|Ahead of print publication
Rheumatology teaching and training in India – From procrastination to implementation!
Department of Rheumatology, Indraprastha Apollo Hospitals, New Delhi, India
Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi - 110 076
Source of Support: None, Conflict of Interest: None
Rheumatology in India has transitioned from infancy to adolescence but is years away from maturity. There continues to be a dyssynchrony between patient numbers, that are easily humongous, and trained rheumatologists, that are visibly minuscule. Against this backdrop, Misra et al. have scientifically and systematically captured real-world information on the prevailing scenario in India. The authors have appropriately chosen to publish their results in the Journal of Physicians of India (JAPI) which is one of the most circulated biomedical journals in the country reaching out to nearly 18,000 physicians who are members of the Association of Physicians of India. This commentary is intentionally being published in the Indian Journal of Rheumatology because many of the important stakeholders in this equation, the rheumatologists, may not be routinely perusing the JAPI.
Misra et al. in their survey of 333 physicians found out that as many as 75% of physicians professed little or no exposure to rheumatology as undergraduates and only 20% perceived adequacy of training during internal medicine residency to treat such diseases confidently. This was notwithstanding the fact that rheumatic diseases were common in internal medicine practice. It is to be noted that almost 25% of the physicians surveyed were in solo practice and as many as 30% of physicians did not feel that they had a rheumatology colleague available to discuss any problems relating to patients with rheumatic diseases. The commonality of rheumatic diseases, inadequacy of exposure to the subject, and nonavailability of an expert is a “triple” not “double” whammy.
With crowded curriculums and each specialty jostling for space, why should rheumatology be singled out for special attention? The data-driven answer to this question comes from a look at the top ten causes of years lived with disability in India in 2017, which are listed in [Figure 1]. Low back pain and “other musculoskeletal (MSK) disorders” which include osteoarthritis (OA) are listed as the third and fifth most important causes of disability, respectively. It would not be out of place to highlight the indirect contribution of OA to the three most important noncommunicable diseases (NCDs) in India. According to the India State-Level Disease Burden Initiative launched in October 2015 (a collaboration between the Indian Council of Medical Research, the Public Health Foundation of India, the Institute for Health Metrics and Evaluation, and other experts), the three leading causes of mortality in India are cardiovascular disease, respiratory disease, and diabetes., This fine-grained picture sidelines one indisputable fact that OA, the most common cause of locomotor disability in the elderly, indirectly, but in no small measure, contributes to the inability to exercise, suboptimal diabetes control, and poor cardiopulmonary reserve. Effective treatments for OA can improve mobility and exercise capacity, thereby contributing to the control of killer NCDs. This fact is often blurred, submerged, and subsumed by number-crunching statistics, and this is where advocacy is vital to throw a spotlight on MSK conditions that are underrecognized, underappreciated, and underaddressed while remaining integral to the quality of life of our patients. OA and back pain are just two of the several rheumatic diseases encountered in routine medical practice!
Rheumatology is marginalized in the undergraduate and postgraduate medical curricula. This is also what emerges from the survey published in JAPI. One of the offshoots of this inadequate rheumatology training at undergraduate and postgraduate level is the knee jerk referral of all MSK complaints by physicians to orthopedic surgeons without as much as a cursory look or perfunctory examination. Public belief, physician unfamiliarity, and traditional role models play an important role in influencing the perception of all MSK disorders as orthopedic problems. Only a small fraction of these ever need surgery. Collaboration and consultation with orthopedic surgeons, physiatrists, physiotherapists, and occupation therapists is vital. However, the primary and pivotal caregiver should be the physician in the multidimensional diseases that comprise rheumatology. The idea is not to exclude orthopedic surgeons but to encourage physicians to start tackling these disorders.
A refreshing feature of the survey is that the authors have not only outlined the problems but also listed possible solutions. As I have emphasized earlier, thought leaders have to project rheumatology not as something esoteric or exotic but as something common that is needed at the community level. It is time that we shed inertia and apathy for unabashed advocacy and proactive action. It is a wake-up call for all stakeholders to adapt to the times and needs of the society with respect to rheumatic MSK disorders. Our patients expect no less and we should delay no more. It is now or never!
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Conflicts of interest
There are no conflicts of interest.
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