consultation-2016-related-documents-for-alumni

Consultation 2016 Every 5 years or so CMC holds a “Consultation” -- strategic planning sessions with national and international invitees as consultants. The last Consultation was held in 2010; Consultation 2016 was held in the first week of October. The Foundation’s Board Chair Dr. Honorine Ward (’69) attended, as did Dr. Anindya Dutta, best outgoing student of the Batch of ‘75, Professor and Chair of Biochemistry and Molecular Genetics at the University of Virginia, and a member of the Foundation’s Corporation and Research Committee. Dr. Dutta presented recommendations for Research on behalf of the Foundation.

Dr. Ward wrote the following: I just got back to Boston after attending Consultation 2016 at CMC, Vellore. It was a very intense and action packed few days! The breadth and depth of topics discussed were quite amazing! Dr. Anindya Dutta gave an excellent presentation on recommendations for Research at CMC, which was very wellreceived. Dr. Dutta’s presentation and the Research Committee’s Recommendations for Research (prepared by Committee Chair Dr. Philip Ninan, ’69) are below.

Nesa Joseph (son of the late CMC Director Dr. LBM Joseph who grew up as a “campus kid” in Vellore) was invited to give a keynote address in the session on Partnerships. He is well-respected in health care management and hospital administration in India and the US. He is currently President and CEO of the Visiting Nurse Association of St. Louis. Mr. Joseph asked me to join him in this presentation.

In the presentation Mr. Joseph spoke of his vision, shared by many in CMC and elsewhere, to establish a Christian Healthcare System in India as a flagship venture of CMC. This concept could raise the profile of CMC in India and globally. I talked about the Foundation Board’s discussion on the concept and read aloud the Resolution of Support passed at its September Board meeting. There was much appreciation expressed by members of the audience for Mr. Joseph’s talk as well as for the interest taken by the Foundation Board on this subject. The presentation went very well and was well-received. There was a lot of discussion at and after the session about feasibility and logistics of the idea.

September 26, 2016

To: Dr. John C. Muthusami, Chairperson, CMC Consultation 2016 Dr. Biju George, Vice-Principal for Research, CMC Dr. Sunil Chandy, Director, CMC

From: The Research Committee, Vellore CMC Foundation, USA.

Subject: CMC Consultation 2016: Recommendations on Research

Background: CMC is recognized as a leading medical institution in India. CMC performs three interlacing functions of 1) healthcare services including outreach, 2) education and 3) research. The focus of this report is on research.

Research is emphasized in CMC’s Vision Statement: CMC aspires to “excellence in education, service and research”. CMC’s Mission Statement also emphasizes research. “Research may be aimed at gaining knowledge of the fundamental basis of health and disease, at improving interventions or in optimizing the use of resources.”

Research is not in competition with services and education, but enhances each of them.

1.

Research is a form of service, to those beyond the institutional walls and immediate neighborhood. a. Research discoveries made in CMC have had a significant impact on services, saving many lives.

Examples in clinical research include the discovery that three doses of oral polio vaccine are inadequate for providing immunity to polio in India and the adoption of oral rehydration solution for prevention of infantile dehydration from diarrhea. Examples of basic science research from CMC include the discovery of HMG-CoAlyase and the cause of metachromatic leukodystrophy. b. Research in healthcare services advances the treatment options for illnesses currently lacking optimal choices.

The definition of research in the Mission Statement includes ‘optimizing the use of resources’, thus indicating quality improvement measures. Research also includes the gathering of information to constantly improve the quality and delivery of services (Varkey 2011).

2. The history of medicine indicates that conventional knowledge is often revised as new information is acquired. Thus research enhances education, patient care and public health. An enquiring mind is not only acquires current knowledge, but also learns to think critically: constantly questioning received wisdom and its underlying assumptions. Thus a research-oriented education is an essential component of life-long learning. Most of CMC’s trainees will not become active researchers, but their clinical careers will benefit greatly from their basic education having been grounded in research.

3. A research perspective teaches “critical thinking” skills at all levels and across disciplines that is valuable in almost all aspects of life in CMC and mission hospitals.

This includes teaching, administration, economics of healthcare, therapy and prevention.

4. Academic accomplishments are major contributors to CMC’s reputation. Excellence in research at CMC will enhance the national visibility of CMC and have both tangible and intangible benefits.

Defining Research: Research is the acquisition of new knowledge and its dissemination through publication. Research can be categorized as: 1. Advancing basic knowledge, in the laboratory, the clinic or in public health. The clinical implications of this type of research is typically realized in the long term 2. Applied and translational research has immediate clinical relevance, and is best performed by teams of clinicians and basic scientists who have a presence both at the bedside, the computer and/or the laboratory.

3. Clinical research systematically examines symptomatology of disease and associated factors, and assesses the value of clinical interventions (trials) in diminishing disease processes and achieving wellness. In today’s highly connected world, this too is carried out by teams of researchers in the clinic, the laboratory or at the computer, with interactions sometimes extending across the globe.

4. Services research addresses processes in delivering care, including quality improvement and outcomes.

5. Public Health research: Clinical and population epidemiology identify the scope of disease (prevalence, incidence, lifetime risk) and identifies potential risk and protective factors, thus leading to the development of services in disease prevention and health promotion. CMC’s longstanding leadership role in this area must not only be sustained, but also integrated into clinical and community health practice.

Research, as defined above, is not merely the domain of physicians, but involves practitioners of all disciplines of health care, ranging from nurses, pharmacists, outreach personnel, laboratory scientists and quantitative scientists. Areas in which CMC has a unique opportunity given the large and diverse patient population seen in its clinics and in its outreach areas include items 26 above.

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The Challenge: Institutions such as CMC have been at the forefront of research advances in India. Advancing knowledge to reduce current and future suffering is a moral obligation. This was the vision and tradition articulated and established by Ida Scudder. As India expands its global impact, CMC, as a leading academic medical institution in India has an opportunity and obligation to advance knowledge in the care of the populations that she uniquely serves.

Medical research in India must match the areas where it is most needed (Arunachalam S. 1998).

Benchmarked nationally, CMC stands out for the high quality of its healthcare and education.

CMC also has a sizable local reputation in research (Prathap G, Gupta BM. 2011). CMC has always strived to stand equally with the best global institutions. However, benchmarked against Asia and the rest of the world, CMC’s research productivity could be improved to match that of other leading medical institutions, particularly given its outstanding intellectual, technical and clinical resources (Godbole M. et al. 2013; Ray S. et al. 2016).

Can research be adopted as a core value throughout all its units and activities? Such an endeavor can only be helped by widespread acceptance of research as a core activity throughout the institution. Research needs to be demystified for all CMC students, faculty and staff, so that they understand it is not a luxury but an essential component of the institution’s mandate; and that its primary purpose is to improve the execution of the other mandates. In turn, regular presentations of research proposals and findings to clinicians, educators, and administrators, with opportunities for researchers to receive questions and feedback, will help keep research relevant to the CMC context.

Recommendations: A. STRATEGIC 1. CMC recognize research as a component of its mission equal to education and service/outreach. a. Reports be commissioned externally to review the Indian landscape of medical research and internally, research at CMC. Evaluate how other institutions of similar reputation have addressed challenges in doing research in the face of an overwhelming clinical load. b. Training in research be made available in multiple formats to all participants in CMC: medical students, nursing and allied students, Ph.D. students, postgraduate students and faculty. This should include the fundamentals of quality research, how to ask a solvable question, ethics of research and protection of research subjects, gathering of data, tools of analysis, inference and publication. Dissemination of research through stringent peer-review is a critical part of the academic enterprise. c. Each department/unit be charged to perform research, and the success of the unit chief be evaluated not only on the quality of service and education, but also on the number and quality of research performed and published. At a minimum, this should be in the area of services research that measures outcomes to improve quality of care.

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d. Modify teaching methods to highlight the role played by research in generating the body of knowledge that provides the foundations of clinical medicine. CMC trains a major fraction of its future generations of faculty and leadership not only in CMC but also at many outlying mission hospitals. Thus, the future of CMC and the mission hospitals depends heavily upon the ability of its current undergraduates and postgraduates to rationally analyze data, take into account new developments, and then reach a testable hypothesis that will improve patient care, outreach and reputation. Thus the academic and intellectual environment in which this education occurs has to emphasize research.

B. TACTICAL 1. A unified administrative structure be developed for Research, with the appointment of an Associate Director for Research, reporting directly to the Director. e. The Vice-Principal’s office of sponsored programs that makes available to faculty and students, avenues for research support, administrative support for managing and reporting financial and other administrative functions, has been a very concrete and positive step towards promoting research. f. It is time now to complement this office by the appointment of an Associate Director for Research, reporting directly to the Director, because research needs resources that are available only in specific systems such as the hospital, the nursing faculty or in the pharmacy. Thus a central point of integration of research must be in the Director’s office.

2. A method be developed for managing service loads when sponsored research funds are obtained. The lack of protected time for research appears to be a critical barrier to research in CMC. If CMC is to build on its formidable reputation by making research a core principle for the institution, CMC has to find ways to facilitate original research by her faculty.

3. Research be measured to monitor progress, benchmarked to India and internationally. a. CMC aim to maintain its leadership position in innovation and research - in the laboratory, the classroom, at the bedside, in the community and at a national level. High rankings in publications such as India Today give CMC the national clout to maintain its independence, guide public discourse and to attract the best faculty and students. b. Innovation be recognized as a major driver in research. Innovations arising from research can guide not just national policies and best practices, but extend even beyond national borders to other developing countries that share similar health problems. Several CMC faculty members have already made important contributions in this respect. c. Providing protected time for research and the publication of peer-reviewed papers should be a major responsibility for each Unit chief throughout the institution.

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4. Clinical trials enhance the care rendered to patients. Increasingly, well-educated patients seek out doctors and hospitals that are publishing groundbreaking papers and are therefore considered leaders in their field. The medical marketplace in India is becoming increasingly competitive and sophisticated. To maintain its high rankings in medicine, CMC has to enlarge its investment in intellectual leadership.

5. CMC has long required a thesis for graduation from postgraduate medical courses.

However it is rare for these theses to be published. This is a lost opportunity to learn how to organize and disseminate valuable information to the larger medical community.

CMC consider submission to a scientific journal as part of the graduation requirement.

Mentoring be made available to the individual in preparing the manuscript(s) for publication. A successful publication will itself be an incentive for continued research and reporting of results.

In closing, CMC stands at the threshold of an expansive future. We, her alumni in external academia, and the Vellore CMC Foundation in the U.S., stand ready to provide the support that CMC requests, to achieve her destiny.

Philip Thoppil Ninan (’69 batch) Chair, Research Committee On behalf of the Research Committee, Vellore CMC Foundation, New York, NY, USA Members: Bobby Cherayil, MD (’74 batch) Anindya Dutta, MD, PhD (’75 batch) Mary Ganguli MD (’68 batch) Meredith Hawkins MD Nissi Varki MD (’68 batch) Christine Wanke MD Vellore CMC Foundation Chair: Honorine Ward-Pillai MD (’69 batch)

References: Arunachalam S. Does India perform medical research in areas where it is most needed? Natl Med J India. 1998 Jan-Feb;11(1):27-34.

Godbole MM, Misra R, Pandey CM, Srivastava S. Report on institutions ranking – Where our medical institutions stand? Our big neighbor & the way forward. Indian J Med Res 2013 Jun; 137(6):1204-1206 Prathap G, Gupta BM. Ranking of Indian medical colleges for their research performance during 1999-2008. Annals of Library and Information Studies. September 2011. 58: 203-210.

Ray S, et al. The research output from Indian medical institutions between 2005 and 2014, Curr Med Res Pract. (2016), http://dx.doi.org/10.1016/j.cmrp.2016.04.002 Varkey P, Kollengode A. A Framework for healthcare quality improvement in India: The time is here and now! J of Postgraduate Medicine 2011;57(3):237-241

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Notes from Dr. Anindya Dutta on CMC’s Consultation 2016 I visited CMC to participate in Consultation 2016 from October 3-5, representing the Research Committee of the Vellore CMC Foundation as well as the CAFEAE Group (CMC Alumni for Enhancing Academic Excellence). The abstract below highlights my 25-minute talk and the attached PowerPoint contains the slides that accompanied the talk.

Abstract: I am representing the alumni and the Vellore CMC Foundation Research Committee in the USA who are very involved in enhancing academic activities at CMC [Founders: Drs. Ajit Varki (’68) and Shiv Pillai (’69); current leaders: Drs. Honorine Ward (’69) and Philip T. Ninan (’69)].

We first want to congratulate CMC for its extensive research activities done in conjunction with its huge impact on the clinical and educational arena. Our advice is very sensitive to the fact that current faculty at CMC are the best judges of what needs to be done to enhance Research activities there. We are all agreed that it is a laudable goal to get CMC Vellore to the forefront of biomedical research in India and the world.

The very concrete steps proposed by the Vice Principal for Research Dr. Biju George (’86) and his committee deserve full support. Research is an integral part of the mission of an academic medical center. CMC Vellore is exceptional in its commitment to service, education and the collaborative delivery of both. The same commitment and collaboration, if slightly redirected to research, will enable the institution to become a thought leader in academic medicine in India and the world.

Simple steps will help achieve this goal.

1) The administration, including the Advisory Council, the Director, the Principal, the Department Chairs and others must agree on the value of research and highlight the research going on at CMC in every forum. Research is very consistent with Christian values, and so there is no barrier to highlighting references to Research done in CMC even in prayers and sermons. Faculty hires, promotions and reappointments should consistently take into consideration the research accomplishments of an individual, though of course, that cannot be the only criterion in an institution that also has a huge service and educational commitment.

2) Research is expensive and even though the Indian research funding environment is good, seed funding and maintenance funding has to come from the clinical enterprise and from philanthropic funds.

3) Research can be clinical, translational, related to quality of care or basic. Thus there should be enough interest in the clinical departments to do some kind of research and the basic science departments should be evaluated on their research output. However, for improvement of academic reputation it is important that almost all research be deemed complete only after peer review and publication.

4) Time for research is a significant concern for clinical faculty (also true in the West). So while everyone in a department may not want time for research, each department should consider giving protected research time to selected individuals on a term-limited basis, with renewal of the term dependent on external peer review of research. CMC alumni can help with such peer-review.

5) Collaborations should be encouraged between clinicians and faculty in basic science departments, and between clinicians and PhD scientists or nurses or paramedical staff, to make a meaningful

advance in the research enterprise. Research collaborations between CMC and the mission hospitals should also be encouraged. The mission hospitals have a very unique perspective on health care delivery and medical data in resource-restricted environments that lends itself very well to scientific analysis of quality control and effectiveness.

6) CMC has been very proactive about sending faculty abroad to acquire new clinical skills as they develop. A similar effort spent on sending faculty abroad to acquire new research skills will benefit the research enterprise.

7) Consistent efforts at a cultural change may be necessary. Research reputation tends to accrue to individuals or groups, and active effort by the senior faculty and administration is necessary to manage any perceptions of inequality that may arise from this. The whole institution gains in reputation when good papers are published from CMC.

Keynote Address on Developing Research at CMC

Recommendations presented by Dr. Aninya Dutta on behalf of the Vellore CMC Fdn. Consultation 2016

What the Wikipedia page on CMC Vellore highlights:

1) started the first College of Nursing in India (1946) Performed the first: 2) reconstructive surgery for leprosy in the world (1948), 3) successful open heart surgery in India (1961), 4) kidney transplant in India (1971), 5) bone marrow transplantation (1986) in India 6) successful ABO incompatible kidney transplant in India (2009)

The establishments of the Fleming Memorial Research Laboratory in Virology in 1965, the Artificial Kidney Laboratory in 1976, the Betatron ICMR Centre for Advanced Research in Virology in 1978, the National AIDS Reference and Surveillance Center in 1986, the Cytogenetics Laboratory in 2002 and the Vellore Bombay Artificial Limb Bioengineering Department in 2003 are significant initiatives in the field of medical research.

Other significant milestones in the history of the hospital are: Establishing the first Neurological Sciences Department in South Asia also in 1948, Performing the first Middle-ear Microsurgery in India also in 1961, Establishing the first Rehabilitation Institute in India in 1966, Performing India's first Bone marrowTransplant in 1986, Performing the first carotid bifurcation stenting procedure in India in 1996, Performing the first trans-septal carotid stenting procedure in the world also in 1996, Performing the first trans-jugular mitral valvuloplasty procedure in the world in 1996,

Which research from Vellore gained worldwide reputation Total Citations 1) Inherited thrombophilia .1. Thrombosis and Hemostasis 1996; 76:651-662 Lane, DA; Mannucci, PM; Bauer, KA; et al.

M. Chandy 483

Per year Citations

23.00

2) Update on the pathophysiology and classification of von Willebrand disease: a report of the Subcommittee on von Willebrand Factor Thrombosis and Hemostasis 2006; 4: 2103-2114 Sadler, J. E.; Budde, U.; Eikenboom, J. C. J.; et al.

A. Srivastava 464 42.18 3) Feasibility, diagnostic accuracy, and effectiveness of decentralised use of the Xpert MTB/RIF test for diagnosis of tuberculosis and multidrug resistance‌Lancet 2011; 377:1495-1505 Boehme, Catharina C.; Nicol, Mark P.; Nabeta, Pamela; et al. Michael, JS 402 67.00 4) Proposed diagnostic criteria for neurocysticercosis Neurology 2001; 57:177-183 Del Brutto, OH; Rajshekhar, V; White, AC; et al.

366

22.88

5) Ipilimumab in Combination With Paclitaxel and Carboplatin As First-Line Treatment in Stage IIIB/IV NSCLC: Results From a Randomized, Double-Blind, Multicenter Phase II Study JCO 2012; 30:2046-2054 Lynch, Thomas J.; Bondarenko, Igor; Luft, Alexander; et al. Raju Chacko 295 59.00 6) Impact, diagnosis and treatment of von Willebrand disease Thrombosis and Hemostasis 2000 84: 160174. Sadler JE, Mannucci PM, Berntorp E ‌ Srivastava A 291 17.12

Which research from Vellore gained worldwide reputation: Total Citations

Per year Citations

7) Factors affecting the immunogenicity of oral poliovirus vaccine in developing-countries Reviews of infectious diseases 1991; 13: 926-939 Patriarca, PA; Wright, Pf; John, TJ 259 9.96 8) Inherited thrombophilia .2. Thrombosis and hemostasis. 1996; 76:824-834 Lane, DA; Mannucci, PM; Bauer, KA; et al.

M. Chandy 248

11.81

9) 10) Rotavirus genotyping: keeping up with an evolving population of human rotaviruses JCV 2004; 31:259-265. Iturriza-Gomara, M; Kang, G; Gray, J 227 17.46 10) Guidelines for the management of hemophilia. Haemophilia 2013; 19 : E1-E47 By: Srivastava, A.; Brewer, A. K.; Mauser-Bunschoten, E. P.; et al.

224

56.00

12) Single-agent arsenic trioxide in the treatment of newly diagnosed acute promyelocytic leukemia: durable remissions with minimal toxicity Blood 2006; 107: 2627-2632 Mathews V, George B, Lakshmi KM, Viswabandya A, Bajel A, Balasubramanian P, Shaji RV, Srivastava VM, Srivastava A, Chandy M. 190 17.27 13) Current consensus guidelines for treatment of neurocysticercosis Clin. Microbio Reviews 2002; 15:747 Garcia, HH; Evans, CAW; Nash, TE; et al.

Rajshekhar V. 187 12.47

Suggestions on how to enhance research from your grateful alumni

1) Congratulations! You are already doing a lot of outstanding research 2) YOU know best what is needed. Pay special attention to the talk after mine 3) P.T. Ninan has sent a beautifully written document with our suggestions. I recommend it be put up on your research website. My job is to simply highlight what we wanted to say

1) 2)

3)

4)

5)

I think you know why CMC should do more research Enhancing the academic reputation of CMC will bring you more patients India is very different from the India we grew up in‌or that Aunt Ida started CMC in. India can produce, and needs, world class centers of excellence and thought leaders (think China, Japan and USA just a few years earlier in history) CMC and you, the faculty, are leaders in India because of your commitment to excellence and because you collaborate. Harnessing the same qualities can lead CMC to become a world leader in research Excellent research training begets excellent clinicians and administrators. Research cultivates a systematic way of thinking. It is no surprise that some of the best physicians in CMC are also the best known for their research.

Your future faculty are being trained right now here in Vellore. Make them exceptional and CMC will remain exceptional

Research valued like a vitamin in the institution The administration from the Advisory Council, the Director, the Principal, the Department Chairs and others must agree on the value of research and highlight the research going on at CMC in every forum The websites, the bulletins, even the sermons and prayers should highlight your research Ecclesiastes 1:13 “And I gave my heart to seek and search�

Dr. Fr. Thomas C. Mathew said earlier how most of the major research universities in the West started out as theological schools.

Research valued like a vitamin in the institution

Faculty hires, promotions and re-appointments should evaluate a faculty member’s research accomplishments, though of course, that cannot be the only criterion in an institution that also has a huge service and educational commitment

Research needs fuel: institutional funding leading to external peer-reviewed funding Research is expensive and even though the Indian research funding environment is good, seed funding and maintenance funding has to come from the clinical enterprise and from philanthropic funds.

Peer-reviewed external funding is a strong measure of the health of an institution’s research enterprise. Make seed funding the first step in getting external funding.

What type of research?

Research can be clinical, translational, related to quality of care or basic. Thus there should be enough interest in the clinical departments to do some kind of research, and the basic science departments should be evaluated on their research output You need a few Centers of Excellence, cultivated with designated faculty inside and help from recent emeritus faculty and from alumni from outside However, for improvement of academic reputation it is important that almost all research be deemed complete only AFTER peer review and publication

Too much work

Time for research is a significant concern for clinical faculty (even in the West). So while everyone in a department may not want time for research, each department should consider giving protected research time to selected individuals on a term-limited basis, with renewal of the term dependent on external peer review of research Use your alumni and retirees to help with the external peer review

You don’t have to do it alone

Collaborations should be encouraged between clinicians and faculty in basic science departments, or between clinicians and Ph.D. scientists in clinical departments and between physicians and nurses and paramedical staff to make a meaningful advance in the research enterprise A fellow alumnus running a mission hospital said that he would like to collaborate with CMC professors to make use of data collected at his hospital. The alumni abroad are also very open to collaborations

You don’t have to do it alone (cont.)

Sending faculty abroad to acquire new research skills will benefit the research enterprise. CMC has done this very effectively for acquiring new clinical skills, so a similar effort will help in the research arena Focused mentoring of potential researchers by current senior faculty is very important

Cultural Change Peer-reviewed research is hard. (Why?) To get people to make the hard choice to do research the environment has to be super-enthusiastic about research.

Consistent efforts at a cultural change may be necessary. Research reputation tends to accrue to individuals or groups, and active effort by the senior faculty and administration is necessary to manage any perceptions of inequality that may arise from this.

Drive home the message: The whole institution gains in reputation when important discoveries are made and good papers are published from CMC