THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 6, NO.4; 1993·

Indian Medical Colleges181

All India Institute of Medical Sciences, New' Delhi

R. L. BULANI

INTRODUCTIONCreating a country imbued with a scientific culture was .Jawaharlal Nehru's dream, and immediately after Indepen-dence he prepared a:grand design to achieve it. Among the'temples of modern India' which he designed, was a centre ofexcellence in the medical sciences. Nehru's dream was thatsuch a centre would set the pace for medical education andresearch in Southeast Asia and in this he had the whole-hearted support of his Health Minister, Rajkumari AmritKaur.

The Health Survey and Development Committee, chairedby Sir Joseph Bhore, an Indian Civil Servant, had in 1946already recommended the establishment of a nationalmedical centre whichwould concentrate on meeting the needfor highly qualified manpower to look after the nation'sexpanding health care activities. The dreams of Nehruand Amrit Kaur and the recommendations of the BhoreCommittee converged to create a proposal which foundfavour with the Government of New Zealand. A generousgrant from New Zealand under the Colombo Plan made itpossible to lay the foundation stone of the All India Instituteof Medical Sciences (AIIMS) in 1952.1 The AIIMS wasfinally created in 1956, as an autonomous institution throughan Act of Parliament, to serve as a nucleus for the develop-ment of excellence in all aspects of health care (Fig. 1). Itsfunctions, as defined in the Act, include undergraduate andpostgraduate teaching in the medical and related physicaland biological sciences, research in these sciences, conduct-ing experiments in medical education, establishing rural andurban health centres (for training in the community settingand conducting community-based medical research), andlast but not the least, providing teachers for other medicalcolleges in India. In keeping with this broad mandate, theAIIMS is engaged in a very wide range of activities. Theirbreadth makes the AIIMS probably the only institution of itskind in the world.

The form that the bricks and mortar assumed seems tohave been based primarily on some very sound convictionsof Dr Jivraj Mehta, the eminent doctor-politician fromBombay." He believed that the college building and thehospital should be interconnected by closed corridorsthrough which students and teachers could walk even in therain (Fig. 2). The intimate physical connection fosters closecollaboration, especially between the preclinical and theclinical departments.

Department of Physiology, All India Institute of Medical Sciences,Ansari Nagar, New Delhi 110029, India

© The National Medical Journal of India 1993

ACTIVITIESThe formal activities of the AIIMS are teaching, patient careand research, there being considerable overlap and inter-dependence between the three.

TeachingThe AIIMS runs a variety of undergraduate courses inmedicine, nursing and related areas, and postgraduatecourses in virtuallyall the basic and clinicalmedical specialtiesand superspecialties. Admissions to these courses are basedon entrance examinations conducted all over the country andabroad.

Our undergraduates are a carefully selected group of ableand intelligent students accustomed to a high level ofachievement who join an environment in which sustainedhard work is the norm. What they need is guidance along thepath to knowledge. Efforts are made to keep their initiativeand curiosity alive by making them active participants in theteaching-learning process. They also have an opportunity tostretch their minds by doing small research projects during

FIG 1. Nehru (left), whose dream the AIIMS was, withDr B. B. Dikshit, who gave the dream a shape

182 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 6, NO.4, 1993

their vacations. We, the faculty, are willing and eager toprovide guidance to them. However, since they are beingtrained to practise medicine, we ensure that they acquirethe necessary knowledge and skills for the purpose. Toinculcate a humane approach to illness in our students, ourcurriculum extends beyond medicine, and includes instruc-tion in the social sciences and psychology. As a result,undergraduate medical education is a blend of severalstreams of competing, and sometimes conflicting, endeavours.We try and make the blend as harmonious as possible byintroducing in adequate measure the elements of science,art and service. We wish to produce competent and caringdoctors while at the same time stimulating their creativeabilities and personal growth. 3

The AIIMS is the only institution in the country runninga B.Sc. (Hons) course in Human Biology. This is aimed atproducing a group of highly proficient young scientists well-versed in basic medical sciences and modem biologicaltechniques. These graduates will eventually fill teachingpositions in medical schools in the basic medical sciences,because medical graduates now seem to be reluctant to jointhese fields.

All postgraduate students at the AIIMS are potential

FIG 2.

The preclinical and teaching block ofthe AIIMS, soon after its completionin 1961

Inset: The insignia of the institute.The motto is from the epic Kumara-sambhavam by Kalidasa. It means'the body is the prime instrument ofdharma'. Dharma, in classicalSanskrit, was used in a secular senseto mean the science and practice ofrighteousness as a means to physicaland spiritual well being

The preclinical and teaching block,interconnected with the wards blockand the outpatient department (notseen)

teachers and research workers. Hence during their stay at theInstitute, they not only acquire competence in a branch ofmedicine or surgery, but also savour the romance of teachingand research. The small pieces of research which post-graduate students complete are treated as guided introductionsto the painfully slow and tedious process of discovery.The AIIMS is also one of the pioneers in initiating an in-service training programme for postgraduate students.

'Residents, while providing patient care, also get formaltraining and education towards their degrees. At presentthe Institute awards postgraduate degrees in 55 differentspecialties (Fig. 3).

Till March 1992, the Institute had produced 1530 medicalgraduates, 591 nursing graduates and 3415 postgraduatesin various basic and clinical specialties as well as thesuperspecial ties. 3

ResearchAt the AIIMS research has three objectives. Its primarypurpose is to satisfy curiosity by disciplined activity, therebyleading to the creation of new knowledge. However, we arealso conscious of the role research can play in improving thequality of teaching and patient care. A teacher engaged in

INDIAN MEDICAL COLLEGES 183

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research is up-to-date with recent information, and can alsoinculcate a spirit of enquiry and freedom of thought into hisor her students. The search for truth and the making of aphysician are inseparable.' A clinician engaged in researchcan extend the benefits of latest advances in knowledge to hisor her patients. Research is a part of our national endeavourto cultivate a scientific temper and to eliminate from oursociety the sway of authority and superstition.

While the AIIMS faculty attracts sizeable grants fromnational and international agencies, the Institute itself alsooffers modest research grants to members of the faculty. Thegrants are sanctioned after the projects submitted have beenscreened by a Faculty Committee and are primarily meant toinitiate the junior faculty into research. Thus, other thingsbeing equal, preference is given to younger applicants. Afteran investigator has made some progress, he or she canapply for bigger grants from other national and internationalagencies. Although recipients of AIIMS research grants haveto submit a report at the end of their projects, this account-ability is kept deliberately low. The aim has always beento encourage even novel and risky ideas which may notnecessarily result in publishable papers.'

There is a wide variety of research performed at this

Institute. On the one hand we do sophisticated investigationsin the neurosciences, in genetics and on computer simulationof hormone-receptor interaction. On the other hand,we undertake clinical and epidemiological studies on theprevention and treatment of national health problems. Weare trying to apply advanced techniques such as DNA recom-binant technology, immunology and electron microscopyto study the common diseases in our country such asleprosy, malaria, tuberculosis, diabetes, diarrhoea,hepatitis, fluorosis and iodine deficiency. We have largeinternationally funded programmes on goal-orientedresearch in reproduction aimed at widening the variety ofacceptable contraceptives. The scientific publicationsemanating from the Institute have been quite steady at about2 publications per faculty member per year. 4 About halfof these publications are in journals covered by the ScienceCitation Index. During the 9-year period from 1980-88,AIIMS topped the list of medical colleges in India with(mean±SD) 237.6±37.3 Science Citation Index-listedpublications per year. 5

Patient carePatient care services at the AIIMS are very extensive in their

184

scope. The hospital is open to all and every citizen of ourcountry has a right to seek the best medical aid from the mosttalented doctors at its premier institute. Our hospital has tocater to patients who have simple and common ailmentsbecause our undergraduates should be taught about them. Italso has to look after patients with rare ailments because theAIIMS is a referral centre.

The result of this heterogeneous involvement is that ourpatient care services are heavily overloaded. The outpatientdepartment (OPO) is so crowded that it isa difficult task tonegotiate its corridors during peak hours. Some morningOPOs go on till 3 pm, and some afternoon specialty clinics goon till 8 pm.

An objective look at the growth of AIIMS may be had byusing faculty strength as an indicator of inputs, and publica-tions, outpatient attendance and surgical proceduresperformed as indicators of the output (Table I). While inputsand output have both grown considerably over the last25 years, the output has grown much faster (Fig. 4). Whatis noteworthy is that in spite of the increase in patientload, AIIMS continues to retain its academic character asshown by the steady increase in research publications.

Other activitiesThe non-formal activities of the AIIMS include various con-ferences, workshops, symposia and updates organized everyyear. In order to demystify medicine for the common man,the AIIMS faculty gives popular lectures on medical subjectsin various forums and on the electronic media, and writes forthe lay press. The Institute provides consultation on specificprojects to national and international agencies. Our facultyis also sent to other developing countries on medium-termassignments. Recently, the AIIMS has taken the lead ingenerating an awareness about the nuances of medical

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FIG 4. Growth of the AIIMS. Percentage increase in facultystrength, outpatient attendance, surgical procedures andpublications over the 25-year period, 1966-91

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 6, NO.4, 1993

education throughout the country by organizing regularworkshops through its Centre for Medical Education andTechnology, named after Or K. L. Wig, the second director.

CONCLUSIONThus, the AIIMS is more than an ordinary medical college.It has a unique atmosphere of scholarship, healthy competi-tion, scientific enquiry and academic freedom. It has adedicated full-time faculty, bright and hardworking students,and committed staff, most of whom live on the campus.As a result, a fraternal feeling pervades all those whoare associated with the Institute. Among the 6000-strongInstitute family, there is a sharing of one-another's interests,joys and sorrows, and a strong sense of belonging to a top

, team. This is one of the intangible factors that contributesto the output of the Institute. Some of the tangible factorswhich contribute to the Institute's special character are:

1. The undergraduates at the AIIMS do not have to attend aminimum number of classes before they can appear forthe final examinations. This imposes on them the respon-sibility to decide what is in their best interests, and on theteachers to make their classes worth attending.

2. The Institute has a well-stocked, efficiently-run librarywhich is open eighteen hours a day, seven days a week.Besides photocopying services, we now have a facility fordoing computerized literature searches (Fig. 5).

3. In patient care, teaching as well as research, the AIIMSpossesses the state-of-the-art technology. Be it the cellsorter or autoanalyser, linear accelerator or the CT orNMR scanner, the AIIMS has them all. Once somethingnew arrives on the scene, someone, somewhere in theInstitute takes the initiative and musters the energy anddrive required to get it (Fig. 6).

4. The AIIMS is a unique institution that brings together avery wide range of activities. This makes it self-sufficienteven in areas needing inter-disciplinary linkages. It thusprovides an opportunity for nurturing the individualtalents of its faculty.

As a result of this tendency to absorb all health-relatedactivities in its fold, the Institute has grown at a phenomenalrate and this has brought with it certain disadvantages.

Many of its green patches have been replaced by concretestructures and in order to meet the need for more residentialaccommodation, hostels and flats have been built or acquiredin nearby areas outside the main campus. Yet, in spite of suchrapid growth in the strength of the faculty, the outpatientsget very little time from doctors and there are long wait-ing lists for investigations and admissions. All this makes ussometimes wonder whether the tremendous expansion of theInstitute has been too much of a good thing. However, thisproblem may be partly remedied by starting a screeningOPO, work on which has already begun. Every patient will

TABLEI. Growth of the All India Institute of Medical Sciences (1966-91)

1966 1971 1976 1981 1986 1991

Faculty 97 185 208 240 284 332Outpatient attendance 339961 427273 569764 891258 1145397 1467251Surgical procedures 14185 26057 41020 60780 70217 84006Publications 132 364 417 464 534 702

INDIAN MEDICAL COLLEGES

FIG 5. The AIIMS library named after the first director Dr B. B. Dikshit (right)and the administrative block (left)

FIG 6. Continuing growth and development are a part of the AIIMS

185

Construction work at the recentlyestablished Department ofBiotechnology

Equipment waiting to be installed atthe new nuclear magnetic resonance .facility

186

then be required to go to this OPD and only if found to be inneed of sophisticated investigations will he or she be referredto the main hospital.

The most important asset of an institution is the quality ofits personnel. The dedication and excellence of the studentsand staff of the AIIMS have earned it worldwide recognitionin a remarkably short time. The future of AIIMS cannot butbe bright. Its alumni are scattered throughout this countryand abroad as teachers and practitioners of medicine atthe highest levels and they have carried the dedication, com-petence and scientific spirit imbibed at their alma mater. TheAIIMS has begun a new culture in Indian medical educationand as the post-Independence Indian renaissance unfolds, it

Letter from Glasgow

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 6, NO.4, 1993

will figure prominently as one of the factors that made itpossible.

REFERENCESDikshit BB. All India Institute of Medical Sciences. All India Inst Med SciMagazine 1960;1:15--17.

2 Pandya SK. Seth Gordhandas Sunderdas Medical College and King EdwardVII Memorial Hospital, Bombay. Natl Med J India 1988;1:4f>..50.

3 Bijlani RL, Susheela AK. Vibrant. New Delhi:AIl India Institute of MedicalSciences, 1989.

4 Annual Reports of the All India Institute of Medical Sciences. New Delhi:AIlIndia Institute of Medical Sciences.

5 Reddy KS, Sahni P, Pande OK, Nundy S. Research in Indian medical institutes.Natl MedJ India 1991;4:9(}-2.

On Thursday 29 April 1992, The Herald' reported thatthe Argyll and Clyde Health Board had noted 'serious dis-crepancies' in the reports of cervical smears done in theGreenock area over a five-year period (from 1987 to early1992). This had come to light when a woman developedinvasive cervical cancer following a recent negative cervicalsmear. The Argyll and Clyde Health Board serves a popula-tion in west Scotland extending from the boundary of Glasgowto the rural areas of Argyll and the southern HebrideanIslands which lie off the west coast of Scotland. .

Further investigations, including random checks of thesuspect smears, revealed that all the smears done duringthat period had not been subject to double-checking of non-negative slides or to any other routine quality assurance.Consequently the Board had no option but to review all20000 smears done during that period and set up specialprocedures to manage women who required further smearsor investigations such as colposcopy. The estimated numberof women who require repeat smears is 2000 and theprobable number of women who will be found to have canceris about 10.

Quite rightly, there have been some very pertinentquestions asked about the failures in the cervical screeningprogramme in Argyll and Clyde. These issues are to be inves-tigated by an independent inquiry headed by Dr EuphemiaMcGoogan,2 a senior lecturer in Edinburgh University'Spathology department, which will no doubt pin-point theweaknesses in the system as well as the human failings. Moreimportantly, it will identify any additional policies or proce-dures which need to be instituted in the cervical screeningprogramme in Britain.

However, it is important to consider the more generalquestions about the running of the cervical screening pro-gramme. Like other population-based screening programmes,cervical screening has never been the subject of a clinicaltrial. There are many reasons for this including the difficultiesof undertaking trials on very large numbers of people over a

long period before results are available. Of course otherepidemiological evidence is usually cited to support theintroduction of screening programmes such as comparisonsbetween and within countries of regions which do not have aparticular screening programme. In Britain, the cervicalscreening programme has developed in a rather ad hoc waysince the 1960s although in recent years national specifications,quality assurance and uptake targets have been introduced.

It should however be stated that measures were already inplace in all Scottish Health Boards to prevent such an eventfrom recurring and other fail-safe mechanisms were alreadybeing established. Unfortunately all this may sound likeempty words for the affected women in Argyll and Clyde,and indeed for other women who have had, until now, faithin the cervical screening programme. It may take a long timefor their faith to be restored.

Finally this episode highlights issues for clinicians who areenthusiastic about screening for their pet diseases or con-ditions. Merely showing that screening tests are effective andcost-effective is not sufficient. What is required is the fulfilmentof Wilson and Junger's" criteria for screening programmesincluding information on how the programme will operate,quality control in the programme and adequate training forall the staff. Until these criteria are met, no population-basedscreening programme should be instituted.

For anyone who has visited Britain a lack of water wouldseem to be the least of the country's problems. However, inthe last decade of the twentieth century a row has been brew-ing between public health professionals and the communityon one side, and the government and (privatized) watercompanies on the other.

In England the water companies have been stripped fromlocal (municipal) authority control and sold off to privatecompanies. Needless to say the motives of these companies,who report to their shareholders, is rather different from