress
has refined the surgeon's armamentarium - but only
if properly recruited. Specialists have lost their
common educational moorings, so too have they lost their
ability to communicate and to strengthen each other's
role in patient care.
Professor K. Mohandas, Director of Sri Chitra
Tirunal Institute of Medical Sciences, in an address at
the Annual Conference of Vice- Chancellors at
Chandigarh in December, 2001 outlined a program of
action through an information technology enabled
flexible education program. This program may be implemented in a phased manner with the
following objectives:
- To ensure quality, relevance and uniformity
of standards in training and evaluation.
- To encourage evidence- based medical
practices and the use of appropriate technology which
are proven, essential and cost-effective.
- To enable a flexible training program allowing
not only quick incorporation of the latest
advances, but also one that will facilitate learning at
one's own pace and place. Most of the training for specialization can be
done at the practitioner's place of work or home, thus reducing
prolonged absence from professional responsibilities
and facilitating conscious learning and updating
of knowledge, techniques and technology.
The proposal should ultimately lead to
individualization of medical education and training so that the
ill-effects of regimented education can be minimized both
in quality and quantity. Moreover, the fruits of
advances in health sciences would become more easily
available to patients across a wider socio-economic spectrum.
Plan of Action
Phase I
1. Establish internet facilities in all the
medical colleges and make it accessible to the
students and teachers.
2. Encourage students to gather information from
the Internet to supplement those from standard
text-books. Small discussion groups mentored by teachers may then discuss all the information,
with the teacher lending his/her experience to
clarify doubts, assess the credibility of the
information and helping to adapt it to the
local/regional realities. The whole process should be aimed
at synthesizing and assimilating information so
that its application becomes clear and practicable.
3. The Health Science Universities and the
medical faculties of traditional universities may set up
e-groups (discussion groups) within and among themselves so that knowledge,
information, experience and problems may be shared
and discussed in a wider circle.
This phase should be completed in about 24
months, at the end of which all training institutions will be
net worked to optimize information acquisition, dissemination and assimilation, both from the
point of view of expanding the knowledge base as well as
its most effective application.
Phase II
Aim to establish the necessary infrastructure to
utilize the benefits and advances in information
technology. With a national nodal agency entrusted to
complete infrastructural development and co-ordinating
the resultant multi media network, the phase should
in five years ensure that the national health
sciences network will be able to adopt, absorb and adapt to
the rapid technological developments that
continuously
repave the information highway.
At the end of this phase the following
objectives must have been achieved
- A National Nodal Agency that coordinates
the functioning of health science network.
- Regional or state agencies responsible for
network operations within the region/state and
operating in tandem with the national co-ordinator.
- A reorganized undergraduate curriculum
that maximizes learning and optimizes practical application of existing and
emerging clinical
and research information, using the tools of information technology.
- Online retrieval of information from a
national main frame computer. Knowledge and
information from all institutions must also be made
available to this central storage facility.
- Video conferencing facilities, if not in
every teaching institution, at least in well dispersed
and strategically located centers so that geographical
distances will not prove to be major impediment.
- Facility for digital data transmission of
texts, biological signals (ECG, EEG, EMG etc) and
images - not necessarily restricted to teaching
institutions, but also accessible and available from
reputed hospitals, research institutions and even
individual practitioners.
Phase III
This phase which should ideally be completed in
10 years should usher in an era of flexible learning
and training at the postgraduate level with facilities
for continuous updating of knowledge and skills, as
well as evaluation and recertification of the competency
of medical teachers and practitioners at optimal intervals.
More specifically
- Acquisition of knowledge and skills for
specialist practice and their evaluation at a pace
affordable and feasable for the aspirants. The curriculum
and training programs must be so designed as to enable the candidates
to undergo the training without having to leave their place of practice
or work for long periods, and the number of candidates need not have
to be restricted as
in the existing educational systems.
- An accreditation system for hospitals which
can serve as training centres so that trainees can choose a hospital
not too far and not too different from their patient population,
epidemiological composition and disease burden.
- Public health programs integrated into
Clinical practice so that the new paradigm of health
care delivery system that would hopefully emerge
from the reorganized education and training
programs, based on flexibility, relevance and feasibility,
will have prevention of diseases and promotion of health as the first
priority.
The Government of India and the State
Governments, in association with the Medical Council of India
should adopt the implementation of technology
enabled medical education as an urgent priority. It should
form part of the new National Health Policy. Perhaps the
first step may be the identification of an agency to
work out the detailed action plan in a time-bound
manner and this could be done by the Union Ministry of
Health following a round of consultations with the
State Governments, the Ministry of Human Resources Development and the Medical Council of India.
Our heritage of Indian Medicine stretches over
5000 years, from the period of the First Urbanization to
the era of the global village. That medical science is
not merely a branch of technical knowledge, but that
it has an important ethical aspect, have been
emphasized in both Susruta and Charka Samhitas as well as
in various medical codes of ethics upto the present
times. Zoroastrianism, the first monothestic religion in
the world, in its scripture, Avesta embodied the tenets
of its priest physicians or Magi in the three
words-humata, hukata, havarasta-which means "good thoughts,"
"good words" "good deeds". The same three words are
the Tata crest adopted by Jamshetji Tata.
"The difficulty lies not in the new ideas, but in escaping
the old ones, which ramify into every corner of our minds."
J. M. Keynes
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