THE CLINICAL SKILL CRISIS

The Clinical Skills Crisis: Why Indian BAMS Graduates Are Increasingly Unskilled

Dr Aakash Kembhavi MD, PGDMLS, MS (Counseling & Psychotherapy)

Author’s Note: This article represents my personal opinions and observations based on over 25 years of experience in Ayurvedic medical education. It has been created with AI collaboration to structure and articulate these concerns systematically. I must apologize to my readers—just yesterday I published a blog article, and here I am again today. But after reading the report on declining math skills among American students, I could not remain silent. The parallels to our own crisis in Ayurvedic medical education were too stark to ignore. Whether you choose to acknowledge these facts or dismiss them is entirely up to you as readers. What I present here is what I have witnessed, what the data shows when we dare to look, and what we must confront if we care about the future of Ayurveda and patient safety.

In the teaching hospitals of India’s Ayurvedic colleges, a quiet catastrophe is unfolding. Institutions once devoted to preserving millennia-old healing traditions are now graduating doctors who cannot perform basic clinical assessments—skills that every Ayurvedic physician should master. The reckoning has arrived, and it demands we confront an uncomfortable truth: we have been certifying incompetent doctors for decades.

The Thirtyfold Surge That Wasn’t Measured

Between 2000 and 2025, something went catastrophically wrong in Ayurvedic medical education, but unlike UC San Diego’s math crisis, nobody bothered to measure it. There were no placement exams, no remedial courses, no internal reports sounding the alarm. Instead, there was silence—a systemic conspiracy of grade inflation, regulatory negligence, and institutional abdication that allowed thousands of fundamentally unprepared doctors to receive BAMS degrees and begin treating patients.

If we could measure clinical competence the way UCSD measured mathematical ability, the numbers would be staggering. Imagine discovering that one in eight graduating BAMS students—roughly 1,250 of the 10,000 annual graduates—cannot reliably perform Nadi Pariksha (pulse diagnosis), cannot differentiate between basic Prakriti types, cannot formulate even elementary treatment protocols, and struggle with clinical reasoning that should have been mastered in their third year of study. But we don’t measure this. We simply certify them, release them into society, and look away.

When Grades Stop Meaning Anything in Medicine

The parallels to the UCSD crisis are haunting. At UCSD, students with 4.0 GPAs in AP Calculus couldn’t round numbers to the nearest hundred. In Indian Ayurveda colleges, students with distinction marks in clinical subjects cannot conduct proper Trividha Pariksha, cannot identify basic herb-drug interactions, and struggle with differential diagnosis that middle-tier practitioners should handle routinely.

The grade inflation is epidemic. In university examinations across India, BAMS students routinely receive 70-85% marks despite demonstrating minimal clinical competence. How? The answer lies in an examination system designed not to evaluate learning but to ensure passage. Multiple-choice questions reward rote memorization over clinical reasoning. Practical examinations become theatrical performances where students rehearse predetermined cases. Viva voce sessions test the ability to recite textbook definitions rather than demonstrate applied knowledge.

A BAMS student can graduate with honors while being unable to:

  • Conduct a comprehensive Ashta Sthana Pariksha
  • Formulate a rational treatment plan based on Samprapti
  • Identify contraindications in classical formulations
  • Interpret tongue diagnosis or skin examination findings
  • Explain the pharmacological basis of their prescriptions
  • Communicate effectively with patients about their conditions

These aren’t edge cases. These represent the norm in many institutions. The transcripts say “distinction,” but the clinical reality says “dangerous.”

The Missing Education: Four and a Half Years of Nothing

The core problem predates the examination system. BAMS students receive virtually no meaningful clinical exposure during their foundational years. While their allopathic counterparts in MBBS programs benefit from structured clinical rotations, standardized patient encounters, and supervised practice beginning in their second year, BAMS students spend four and a half years in a theoretical vacuum.

Consider the typical BAMS student’s educational experience:

First and Second Year: Memorizing Sanskrit verses from ancient texts without understanding their clinical application. Learning anatomy from outdated charts while the dissection hall remains underutilized. Studying Rachana Sharira (anatomy) and Kriya Sharira (physiology) as abstract concepts divorced from patient care.

Third and Fourth Year: The so-called “clinical” years where students might observe a few OPD sessions, stand in crowded hospital wards without meaningful patient interaction, and copy case histories from seniors’ old notebooks. Faculty shortages exceeding 50% mean there’s often nobody to teach them. When teachers are present, they’re overwhelmed with administrative burdens, underpaid, demoralized, and often themselves trained in the same deficient system.

Internship Year: The desperate attempt to acquire in twelve months what should have been learned over five years. And where do these students go? Not to Ayurveda hospitals where they might finally learn their own system, but to modern medicine hospitals, emergency rooms, and allopathic settings where they observe, assist, and absorb Western medical approaches because—for the first time—they see results, they see protocols that work, they see a system that actually produces clinical confidence.

The Allopathy Exodus: A Predictable Consequence

We express shock when 70-80% of BAMS graduates abandon Ayurvedic practice within five years of graduation, but this outcome is entirely predictable. These doctors were admitted with NEET scores as low as 110-150 out of 720—students who wanted MBBS seats but didn’t qualify—and then received five years of substandard education that left them clinically incompetent in their own field.

During their internship year, they discover that allopathic medicine offers them something Ayurvedic education never did: clarity, protocols, predictable results, and most importantly, the ability to actually help patients and earn a livelihood. They see antibiotics clear infections, antihypertensives reduce blood pressure, and emergency interventions save lives. They don’t see comparable results from Ayurvedic approaches because they were never taught how to apply Ayurveda properly.

From their perspective, the choice is simple: practice a system they never properly learned with uncertain outcomes, or adopt the system that gave them their only real clinical training, produces visible results, and meets the expectations of a society that increasingly views Ayurveda with skepticism.

Can we blame them? Each student comes from different socio-economic circumstances. Many have families depending on them to establish a practice quickly and generate income. They’re not abandoning Ayurveda by choice; they’re abandoning a system that abandoned them first.

The Accountability Vacuum: Everybody’s Guilty, Nobody’s Responsible

This crisis has been unfolding for decades, yet nobody bears accountability:

The National Commission for Indian System of Medicine (NCISM): Established to regulate and maintain standards, NCISM has presided over the systematic degradation of those standards. Its inspections are theatrical—institutions receive advance notice, stage temporary improvements, and return to dysfunction once inspectors leave. Recognition is granted to colleges that exist only on paper. Minimum faculty requirements are routinely waived. The regulatory body meant to enforce standards has become complicit in their erosion.

Universities: Examination reforms are announced with great fanfare, then implemented with such laxity that they become meaningless. Question papers leak, evaluation standards collapse, and grace marks are distributed generously to maintain pass percentages. Universities have transformed from gatekeepers of competence to assembly lines of certification.

Colleges and Hospitals: Managements operate institutions as commercial ventures rather than educational establishments. Infrastructure remains inadequate, libraries are outdated, teaching hospitals lack patients (or lack the systems to properly utilize the patients they have), and faculty positions remain vacant for years. Many colleges function primarily as real estate holdings where education is an incidental activity.

Teachers: While many individual teachers are dedicated and competent, the system has demoralized them into ineffectiveness. Underpaid, overburdened with administrative tasks, lacking institutional support, and often themselves products of the same deficient educational system, they can neither model clinical excellence nor effectively mentor students. The best potential teachers often leave academics for better-paying clinical practice.

Students: Society routinely blames students for being “not interested in Ayurveda” or “lacking dedication,” but this is victim-blaming. Students are admitted with low qualifications, receive inadequate instruction, observe faculty disengagement, and correctly conclude that the system isn’t serious about actually training them. Their disengagement is rational response to institutional failure.

The COVID Excuse That Doesn’t Apply

The UCSD report cites COVID-19 disruptions as a significant factor in declining math skills. Indian Ayurvedic education cannot even claim this excuse. The clinical competence crisis predates COVID by decades. The pandemic merely made visible what was always true: BAMS education had become disconnected from clinical reality long before lockdowns forced students into online classes.

If anything, COVID exposed the system’s fundamental emptiness. When education moved online, the loss was minimal because there had been little meaningful clinical education happening in person anyway. The transition from “standing uselessly in crowded OPDs” to “attending Zoom lectures” changed little of substance.

The Mission Creep Problem

Modern Ayurvedic education has attempted to integrate modern medical sciences—anatomy, physiology, pharmacology, biochemistry—into the curriculum, often at the expense of traditional knowledge systems. The result is students who understand neither system well. They learn modern anatomy superficially and traditional Sharira incompletely. They memorize pharmaceutical drug names without understanding Ayurvedic dravyaguna. They study pathology without grasping samprapti.

This isn’t integration; it’s dilution. Students graduate with fragmented knowledge—bits of modern medicine, pieces of Ayurvedic theory—but no coherent framework for clinical practice in either system.

Setting Students Up for Failure: The Cruel Equity Myth

The UCSD report makes a critical observation: “Admitting large numbers of students who are profoundly underprepared risks harming the very students we hope to support, by setting them up for failure.” This applies with devastating accuracy to BAMS education.

India’s Ayurvedic colleges admit 10,000+ students annually, many with NEET scores indicating they struggled with basic science concepts. The stated goal is democratizing medical education and providing opportunities for students from disadvantaged backgrounds. The reality is cruel: we admit students who lack foundational preparation, provide them inadequate education, and release them with degrees that don’t certify competence.

This isn’t equity; it’s institutional malpractice disguised as access. Real equity would require:

  • Adequate preparation before admission
  • Intensive remedial education where needed
  • Sufficient faculty and infrastructure to actually teach
  • Clinical training systems that build genuine competence
  • Assessment that measures real capability, not theatrical performance

Instead, we offer the appearance of opportunity while delivering the substance of failure. These graduates can’t establish successful Ayurvedic practices because they weren’t taught how. They can’t compete with MBBS doctors because they received inferior training. They’re trapped in a professional purgatory—overqualified to abandon medicine entirely, underqualified to practice it effectively.

The Public Health Consequence: Incompetent Doctors Treating Patients

The ultimate victims of this system are patients. Every incompetent BAMS graduate who opens a clinic represents a public health risk. They may:

  • Misdiagnose serious conditions requiring urgent medical attention
  • Prescribe inappropriate or dangerous treatment combinations
  • Fail to recognize contraindications and drug interactions
  • Provide false reassurance while conditions worsen
  • Damage the reputation of Ayurveda through poor outcomes

When these predictable failures occur, society blames “Ayurveda” rather than recognizing that what failed was Ayurvedic education and regulation. The system gradually degrades public confidence in traditional medicine, creating a vicious cycle where declining credibility justifies declining standards, which further erodes credibility.

The Antimicrobial Resistance Crisis: Are BAMS Doctors Major Contributors?

Recent findings paint an alarming picture of India’s antimicrobial resistance (AMR) crisis. In 2019 alone, nearly 300,000 Indians died from AMR-related infections. India has been labeled “the AMR capital of the world,” with resistance rates that shock even seasoned epidemiologists. More than 70% of E. coli, Klebsiella pneumoniae, and Acinetobacter baumannii isolates show resistance to fluoroquinolones and third-generation cephalosporins. Carbapenem resistance in Acinetobacter has reached 71%, forcing clinicians to resort to last-line antibiotics like colistin—to which resistance is now emerging. The National Academy of Medical Sciences task force reports that MRSA rates increased from 33% in 2017 to 44.5% in 2023.

These statistics represent not just numbers but a public health catastrophe in progress. Every treatment failure, every prolonged hospitalization, every preventable death can be traced back to the inappropriate use of antimicrobial agents. And here we must ask an uncomfortable question that India’s medical establishment has studiously avoided: What role are BAMS doctors playing in driving this antimicrobial apocalypse?

The reality is documented but rarely discussed with appropriate urgency. Research shows that approximately 60-70% of BAMS graduates practice predominantly or exclusively allopathic medicine, with antibiotics, painkillers, anti-emetics, and bronchodilators forming the core of their prescriptions. Multiple state governments—Maharashtra, Uttar Pradesh, Punjab, Karnataka, and others—have issued circulars allowing AYUSH practitioners to prescribe allopathic medicines, creating a legal gray zone that enables this practice despite Supreme Court rulings that technically restrict it.

The scale is staggering. India has over 770,000 registered AYUSH practitioners, with Ayurveda constituting 428,884 practitioners. If even 50% of BAMS graduates practice predominantly allopathic medicine, we’re discussing over 200,000 doctors prescribing antibiotics and other modern drugs with fundamentally inadequate training in their appropriate use.

Consider what this means for antimicrobial stewardship. The BAMS curriculum includes superficial exposure to modern pharmacology—nowhere near the year and a half of intensive study that MBBS students receive. These doctors learn enough to recognize antibiotic names and basic indications but lack the depth of training to understand:

  • Appropriate antibiotic selection based on pharmacokinetics and tissue penetration
  • Duration of therapy and de-escalation strategies
  • Recognition of resistance patterns and local antibiograms
  • Drug interactions with concurrent medications
  • Appropriate diagnostic workup before initiating therapy
  • The difference between viral and bacterial infections requiring antibiotics

The consequence is predictable: inappropriate antibiotic prescribing. Without adequate microbiological training, the temptation is to prescribe broad-spectrum antibiotics empirically. Without understanding of appropriate duration, treatment courses may be too short (encouraging resistance) or too long (unnecessary selection pressure). Without knowledge of local resistance patterns, ineffective agents are prescribed while effective alternatives are overlooked.

Research on prescription patterns is telling. When BAMS doctors practice in rural areas filling healthcare gaps, they predominantly prescribe allopathic medicines because “antibiotics, painkillers, anti-emetics, anti-spasmodic, bronchodilators give prompt relief in acute cases.” This approach—selecting drugs based on rapid symptom relief rather than appropriate diagnosis and targeted therapy—is precisely what drives antimicrobial resistance.

The problem is exacerbated by patient expectations. Villagers, as one doctor noted, “don’t bother whether doctor is ayurvedic or allopathic, they insist for injection.” The pressure to provide immediate symptomatic relief, combined with inadequate training in antimicrobial stewardship, creates a perfect storm for inappropriate prescribing.

But here’s the truly disturbing aspect: there is virtually no oversight. The National Action Plan on AMR, released in 2017, focuses on surveillance, infection control, and antibiotic stewardship programs—but these are primarily implemented in major hospitals and MBBS training institutions. The hundreds of thousands of BAMS practitioners working in small clinics, rural areas, and private nursing homes operate largely outside these systems. They don’t participate in antimicrobial stewardship training. They don’t receive feedback on their prescribing patterns. They don’t have access to institutional antibiograms. Many lack even basic diagnostic facilities.

The regulatory vacuum is complete. NCISM doesn’t monitor prescribing practices. State medical councils that technically regulate AYUSH practitioners have no systems to audit antibiotic use. The Drugs and Cosmetics Act’s Schedule H1 requiring maintenance of antibiotic prescription records is poorly enforced in small clinics. The result is hundreds of thousands of practitioners prescribing antibiotics with inadequate training and zero accountability.

Some might argue that this reflects a pragmatic solution to India’s healthcare access crisis—that BAMS doctors fill essential gaps in underserved areas. But this framing is dishonest. Providing access to healthcare by enabling inadequately trained practitioners to prescribe antibiotics inappropriately is not solving the healthcare crisis; it’s creating a different public health disaster. We’re trading immediate symptom relief for long-term antimicrobial resistance that will kill millions.

The Indian medical establishment treats this as a BAMS vs. MBBS turf war rather than a public health emergency. The IMA issues circulars condemning AYUSH practitioners for prescribing allopathy. AYUSH organizations assert their right to prescribe based on partial training. Courts issue contradictory rulings. Meanwhile, antibiotic resistance climbs inexorably, and nobody measures how much of it stems from inappropriate prescribing by inadequately trained practitioners.

This isn’t speculation. India’s antimicrobial resistance crisis is real, measurable, and worsening. The contribution of BAMS practitioners to this crisis is logical, probable, and essentially unmeasured. If we’re serious about addressing AMR, we cannot ignore the elephant in the room: a substantial fraction of India’s antibiotic prescriptions come from doctors who never received adequate training in their appropriate use.

The question isn’t whether BAMS doctors should be allowed to practice allopathy—that ship has sailed in practical terms. The question is: Given that hundreds of thousands of BAMS graduates are prescribing antibiotics, shouldn’t we be deeply concerned about their training deficiencies and their contribution to the antimicrobial resistance crisis? Shouldn’t we be measuring their prescribing patterns? Shouldn’t we be implementing urgent antimicrobial stewardship interventions specifically targeting this population?

Or will we continue ignoring this uncomfortable truth until antibiotic resistance reaches such catastrophic levels that common infections become untreatable—at which point we’ll have the dubious distinction of having known about the problem decades in advance and done nothing?

What Would Real Reform Require?

The UCSD faculty proposed concrete interventions: math placement indices, mandatory testing by June 1st, feedback mechanisms with high schools, and expanded remedial capacity. These are pragmatic responses to a measured problem.

Ayurvedic education needs equivalent—and more radical—reforms:

Admission Reform: Raise NEET cutoffs substantially or create Ayurveda-specific aptitude testing that assesses genuine interest and foundational preparation. Stop admitting students who wanted MBBS but “settled” for BAMS.

Faculty Development: Mandate minimum faculty-student ratios and enforce them without exceptions. Increase faculty compensation to competitive levels. Create systems for faculty continuous education and clinical skill maintenance. Establish teaching excellence as a criterion for advancement.

Curriculum Restructuring: Integrate clinical exposure from first year. Design case-based learning rather than theoretical lectures. Require minimum patient contact hours with documented supervised encounters. Create standardized clinical competency milestones that must be demonstrated before degree conferral.

Infrastructure Investment: Mandate functional teaching hospitals with sufficient patient flow. Require modern clinical laboratories and diagnostic facilities. Ensure libraries have current journals and digital resources. Create simulation centers for skills practice before patient contact.

Examination Reform: Implement clinical competency assessments using standardized patients. Require dissertation-quality research rather than copy-paste projects. Use external examiners from high-performing institutions. Publish outcome data—graduation rates, time to graduation, clinical competency scores—for every institution.

Regulatory Enforcement: Make NCISM inspections unannounced and consequential. Revoke recognition from non-compliant institutions regardless of political pressure. Create public databases of institutional performance. Empower students to report deficiencies without fear of retaliation.

Mandatory Competency Certification: Before any BAMS graduate can begin independent practice, require them to pass a national clinical competency examination—a practical assessment of actual ability to diagnose, formulate treatments, and manage common conditions. Similar to the USMLE (United States Medical Licensing Examination) system, this would ensure a minimum standard regardless of institutional variations.

The Cost of Continued Denial

The UCSD faculty deserve credit for their brutal honesty in documenting their institutional crisis. Indian Ayurvedic education lacks even this level of self-awareness. We have no comprehensive reports, no measurement systems, no public acknowledgment of the magnitude of our failure.

Instead, we have:

  • Conferences celebrating “ancient wisdom” while ignoring modern incompetence
  • Research papers on theoretical concepts disconnected from clinical reality
  • Regulatory pronouncements about standards that nobody enforces
  • Political speeches about “making Ayurveda mainstream” without addressing why it’s being abandoned
  • Marketing campaigns promoting Ayurvedic products while Ayurvedic doctors flee the profession

This denial has consequences. Each year, another 10,000 inadequately trained doctors enter practice or abandon the field entirely. Each year, public confidence in Ayurveda erodes further. Each year, the gap between ancient wisdom and modern mediocrity widens.

A Profession at the Crossroads

The contrast is stark: UC San Diego identified a crisis, measured its magnitude, analyzed its causes, and proposed concrete interventions—all within a few years of recognizing the problem. Indian Ayurvedic education has ignored an equivalent crisis for decades.

UCSD students are underprepared in mathematics but will likely receive remedial education and support to succeed. BAMS students are underprepared for clinical practice and receive neither honest assessment nor adequate remediation. Instead, they receive degrees that certify competence they don’t possess, then face a professional life of either practicing incompetently or abandoning their field.

The question facing Indian Ayurvedic education isn’t whether reform is necessary—the necessity is obvious to anyone willing to look honestly at the system. The question is whether we have the institutional courage to acknowledge the crisis, the political will to implement genuine reform, and the moral clarity to prioritize competence over access, substance over appearance, and patient safety over institutional convenience.

Until we can answer those questions affirmatively, we will continue the cruel charade of admitting unprepared students, providing inadequate education, certifying incompetent graduates, and wondering why Ayurveda struggles for credibility in the modern world.

The math crisis at UCSD shocked observers because a prestigious institution measured and acknowledged its failing. The clinical competence crisis in Ayurvedic education should shock us more—because we haven’t even bothered to measure it, let alone fix it. That indifference to our own institutional failure may be the greatest failure of all.

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