Vol , Issue Date of Publication: June 17, 2024
DOI: https://doi.org/10.20529/IJME.2024.039

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Myth and reality of “theory-driven individualised practice” in Ayurveda: Mapping physicians’ approaches using case-based scenarios

Mayank Chauhan
Vijay Kumar Srivastava
Kishor Patwardhan
Abstract:

Background: The curricula of Ayurveda programmes emphasise various theoretical constructs such as Tridosha (three factors determining the state of health), Agnibala (digestive strength), Samprapti (patho-physiology), among others. It is often argued that practitioners follow an individualised approach based on these principles while treating patients. Yet, dependable data on their real-world influence is lacking. The aim of this study was to record the extent to which these constructs drive decision-making among Ayurveda practitioners and to examine whether these constructs determine individualisation of the interventions.

Methods: We employed an emailed survey to record physicians’ perceptions. Convenience sampling was chosen as the sampling method. Registered Ayurveda practitioners located across India with a minimum of five years of clinical experience were invited to participate. Five case-based scenarios depicting different clinical conditions were presented to the physicians. Questions that accompanied each case scenario asked the physicians to record clinical diagnoses, treatment plans, and the Ayurveda principles that determined their treatment.

Results: A total of 141 physicians responded, from whom we received 152 responses as seven physicians responded to more than one scenario. The results suggest a significant lack of consensus among physicians regarding clinical diagnoses, interventions, and their understanding of pathophysiology in the given clinical scenarios. Many conflicting opinions were also noted.

Conclusion: Theoretical constructs do not appear to determine either prescriptions or individualisation uniformly. Two ethical questions arise: “Is this situation due to an inherently weak theoretical framework of Ayurveda?” and “How can one justify spending hundreds of hours teaching these theories?”


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©Indian Journal of Medical Ethics 2024: Open Access and Distributed under the Creative Commons license ( CC BY-NC-ND 4.0),
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Comments:
  1. Alok Srivastava
    MD Sangyaharan 2011 , India
    18 June 2024

    Respected sir
    Your study is marvelous for the future generation but no one going to change anything because policies makers are in today’s time is mostly old version.and new generation mostly involved in short cut money making. BAMS doctor means duplicate version of Indian health professional.

    • Affiliation: MD Sangyaharan 2011
    • Country: India
  2. G L Krishna
    NCBS , India
    18 June 2024

    The conclusions of the paper are perhaps right, but the method of the study does not compellingly drive home the conclusions. Registered Ayurveda practitioners located across India with a minimum of five years of clinical experience were included in the study. Based on their approaches to diagnosis and treatment, the conclusions have been arrived at. Their approaches have been used to suggest that ayurveda’s theoretical framework is weak.

    It can be argued that the participant practitioners in the study were not selected based on competence. An ayurvedic degree along with five years of experience does not guarantee competence. Earlier papers* have noted that “healthcare providers with medical degrees in urban Delhi can range from the very best to among the worst in terms of pure technical competence, depending on where they were trained.” Even among providers with medical qualifications “Correct diagnoses were rare, incorrect treatments were widely prescribed.”

    Just as poorly skilled MBBS doctors cannot be used as proofs against the scientific soundness of modern medicine, it can be argued that poorly skilled BAMS doctors cannot used as proofs against the soundness of ayurvedic theories.

    To tighten their case, the authors should have selected for their study only those ayurvedic practitioners who were renowned for their theoretical and practical knowledge of ayurveda. They could have, for instance, chosen the fellows of the National Academy of Ayurveda.

    A few other aspects of the study too needed modifications.

    I am not saying that the ayurvedic theories are very sound. As my papers have shown, they are not. The singular point I am making now is that the design of the current study is not robust enough to suggest that ayurveda’s theories are inherently weak.

    * BMJ 2012;345:e8437
    * Das, Jishnu et al. “In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps.” Health affairs (Project Hope) vol. 31,12 (2012): 2774-84. doi:10.1377/hlthaff.2011.1356

    • Affiliation: NCBS
    • Country: India
  3. Dr Vasant C.
    Practitioner, Researcher, Professor , India
    18 June 2024

    The findings of this survey are partially truth. The genuine Ayurveda Vaidya considers Prakruti, Vikruti, Agni, Ama, Koshta, Desha, Kala, Bala, Oja and then treatment is planned. The sample size is very small, and I think not many of these participants are not classical and Experienced Vaidya.

    • Affiliation: Practitioner, Researcher, Professor
    • Country: India
  4. Dr.Dinesh KS,Dr.Geethu Balakrishnan
    Professor & Head,Dept. of Kaumarabhrithya, Vaidyaratnam P S Varrier Ayurveda College,Kottakkal & Senior Research Fellow,Amrita Centre for Advanced Research in Ayurveda(ACARA),Amrita School of Ayurveda,Amritapuri , India
    20 June 2024

    A CRITICAL EXAMINATION: REFINING THE ASSESSMENT OF AYURVEDIC THEORY IN PRACTICE

    Introduction
    In the recent article titled ‘Myth and Reality of “Theory-Driven Individualised Practice” in Ayurveda Mapping Physicians’ Approaches Using Case-Based Scenarios’ (Chauhan et al., 2024), published in the Indian Journal of Medical Ethics, the authors investigate a novel approach to assess how well Ayurvedic theory translates into individualized patient care. This study is of interest because it addresses a critical gap in understanding the real-world application of Ayurvedic principles. The authors’ approach using case-based scenarios to assess the application of theory in real-world patient care is particularly insightful. Furthermore, the paper emphasizes the significance of internal critique within a scientific system, a concept crucial for the ongoing development of Ayurveda.

    Specific Point and Observation:
    While the paper by Chauhan et al. (2024)[1] provides valuable insights, it is worth considering how their methodology might not fully capture the epistemological underpinnings of Ayurveda. Future research could explore alternative approaches that integrate both theoretical and experiential aspects of Ayurvedic knowledge to provide a more comprehensive understanding of theory-practice relationships.

    The article highlights limitations to interdisciplinary interaction within Ayurveda. However, it is important to acknowledge the growing recognition of integrative healthcare approaches that combine Ayurveda with other medical systems[2,3,4,5,6]. The inclusion of AYUSH systems (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy) in India’s national health policy reflects this trend towards interdisciplinary collaboration[7]. Future research could explore successful models of integrating Ayurvedic principles with other healthcare systems to optimize patient care.

    The reference used to discuss the Ayurvedic education system predates significant revisions implemented after 2011[8]. These revisions, while not yet validated by rigorous peer review, represent an effort to modernize the educational system. For a more current perspective, future iterations of this research could consider incorporating information from the Quality Council of India regarding the implementation of the new minimum standards for Ayurvedic education[9].

    The article focuses only on individualization in Ayurvedic practice. While individual customization is a key aspect of Ayurveda, it’s important to acknowledge that the system also incorporates standardized treatment guidelines. Ayurveda’s treatment protocol for every disease is structured to start with a general approach, followed by dosha-specific and condition-based protocols outlined to address the unique manifestations of the disease in the patient. Additionally, Ayurveda allows for further modifications based on individual consultations showcasing Ayurveda’s unique individualized care. A physician’s success hinges on effectively combining these general principles with tailored approaches for each patient. Future research could explore how Ayurvedic practitioners navigate this balance between standardized protocols and individualized treatment plans because it is worth considering the potential for selection bias. The choice of specific case studies might unintentionally overrepresent examples where theory and practice diverge.

    The authors have not considered the five-fold diagnostic tool (Nidana Panchaka) essential for disease examination in Ayurveda[10]. This omission is highly pivotal, and therefore, the information derived from these limited observations cannot be generalized. it appears that the authors may not fully appreciate the clinical holism inherent in Ayurveda. The perception of each case in Ayurveda is unique and should be validated based on therapeutic efficacy rather than merely by its name or terminology[11]. The validity of a diagnosis in Ayurveda should be evaluated also by examining the therapeutic outcomes of the proposed protocol and the understanding of the disease process (samprapti). However, a crucial aspect of Ayurvedic diagnosis and treatment is chikitsāsiddhi, or therapeutic efficacy[12]. Future research could explore how Ayurvedic practitioners evaluate the effectiveness of their treatment plans based on this concept. Additionally, incorporating upashaya-anupashaya the distinction between improvement and lack of improvement, could provide a more nuanced understanding of treatment outcomes in Ayurvedic practice[13].

    While the questionnaire explores some details of patient examination, it’s important to distinguish this from the comprehensive āyurvedik parikshā, or Ayurvedic examination. This examination encompasses various methods beyond those typically used in biomedicine. For instance, dhātu parikshā, the examination of bodily tissues, is a crucial component of Ayurvedic diagnosis[14]. Future research could explore alternative methodologies that more completely capture the richness of Ayurvedic examination techniques used by practitioners in clinical settings.
    The case studies employed by Chauhan et al. (2024) do not consider prior Ayurvedic treatment history. In Ayurvedic evaluation, upashaya-anupashaya, the distinction between improvement and lack of improvement, is crucial. Understanding a patient’s response to previous Ayurvedic interventions would provide valuable context for assessing the physician’s approach in each case study. Additionally, the article does not address the potential impact of biomedical treatments on samprapti, the pathogenesis of the disease according to Ayurveda. For instance, some biomedical painkillers may exacerbate pitta dosha, potentially complicating the disease picture.

    In this study, the responses regarding insufficient information about the disease and patient were as follows: anaemia (6), IVDP (52), COVID-19 (14), pompholyx (30), and male infertility (6), totaling 108 responses. According to Ayurvedic epistemology, the available information is insufficient regarding disease as well as patient.

    All five cases presented in the scenario contain highly insufficient data to accurately depict the Ayurvedic analysis of the given diseases. For example, in the analysis of Pandu (anemia), the status of Kapha and Rakta vitiation is not mentioned, even though Pandu is characterized by disturbances in Rakta (blood) and Kapha dosha[15]. In musculoskeletal disorders, which are primarily due to Vata vitiation in Mamsa (muscle) and Asthi (bone) dhatus[16], the status of these dhatus is not evaluated. COVID-19 is primarily a Rasa-vitiated disease affecting various koshtangas (internal organs), yet the spectrum of Rasa dhatu vitiation is not elucidated. Skin diseases are mainly caused by Kapha and Pitta vitiation involving Rasa, Rakta, Mamsa, and Kleda factors[17]; however, no comprehensive dhatu analysis is presented. In the case of male infertility, the authors only examine Shukra dhatu, whereas infertility in Ayurveda is a result of imbalances in multiple dhatus, and these additional evaluations are absent. This insufficiency significantly affects the data analysis and results. Moreover, these critical areas of opinion are not discussed in the article. The authors’ judgment based on this biased data in the crucial process of disease evaluation indicates either a lack of understanding or prejudice. Based on this biased judgment, a generalized evaluation of the fundamental practices of Ayurveda is unscientific.

    Conclusion
    Chauhan et al. (2024) offer valuable insights into the application of Ayurvedic theory in practice. Their use of case studies and focus on internal critique are strengths. However, the review highlights limitations in capturing the full picture of Ayurvedic practice. Future research can address these by integrating experiential knowledge with theory, exploring interdisciplinary models, and incorporating up-to-date information on Ayurvedic education. Additionally, investigating the balance between standardized protocols and individualization, utilizing methods that capture Ayurvedic diagnostic richness, and considering therapeutic outcomes would provide a more nuanced understanding. Finally, employing larger and more representative samples would strengthen the generalizability of findings. By addressing these limitations, future research can build on Chauhan et al.’s work to provide a more comprehensive picture of how Ayurvedic theory translates into real-world patient care.

    REFERENCES

    1. Chauhan M, Srivastava VK, Patwardhan K. Myth and reality of “theory-driven individualised practice” in Ayurveda: Mapping physicians’ approaches using case-based scenarios. Indian J Med Ethics. Published online first on June 17, 2024.DOI: 10.20529/IJME.2024.039.
    2. Bendale YN, Kadam A, Birari-Gawande P, Patil A, Ingale D. Exploring the potential of the traditional Indian system of medicine, Ayurveda, for developing an evidence-based integrative model of cancer care in elderly patients with cancer.

    3. Arnold JT. Integrating ayurvedic medicine into cancer research programs part 2: Ayurvedic herbs and research opportunities. Journal of Ayurveda and Integrative Medicine. 2023 Mar 1;14(2):100677.

    4. Banerjee S, Debnath P, Debnath PK. Ayurnutrigenomics: Ayurveda-inspired personalized nutrition from inception to evidence. J Tradit Complement Med. 2015 Mar 24;5(4):228-33. doi: 10.1016/j.jtcme.2014.12.009. PMID: 26587393; PMCID: PMC4624353.

    5. Purushotham A, Hankey A. Vegetarian Diets, Ayurveda, and the Case for an Integrative Nutrition Science. Medicina. 2021; 57(9):858. https://doi.org/10.3390/medicina57090858.

    6. Thottapillil A, Kouser S, Kukkupuni SK, Vishnuprasad CN. An ‘Ayurveda-Biology’platform for integrative diabetes management. Journal of ethnopharmacology. 2021 Mar 25;268:113575.

    7. Ministry of Health and Family Welfare. (2017). National Health Policy 2017. Government of India. Available at: https://main.mohfw.gov.in/sites/default/files/9147562941489753121.pdf

    8. Patwardhan K, Gehlot S, Singh G, Rathore HC. The ayurveda education in India: how well are the graduates exposed to basic clinical skills? Evid Based Complement Alternat Med. 2011 Feb; 2011:197391. https://doi.org/10.1093/ecam/nep113

    9. National Commission for Indian System of Medicine (2022).NCISM India rules and regulations. https://ncismindia.org/rulesandregulations.php

    10. Prof.K.R.Srikantha Murthy, Vagbhata’s Astanga hridayam.Varanasi,Chowkhamba Krishnadas Academy, Reprint 2006,p.3.

    11. Vaidya Bhagwan Das,Agnivesa’s Caraka Samhitha,Varanasi,Chowkhamba Sanskrit Series Office,Reprint 2008, p.345.

    12. Vaidya Bhagwan Das,Agnivesa’s Caraka Samhitha,Varanasi,Chowkhamba Sanskrit Series Office,Reprint 2008, p.61.

    13. Prof.K.R.Srikantha Murthy, Vagbhata’s Astanga hridayam.Varanasi,Chowkhamba Krishnadas Academy, Reprint 2006,p.5.

    14. Prof.K.R.Srikantha Murthy, Vagbhata’s Astanga hridayam.Varanasi,Chowkhamba Krishnadas Academy, Reprint 2003,p.179.

    15. Dr.B.Rama Rao,Astanga Samgraha of Vagbhata Vol.I,Varanasi,Chaukhambha Visvabharati,2006,p.294.

    16. Prof.K.R.Srikantha Murthy,Ashtanga Samgraha of Vagbhata,Vol.II,Varansai, Chaukhambha Orientalia, Second edition 1999,p.243.

    17. Prof.K.R.Srikantha Murthy, Vagbhata’s Astanga hridayam.Varanasi,Chowkhamba Krishnadas Academy, Fifth 2003,p.136.

    • Affiliation: Professor & Head,Dept. of Kaumarabhrithya, Vaidyaratnam P S Varrier Ayurveda College,Kottakkal & Senior Research Fellow,Amrita Centre for Advanced Research in Ayurveda(ACARA),Amrita School of Ayurveda,Amritapuri
    • Country: India
  5. Dr. Simi Ravindran
    Government , India
    21 June 2024

    The study reveals significant variability among Ayurveda practitioners in diagnoses and treatments, questioning the consistency of applying theoretical constructs. It suggests that Ayurveda’s theoretical framework may not effectively guide clinical practice. Methodological limitations, such as convenience sampling, may affect the study’s conclusions. The findings indicate a potential need to re-evaluate Ayurveda education to better integrate theory and practice. Further research with more rigorous participant selection is recommended to validate these insights.

    • Affiliation: Government
    • Country: India
  6. Dr Haroon Irshad
    Professor, Dept of Samhita Siddhanta, SDM college of Ayurveda & Hospital, Hassan , India
    24 June 2024

    A good attempt Sir… Acharya Charaka himself said, one can be a Kushala vaidya only when he finds the truth after proper examination, Parikshyakarinohi kushala bhavanti. Theoretical frameworks must be examined properly for a sound practical knowledge. The upcoming generations must get a proper understanding of this life science. Its high time for all of us to develop critical thinking than accept everything as such. Present education system makes a student biheart and pass the exam.. but what next is the big question ..
    just want to quote few words from Cha.Sam.Su. 15/4-5,
    Query by Agnivesha to Atreya about success of treatment;
    “O Lord! A learned physician should prescribe a treatment in such a way that it should surely and invariably be successful. The success of all treatments depends upon proper administration and complications due to improper administration. However, sometimes, the success or failure of treatment doesn’t follow the rules of proper or improper administration, hence knowledge and ignorance becomes equal.”
    Lord Atreya replied, “Oh Agnivesha!, it is possible for us to treat the patients successfully and also impart instructions for correct administration. But there is none who is able to grasp such instructions or having grasped it, is able to apply it or put it into practice. The variations in conditions of dosha, drugs, place, time, strength, body, diet, suitability, mind pattern, constitution, and age are subtle to understand. While considering these factors, when even a person with great intellect and pure knowledge gets confused, then what will be the condition of a person with less intellect?

    • Affiliation: Professor, Dept of Samhita Siddhanta, SDM college of Ayurveda & Hospital, Hassan
    • Country: India
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