On June 16, 2021, a Central Institute Body meeting of the All India Institute of Medical Sciences (AIIMS), New Delhi, chaired by the Union Health Minister, discussed a proposal to have a rotating leadership in India’s best medical institutes, including the newer AIIMS and the Postgraduate Institute of Medical Education and Research in Chandigarh.
(The author is the head of a department at PGIMER.)
In August 2022, the health minister constituted a five-member committee to consider the proposal in depth, as well as seek the inputs and feedback of various government medical institutions on the idea.
Predictably, the announcement prompted quite a bit of furore on both sides of the issue and unearthed a diverse array of opinions. But some careful consideration leads us to two conclusions – one: about the set of things on which we can all agree; and two: about what will need to be in place before a rotating leadership system can be reasonably implemented at these institutions.
What we can agree on
First, there are some departments with problems, and some of them have dysfunctional heads of department (HODs) – whereas some departments have done really well, for which the HODs deserve the credit.
Second, with the current system in place since their inception, AIIMS Delhi and PGIMER Chandigarh have become outstanding educational, research and patient-care centres.
Third, we must acknowledge that the rotational system has beneficial elements, and at the same time accept that it will not be a silver bullet for all the maladies plaguing our leading institutes. No system can be flawless, after all.
Fourth, changing the existing system to that of rotational headship is a radical idea. Radical ideas are capable of revolutionising existing structures for the better or destroying them, perhaps irreversibly.
What needs to be in place
So, what can be done? We could identify departments that have measurable problems and undertake a causality assessment to determine if the issues are the product of a dysfunctional HOD. However, if an HOD is found to be responsible, it is not clear how one can or should proceed.
We can also call for severely restricting the powers of the HODs, such as by abolishing the need for their signatures with remarks of the type “recommended and forwarded”, which is the norm when a faculty member submits a research project for the ethics committee’s approval. (Personally, I am against hierarchical power structures.)
These and similar issues bring us to the most agreeable logical outcome: before implementing a sweeping idea like rotating leaderships across around a thousand departments in these institutions, there must be a systematic review or audit conducted by independent researchers (as opposed to officials) with no stake in the outcome.
Institutions like the IITs, JIPMER, and other medical/allied sciences institutes and universities, where this system has been in place for many years, could serve as excellent comparators.
The first task of the researchers performing this systematic analysis will be to estimate the prevalence of dysfunctional HODs. Then, they will have to identify the parameters for assessment.
These could include patient care metrics, educational indices, rating scales, research (quality as well as quantity), number of research publications, foreign collaborations, complaints against HODs lying with the institutes, and infighting instances on record. Published papers, institutional records, and other materials should be accessed for the same – supplemented by qualitative research following the best methodologies. (This list is by no means exhaustive.)
If this review finds that the prevalence of dysfunctional HODs is greater than 95%, for example, the case for rotating leaderships may be greater than if it finds that dysfunctional HODs constitute fewer than 5%.
A well-selected set of parameters for the review could also define the possibility of inflicting irreversible damage with a rotating leadership as well as the room for alternative systems that avoid the pitfalls of existing ones.
All of us claim to follow evidence-based medicine. Once such evidence is generated and circulated (preferably via a peer-reviewed journal), and if it demonstrates the unequivocal superiority of one system over another, we should follow that evidence – some may do so gladly, others may do so reluctantly, depending on the side of the aisle on which they currently fall.
The author acknowledges the discussions with his colleagues and peers in AIIMS Delhi, JIPMER, and PGIMER Chandigarh that led to this article.
Samir Malhotra works in PGIMER Chandigarh. The opinions expressed here are personal.
