Move From Clinical To Investigative Medicine

Meha Mathur Sep 13, 2022

Covid came as the litmus test for the medical community and the doctors, nurses, technicians, cleaning staff and security guards all stood the ultimate test of the time. At the All India Institute of Medical Sciences (AIIMS), Director Randeep Guleria led from the front, keeping his team inspired all through the ordeal. The institute not only set up emergency response mechanism within the premises, but also played a key role in the fight against Covid at the country level, with trainings, preparing guidelines, providing expert guidance and other aspects.

Drawing from the learnings of this period, as well as from the trends discernible in medicine this century, Guleria sheds light on the challenge of incorporating the new advances in the medical education, and the need to maintain quality teaching ecosystem.

Guleria is a pulmonologist and heads the Department of Pulmonary Medicine and Sleep Disorders of AIIMS, created in 2011 under his leadership. Joining AIIMS in 1992 as assistant professor, he has done pioneering work in respiratory medicine.

Guleria was conferred the Padma Shri Award in 2015 by the President of India. He also received Dr BC Roy Award in the category of ‘Eminent Medical Person’ for the year 2014; and Dr CV Ramakrishnan Oration Award for his outstanding contribution in respiratory diseases in 2011 by the Academy of Respiratory Medicine, besides several other awards. Excerpts from the interview:

How did you, as the director of AIIMS, galvanise the medical fraternity, including the doctors, nurses and other staff, to rise to the occasion when Covid struck. What was the call given by you?

When Covid struck in 2020, it was a novel virus about which we knew nothing. Based on the reports that we were getting, first from China and then Italy, we realised it’s going to create a lot of problems. What we did, since early days, was to have regular interactions. We met the faculty, resident doctors, nurses, technicians and other staff every morning to discuss all issues with them and to motivate them. We realised that two things were very important. One was to make them understand the responsibility that they have, to assure them that we are a team and to help them understand that we should not get into fear psychosis. No doubt, we were dealing with something unknown. So we started disinfection control practices and training of all our staff, including our security staff. So that all our healthcare workers felt they were protected. All issues that came up, we discussed in the morning meeting every day. Every day new issues would come up, like availability of PPE kits and quality of N95 masks. One of our staff member’s wife was pregnant and she became Covid-positive. So, overnight we had to prepare a Covid labour room so that the delivery could be done. These were the kind of challenges. But since we could address them, people felt they were part of the team and decision-making, that their concerns were being looked after, the initial fear that they had was addressed and they were motivated.

What was the biggest learning of this period? Moving ahead, given the extreme climate events that we are witnessing, what will be the impact of healthcare?

Be it vaccine or PPE kits – this was the time when we had to be totally self-sufficient. Getting resources from outside was not possible. So that was the learning.

The good thing is that we have the capacity and the resilience to go the extra mile. We just need to be more focussed and make it happen. Also, health is an important subject and has to be given more and more importance. Especially as far as our public sector is concerned, there the focus has to be on preventive health and early diagnosis.

And you are right. As climate change is happening, and as travel is happening, and as there is more and more encroachment of humans into forest areas, there will be a lot of outbreaks. In this century, in the last 22 years, we have had SARS, MERS, ZIKA, Ebola and Swine Flu, to name a few. This is happening because viruses are jumping species and travelling, as the world is becoming a global village. So, we have to brace ourselves for outbreaks, which will happen more frequently in future. So, very good surveillance, testing labs and public health are what we need for future.

You have been in the vantage point during your long career to observe what have been the significant shifts in medical education and careers and how should the young students and professionals be groomed accordingly. Also, what role is technology playing in this field?

Medicine is undergoing a revolution. And this change has become faster, as seen in the last one decade or so. Technology has arrived in a big way. We have moved from what 30 years ago was clinical medicine, to investigative medicine. We were earlier using clinical medicine to make a diagnosis. Now, the reliance is more on lab and technology, MRI and molecular testing to make a diagnosis. As we move forward, we see robotics being used in a big way, besides AI, data analysis, 3D printing. But that has also led to medicine becoming costly.

For medical education, the challenge is, how do we start training doctors when technology is going to play such a big role. To give an analogy, there was a time when students would try to remember what was given in text books. But now everything is available in digital library, it’s how one uses that information that’s important. So, medicine is seeing a huge shift in terms of technology and patient care and therefore there is a challenge to bring changes in the curriculum as innovations come in.

You mentioned the cost of medicine going up. And in the era of super-specialisations, how can basic healthcare be provided to all? How will common man have access to good healthcare?

This is a big challenge and which is why we need a balance. We still need family physicians and general practitioners (GPs). A majority of illnesses like common cold, diarrhoea, diabetes can be handled by them. You don’t have to go to gastroenterologist for acidity or diarrhoea or to a cardiologist if your BP is high. And that would bring down the cost also. A referral system needs to be put in place, wherein the initial treatment is done at GP level and only if the case is complicated should the patient be referred to a specialist. Unfortunately, although such a system was envisaged, it has not worked well in the country, which is why we have more specialists than GPs.

Do you think that tele medicine, that has really caught on in the last few years, especially during Covid, is the answer to issue of access that we have at the moment?

Yes, it allows us to use technology to reach out to patients who we were not able to reach out to. And it helps patients in case of follow-ups, especially if they have to travel long distances. Tele medicine, e-ICU, teleconsultation and doctor-to-doctor consultation (not just patient-to-doctor) can help. A doctor managing the e-ICU can consult a specialist far off and therefore provide better care. It can be a game changer in patient care, primary health centres and district hospitals, where the doctors can consult through the network of teleconsultants.

In the last few years, we have seen a large number of students return from Wuhan in China and Ukraine. In such cases, their dream of getting a medical degree might remain unfulfilled. What solution would you suggest for that?

We need to increase the number of seats as there is a huge demand for medical education. But at the same time, we must also ensure that we maintain good quality. If we increase the seats, we must ensure that we have good teachers and ecosystem so that the students are well trained to become doctors and save lives.

What is the value addition that some of the foreign degrees are doing?

Students have to appear for an examination once they come back, before they are allowed to practice in India. Because there is no uniformity. And many a time, we hear of a student getting a degree without seeing a patient, because only theoretical knowledge has been imparted while clinical skill is lacking. Which is why, there is a need for foreign medical education evaluation examination. But at the end of the day, we should have a mechanism so that students don’t have to go outside to pursue medical education.

In addition to healthcare, a lot of attention is now being given to wellbeing, mental health and also alternative therapies. What is your take on that?

Mental health is very important. There was a stigma attached to it. But the pandemic took mental health to centre-stage, both for healthcare workers and for patients and others in home isolation or worried during lockdown. We focussed more and more on mental health during this period and tried to reach out using social media.

As regards alternative therapies, India has the advantage of having systems like the Ayurveda, but we need to have a patient-centric system wherein best in each system is brought forward to provide holistic care. A lot of effort is under way. We have a Centre for Integrated medicine and Research. The focus currently is on Yoga, with a number of projects underway for treatment of various diseases. In the long run it will become something that is integrated.

Finally, in your long career, what has been the biggest point of satisfaction?

My biggest satisfaction is the smile on my patients’ face when they become alright. For a doctor, nothing can be more satisfying.

Also, our handling of Covid pandemic was very satisfying, both at AIIMS level, and also in the way we were able to help the nation in many ways, from patient care to developing training modules.