|Ahead of print publication
Addressing the unmet needs in medical training for alarmingly widening demand–supply gap in rheumatic diseases: A tale of two countries
Shivani Garg1, Ram Raj Singh2
1 Department of Medicine, Division of Rheumatology, The University of Wisconsin, Madison, Wisconsin, USA
2 Department of Medicine, Division of Rheumatology; Department of Pathology and Laboratory Medicine; Molecular Toxicology Interdepartmental Program; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
Ram Raj Singh,
Professor of Medicine and Pathology, Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
Source of Support: None, Conflict of Interest: None
|How to cite this URL:|
Garg S, Singh RR. Addressing the unmet needs in medical training for alarmingly widening demand–supply gap in rheumatic diseases: A tale of two countries. Indian J Rheumatol [Epub ahead of print] [cited 2019 Oct 22]. Available from: http://www.indianjrheumatol.com/preprintarticle.asp?id=266933
| Perspective on Medical Training and the Growing Rheumatic Disease Burden|| |
The first encounter with a patient with rheumatoid arthritis was during our medical school in India almost two decades apart, 1980 and 2005, and during inpatient rounds, we were informed that these diseases were rare in India and more common in the western world. As a gullible medical student, this was our first take-home message regarding rheumatic diseases. Still, the impression on rheumatic diseases in Indian medical schools has not significantly changed over the last several decades despite the fact that the researchers since the early 1990s have reported that the prevalence of rheumatic diseases in India (e.g., rheumatoid arthritis) is similar to that in the western world., Studies have shown that approximately 5–7 million Indians are living with one rheumatic disease alone, i.e., rheumatoid arthritis., Recent studies, and our experiences underscore a major deficit in Indian medical education curriculum that does not adequately address rheumatic disorders, which are among the leading causes of years lived with disability in the Global Burden of Disease (2017) study. It is anticipated that the burden of rheumatic conditions will keep growing exponentially across the world and hence, there is an urgent need to dedicate attention and resources toward early diagnosis and treatment of rheumatic and musculoskeletal conditions.
| Rheumatic and Musculoskeletal Disorders and Scope of Rheumatology in India|| |
Rheumatic or musculoskeletal conditions comprise over 150 diseases and syndromes, which are usually chronic, progressive, and associated with pain and disability. They can broadly be categorized as immune-mediated inflammatory arthritis and connective tissue diseases, degenerative, infectious and metabolic causes of arthritis, regional musculoskeletal disorders, and musculoskeletal pain. A recent World Health Organization (WHO) study reported that rheumatic and musculoskeletal diseases are the 2nd largest cause of disability in the world with a striking increase of 45% over the past two decades.
India is the second-most populous country in the world with a population of 1.35 billion people. In 1993, the first probable point prevalence of rheumatoid arthritis and lupus, based on population surveys, was reported to be 0.75% and 0.032%, respectively., Two population survey-based registries have been established in India since then, including the WHO International League of Associations for Rheumatology Community-Oriented Program for the control of rheumatic diseases Bhigwan (1996–2014) and bone and joint decade India. These registries together have surveyed more than 50,000 people since 1996 over 12 sites in India. These registries together reported that the prevalence of rheumatic and musculoskeletal diseases in India ranges from 6% to 24%, with an estimated 80–300 million Indians living with rheumatic diseases.,,, These studies highlight that osteoarthritis, a degenerative joint disease which leads to pain and disability, is one of the leading rheumatic diseases in India, followed by soft-tissue rheumatism [Table 1]. Chopra underscores that even though the prevalence of life-threatening inflammatory diseases, rheumatoid arthritis, and lupus, is relatively lower, yet the number of patients living with these diseases in India is strikingly significant, 0.3–5 million.,,, Moreover, patients with these diseases require frequent clinic and hospital visits and incur high societal burden and mortality.,,,
|Table 1: Standardized prevalence and estimated number of patients living with rheumatic diseases in Bone and Joint Decade India Community-Oriented Program for Control of Rheumatic Diseases (n=56,541) and Community-Oriented Program for Control of Rheumatic Diseases Bhigwan (n=4092) surveys|
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| The Demand and Supply Mismatch in India|| |
Despite the growing need, there are <1300 practicing rheumatologists in India, with 1 rheumatologist available for more than 0.5 million arthritis patients., The limited number of rheumatologists, lack of tools to effectively assess the competency of local providers in rheumatic diseases, and lack of partnership with government agencies to increase awareness about rheumatic diseases have been cited as important reasons underlying delayed diagnosis and treatment of these diseases in India and other developing countries. Further, researchers highlight that untreated or delay in the treatment of rheumatic diseases results in limited functionality and early disability leading to economic loss, increased need for expensive surgical procedures, for example, arthroplasty and early death.
There are <10 centers of excellence providing rheumatology fellowship training with 20 training positions offered every year. A recent survey assessed the confidence of practicing physicians in diagnosing and managing rheumatic diseases as well as their current perception of the adequacy of training and exposure to rheumatic diseases in undergraduate (UG) and postgraduate (PG) medical education in India. The findings of this study were remarkable, as >75% of 333 physicians in the survey reported inadequate exposure or training in rheumatic diseases during UG training. Further, 99% of the respondents felt a need for more exposure and training in rheumatic diseases during UG and PG training. This study and others have highlighted the current gaps that have led to unmet rheumatic disease needs, including a lack of exposure, poor planning of medical education, and inadequate curriculum reforms., These all have contributed to a lack of interest in rheumatology as a career option among medical students in India.
| Increasing Demand for Rheumatic Disease Care and Gaps in Addressing the Need in the U.S.|| |
The National Health Interview Survey conducted from 2003 to 2005 found more than 21% of U.S. adults (46.4 million persons) to have self-reported doctor-diagnosed arthritis, including 19 million people living with functional limitations and disability. Even more worrisome is the projection that the number of persons with doctor-diagnosed arthritis will increase by ~40% to nearly 67 million by 2030; approximately 10% of the population will be living with functional limitations. Similarly, researchers have found indisputable evidence of a significant increase in other rheumatic and musculoskeletal diseases that will occur over the next decade in the U.S., thus underscoring the growing health-care needs of patients suffering from these diseases.
The American College of Rheumatology Workforce Study estimated the total number of adult rheumatology care providers in 2015 to be just over 6000 in the U.S., including 5595 adult rheumatologists, 248 nurse practitioners, and 207 physician assistants. This workforce supply of about 1.7 rheumatologists per 100,000 patients with rheumatic diseases was deemed short by 700 rheumatologists (12.9%) based on the estimated demand. Although there has been a significant increase in rheumatic diseases burden, there has been a decline in the growth of rheumatology taskforce by 25.2% from 2015 to 2018. This is probably because of subspecialty income disparity, increases in student debt, and high burnout in rheumatologists. By 2030, the demand of rheumatology workforce is anticipated to exceed the supply by 102%., The situation is worse in rural sectors of the U.S., with populations over 200,000 people, where there are no practicing rheumatologists within 200 miles distance. In addition, there is a regional maldistribution of rheumatologists in the U.S., with 50% less rheumatologists in the southwest part of the country in comparison to other regions. Due to these gaps, the current wait times to be seen in specialty clinics ranges from 60 to 120 days. These long wait times can significantly delay diagnosis and treatment thereby leading to worse clinical outcomes, irreversible damage, and premature death in patients with rheumatic diseases.
| Addressing the Unmet Need in Medical Education and Reducing the Demand–supply Gap in the U.S.|| |
In the next 15 years, it is estimated that 4000 more rheumatologists will be required to target closure of this gap in the U.S. The current U.S., graduate medical education (GME) training structure and available fellowship positions are not enough to meet the rapidly increasing demand. As a preventive step, the American College of Rheumatology and the Rheumatology Research Foundation have initiated several measures, including rheumatic disease awareness programs, institutional grants to training programs to provide salary support to rheumatology fellows, individual fellowship and career development awards to support rheumatology trainees interested in pursuing research career from their 2nd year of training up to the first 4–5 years of faculty appointment, preceptorship awards to internal medicine and pediatrics residents and medical and graduate students for a few weeks of dedicated rheumatic disease research or clinical exposure, and scholarships and student achievement awards to residents and students to attend annual meeting of the American College of Rheumatology (https://www.rheumresearch.org/awards-grants). These efforts might have begun to have some positive effects. From 2008 to 2013, the total number of annual rheumatology fellowship applicants in the U.S. decreased from 251 to 244 applicants, a 3% decrease. However, from 2014 to 2017, annual rheumatology applications increased from 230 to 332 applicants, a 44% increase. Other nonprocedural and procedural internal medicine subspecialties did not exhibit a similar increase. There are also efforts to increase fellowship positions. For the 2019 appointment year, there were 236 rheumatology fellowship positions available, up from 221 positions available in 2018. However, this pace of increase in fellowship positions is still likely to fall short of the increasing demand for rheumatology workforce in the future.
Major efforts have been invested by most institutes in the U.S., to undertake a curriculum redesign where instead of teaching rheumatic diseases to medical students in a 15-h crammed course over 2 days, educators have started teaching rheumatology over a course of 6 weeks. Another important measure being utilized by educators is to use the flipped classroom approach and clinicopathological conferences (CPC). These virtual live classrooms are believed to help to invigorate interest and enhance learning. Other measures include starting rotations in rheumatology clinics right from the beginning of medical school, which generates real-life experiences and tailors education based on students' needs and interests. Finally, providing objective information to lecturers can help in creating customized lectures that increase learning at all training levels., Such approaches generate not only in-depth knowledge about rheumatic diseases but also invoke interest in pursuing rheumatology as a career. Other future strategies to target the impending rheumatic disease workforce crisis include telemedicine, increasing nurse practitioner and physician-assistant training in rheumatology, outreach clinics, and balancing work environments to reduce rheumatologist burnout.
| Applicable Innovative Ideas to Reform Current Rheumatology Training in India|| |
As India is embarking on the most ambitious national health protection scheme, called Ayushman Bharat, it becomes imperative to carefully assess the disease burden as well as health needs of the population, and accordingly, reassess and redesign the current medical education curriculum of UG and PG training courses., With regard to rheumatology, currently <5% of all medical schools in India have a rheumatologist, with mere ten rheumatology departments or sections. Consequently, most medical schools have none to 1 or 2 lectures on rheumatic diseases during UG, thus aspiring physicians get minimum exposure to clinical rheumatology [Figure 1]a and [Figure 2]a. Other gaps in medical education include lack of government-supported efforts to change curriculum and to increase the representation of rheumatic diseases in medical teaching and examinations [Figure 1]a. Hence, it is necessary to introduce education methods such as early clinical exposure, tailored education based on the students' interests, and live classroom approaches using CPCs that challenge students to think beyond textbooks to instead witness real-life game-changer experiences [Figure 1]b.,, The traditional hierarchical classroom model that places educators and administrators on the top and learners on the bottom is becoming untenable with the expanding scope of medical education. In its place, a flat and flipped classroom approaches, as illustrated in [Figure 1]b, are more likely to enhance student engagement and learning.,
|Figure 1: The current gaps in medical education and training, and recommendations to address the unmet need. (a) Illustrates the current gaps in medical education leading to unmet needs of the increasing demand of rheumatic diseases. (b) Highlights initial steps or strategies to address current gaps, and (c) highlights other strategies to improve rheumatology (rheum) training which will further address the unmet needs|
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|Figure 2: Traditional and flipped classroom models. (a) Illustrates the current traditional teaching model for rheumatic diseases in Indian medical education with some emphasis on in-class teaching, (b) represents the flipped classroom model with emphasis at each step of learning and with equal contribution from students and teachers to generate interest, increase awareness, and overall improve the competency of aspiring physicians to diagnose and treat rheumatic diseases|
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The flat and flipped classroom approaches initiate a collaborative effort between teachers and students toward objective-driven learning that enhances all the requisite traits of an aspiring physician, including engagement in problem-solving, curiosity, critical thinking, and teamwork [Figure 2]b., Such experiences will heighten interest and improve understanding of rheumatic diseases, thereby attracting more students to consider advanced training in rheumatology. Other approaches that could be helpful include establishing a national core curriculum to train nurse practitioners and physician assistants in rheumatology and organizing continuing medical education workshops in rheumatology [Figure 1]c. Finally, rheumatological procedures should be taught during internships, for example, steroid injections in joints to temporarily alleviate pain and disability from osteoarthritis, and aspiration and microscopic examination of joint fluid to diagnose gout and infective arthritis [Figure 1]c. These experiences during UG and PG courses will be vital in enhancing the competency of young physicians in early diagnosis and providing care to patients with rheumatic disease, who might be the first-contact providers for these patients. Continuation of this training during PG in internal medicine and pediatrics with an emphasis on individual rheumatic disease recognition and basic principles of treatment including physical therapy and rehabilitation techniques would not only increase the overall proficiency of aspiring physicians in identifying and treating rheumatic diseases, but also increase their interest to pursue future training in rheumatology.
| Conclusion|| |
Rheumatic or musculoskeletal conditions comprise over 150 diseases and syndromes, which are leading causes of morbidity and disability, giving rise to loss of work and income, and enormous health-care expenditures. For one rheumatic disease alone, there are estimated about 5 million patients with rheumatoid arthritis in India who need to be seen 2–5 times a year from a relatively young age until death. Over 3000 physicians with expertise in rheumatic diseases are needed to care for patients with one rheumatic disease alone. Currently, there are only 1,308 physician members of the Indian Rheumatology Association. The lack of tools to recognize and treat these diseases might underlie the apathy in rheumatology training until now. With remarkable advances in the management of these diseases over the past two decades, it is now imperative to develop a national policy to promote rheumatic disease education and training. The uniquely multisystem nature of rheumatic diseases, as well as availability of new molecular scalpels to treat these diseases, require specialized, yet broad-based, training in basic science and clinical medicine. The urgent need to dramatically increase rheumatology workforce will require a multipronged approach that may involve curriculum redesign in UG and PG medical education, use of innovative classroom models, awareness campaigns by rheumatology associations, partnership with medical college principals and deans, funding to attract and recruit trainees, and resources at the state and national level. We enjoin the medical students and residents that it is an exciting time to train in rheumatic diseases.
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