|Year : 2018 | Volume
| Issue : 2 | Page : 113-116
Rheumatology training in India compared to the United Kingdom
Parthajit Das1, Arumugan Moorthy2, Balebail Dharmanand3
1 Department of Rheumatology, Consultant Rheumatologist in Kettering General Hospital NHS Foundation Trust and Honorary Lecturer, University of Leicester, England, United Kingdom
2 Department of Rheumatology, Consultant Rheumatologist and Honorary Senior Lecturer, University of Leicester, England, United Kingdom
3 Department of Rheumatology, Consultant Rheumatologist, Sakra World Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||24-May-2018|
Dr. Parthajit Das
Kettering General Hospital and Foundation NHS Trust, and Honorary Lecturer, University of Leicester, England
Source of Support: None, Conflict of Interest: None
Background: Rheumatology is an emerging specialty in India, and there is a huge demand for trained rheumatologist to satiate the overwhelming musculoskeletal disease burden in India. Rheumatology training in the UK is structured and comprehensive. This study was aimed to explore the strengths and weaknesses in the rheumatology training in India as compared to the UK.
Methods: This was an observational semiqualitative study. An online questionnaire was circulated electronically to rheumatology trainees across the UK and India. The questionnaire was designed to explore the curriculum content, training and research opportunities, training assessment methodologies, and employability in two countries.
Results: A total of 77 respondents participated in this study, 52% (40/77) were from the UK and 48% (37/77) from India. We noted heterogeneity in the structure and delivery of training with multiple incongruous training curricula being prevalent in India. Institutional academic training supervision was comparable in both countries. UK trainees received comparatively more structured supervision for procedural skills. Indian trainees were proficient with laboratory-based rheumatological and immunological tests. Professional research and academic programs were incorporated in UK training. Mandatory training for generic skills was lacking in India. Specialty exit examination was mandatory in both countries. Employment opportunities were better perceived in the Indian subcontinent.
Conclusions: In this study comparing rheumatology training between the UK and India,a lack of structured and coherent national curriculum in India was noted. Harmonisation of rheumatology training in India is essential to be at par with the well-established postgraduate rheumatology training curriculum in developed countries.
Keywords: Curriculum, education, rheumatology, training, the United Kingdom
|How to cite this article:|
Das P, Moorthy A, Dharmanand B. Rheumatology training in India compared to the United Kingdom. Indian J Rheumatol 2018;13:113-6
| Introduction|| |
Rheumatology is an emerging medical specialty in the paradigm of higher medical specialty qualifications. Novel therapeutic embellishments such as biologics therapies have revolutionized the disease outcome in rheumatic diseases. Young medical trainees are increasingly choosing this challenging specialty as their future career. The heterogeneity and complexities of rheumatic diseases demand careful clinical evaluation and thorough diagnostic and therapeutic strategies. A robust training curriculum is, therefore, essential to train and produce competent specialists. A well-designed curriculum should clearly delineate the educational objectives and emphasize on essential competencies that should equip a trainee to become an independent practitioner. Diversity in rheumatology training has been observed in different countries pertaining to demographics and available health-care infrastructure.
India is considered to be one of the largest growing economies. Community Oriented Program for Control of Rheumatic Disorders (COPCORD) survey has established the overwhelming burden of rheumatic and musculoskeletal diseases in rural Indian population. There is a huge need for trained specialists to manage musculoskeletal health burden in India. Only a handful of institutions are equipped to deliver high standard of postgraduate training in rheumatology.
Previous studies have explored the rheumatology training programs in the UK, Canada, New Zealand and South Asian countries, and European countries. The UK training curriculum was found to be more structured and supervised, with a range of strengths and weaknesses in the individual training programs. Therefore, we felt it was appropriate to evaluate the rheumatology training in India, keeping UK rheumatology training as a bench mark. We attempted to explore the curriculum content, research opportunities, training and competence assessment, and job opportunities in these two countries.
| Methods|| |
This was a prospective, questionnaire-based, semiqualitative study. The target population consisted of rheumatology trainees across the UK and India. An online survey consisting of 34 questions was initially piloted regionally and the improved questionnaire was circulated electronically to all the rheumatology trainees across the UK through their training program directors between August 2012 and January 2013 and to the Indian trainees through the institutional leads between September 2015 and January 2016. Data were collected through a centralized portal of entry after being anonymized for responder-identifiable material. Descriptive statistics were applied to analyze the data to provide relevant metrics.
| Results|| |
A total of 77 respondents - 52% (40/77) from the UK and 48% (37/77) from India. Response rate, however, was poor among the UK trainees (40/249, 16% ) and better among the Indian trainees (37/75, 49%). Five responses from the UK and four responses from India were excluded because of incomplete data. There were more female respondents from (55%) in the UK and more males (71%) in India.
Structure of rheumatology training
This study highlighted a wide difference in the admission procedure, structure, and duration of training in these two countries. The essential criteria for entry to training program in the UK were as follows: (i) 4 years of postgraduate general medical training, i.e., 2 years foundation training and 2 years core medical training and (ii) the Member of Royal College of Physicians (MRCP) or its equivalent. Whereas, successful completion of postgraduate degree (MD) or Diplomate of national board (DNB) examination in general internal medicine or pediatrics was considered a mandatory admission criterion in India.
In the UK, the application process included point-based national registration portal of entry and a structured interview process exploring the clinical and generic skills, whereas Indian trainees had to appear for highly competitive institution specefic multiple choice question (MCQ)-based theoretical exam, and in some cases, an interview before the final selection. UK trainees underwent either 5 years of combined specialist training in rheumatology and internal medicine or 4 years of pure rheumatology, whereas Indian trainees underwent 3 years of specialist training in rheumatology. Majority (89%) of the UK respondents opted for full-time training posts, whereas the concept of part-time training program was unrecognized in the Indian training system.
Successful completion of training would translate into Certified Completion of Specialist Training (CCT) for the UK trainees and postgraduate degrees, for example, Doctorate of Medicine (DM) or DNB for Indian trainees.
Trainees from both countries received comparable weekly in-house institutional teaching supervision. The UK trainees received more structured supervision for large joints, small joints, and soft-tissue injections [Table 1]. Indian trainees were proficient in laboratory investigations, for example, crystal identification and immunological assays, which was distinctly lacking in UK training.
Training for generic skills such as communication, leadership, and management was deemed essential in the UK curriculum and not formally assessed in India [Table 1].
Combined clinics with allied specialists such as chest physicians, renal physicians, dermatologists, and orthopedics were widely practiced in the UK training centers and rarely performed in Indian training institutes.
Training in musculoskeletal ultrasound
UK centers were relatively more equipped with departmental ultrasound machines and musculoskeletal ultrasound (MSUS)-trained rheumatologists. However, ultrasound training was incoherent across various centers in the UK. Around 35% of the UK respondents received adequate supervision in MSUS. Respondents from India reported limited access to structured MSUS training programs.
Although 78% of all the respondents from both countries were involved in regional or national projects, 28% of the UK respondents were actively involved in postgraduate research and academic programs such as MSc, MD, or PhD. A submission of dissertation/thesis project is an mandatory requirement for a postgraduate qualification (DM/DNB) in rheumatology in India.
UK trainees maintained an electronic portfolio recording their achievement of core and generic competencies through multisource patient feedback, case-based discussions, directly observed procedural skills, acute care assessment tools, audit and teaching assessments, etc. Indian trainees used paper log books for maintenance of competence records and work-based assessments.
UK training was supervised by trained and General Medical Council (GMC) accredited educators such as training program director and educational and clinical supervisors. Indian trainees generally received supervision from their mentors and qualified rheumatologists in the relevant institutions.
Exit examination was mandatory in both countries following completion of training. UK trainees were required to pass three knowledge-based extended MCQ style examinations. Exit examination in India encompassed essay-type theoretical paper, clinical examination with long and short cases, and a viva voce.
Nearly 78% of the UK respondents were uncertain about their job prospects in the highly competitive National Health Service milieu. UK respondents expressed better employment prospects with dual accreditation in rheumatology and internal medicine. Indian trainees perceived better job opportunities following successful completion of training when they could proceed to take up a teaching or independent private practitioner role [Figure 1].
| Discussion|| |
This study endeavored to identify the shortcomings and learn from the positive determinants in the existent training curricula in the two countries.
Rheumatology training curriculum in the UK appeared to be more descriptive and comprehensive in both generic and specialty-specific skills.,, Rheumatology as a subspecialty is still evolving in India when compared to other specialties such as cardiology or gastroenterology.
Postgraduate medical training is delivered through knowledge- and competency-based curriculum in both countries. The national curriculum in rheumatology in the UK was developed by Specialty Advisory Committee for Rheumatology under the direction of Joint Royal Colleges of Physicians Training Board in August 2010. This was coherently followed across all the health education regions in the UK, with some variations in Scotland and Northern Ireland. The Medical Council of India (MCI) is mandated with the maintenance of uniform standards of undergraduate and postgraduate medical education across the country. Handa  has discussed several shortcomings in the Indian medical education system including widespread lack of implementation of MCI regulations, paucity of trained rheumatologists, and lack of advocacy for rheumatology with no rheumatologists on medical faculty board of education. We observed the prevalence of multifarious and diverse regional rheumatology curricula across various universities, national boards, and autonomous institutions in India. This reiterates the obligation for robust implementation strategies involving the professional health authorities in India such as MCI, Association of Physician of India, and the Indian Rheumatology Association (IRA) to fortify this specialty and design a structured and harmonized national training curriculum in rheumatology.
MSUS has been extensively used by the rheumatologists in this era of “treat to target” therapeutic approach. Training in MSUS is mandatory in the rheumatology postgraduate medical education in Germany, Italy, and Ireland. Several certified and online training courses are available such as American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) online courses. Cunnington et al. have reported that 93% of UK rheumatologists have used MSUS as a diagnostic tool and 33% performing it themselves. Our study has reflected similar responses from the UK trainees. Training exposure to MSUS was in its primitive stage in India.
The curricula across both countries promoted adequate understanding of research methodologies. Only UK trainees were involved in professional academic research programs such as MD, PhD, or MSc. Out of training program (OOP) for research was optional and encouraged only in the UK. According to the Gold guide for the specialty training, OOP could be considered for (a) clinical training beyond the trainee's specialty training program (OOPT), (b) a clinical experience beneficial to the doctor (OOPE), (c) undertaking a period of research (OOPR), and (d) planned career break (OOPC). OOP was unrecognized in the training curriculum in India which could be helpful for trainees with specialist interests or special needs.
Competency-based training programs were outlined to minimize subjectivity and create a positive learning environment between the trainers and the trainees. The Royal College of Physicians (RCPs) of UK has developed educational supervisor workshop and accreditation to meet the GMC standards and train the educators with an explicit supervision role. Similar training programs were limited in the Indian training system. There was lack of MCI recommendations to encourage and recognize the trained rheumatologist to take up the “medical teachers” role in India.
Notwithstanding the usual limitations in this type of study including a poor response rate, this study comparing the rheumatology training between the UK and India does provide some useful insights. It was observed that rheumatology training in the UK was more structured and supervised, although employment prospect was perceived better in India. A harmonized national training curriculum is essential in rheumatology. Health authorities and professional bodies in India should work in alliance to enhance the profile of rheumatology as a specialty.
We acknowledge the help and support from all the rheumatology trainees, training program directors, and the clinicians across the UK and India for participating in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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