|Ahead of print publication
Rheumatology practice and training in India – A perspective from rheumatology consultants
Durga Prasanna Misra1, Vinod Ravindran2, Aman Sharma3, Anupam Wakhlu4, Vir Singh Negi5, Ved Chaturvedi6, Vikas Agarwal1
1 Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Centre for Rheumatology, Calicut, Kerala, India
3 Department of Internal Medicine, Clinical Immunology and Rheumatology Services, Postgraduate Institute of Medical Education and Research, Chandigarh, India
4 Department of Rheumatology, King George's Medical University, Lucknow, Uttar Pradesh, India
5 Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
6 Department of Rheumatology and Clinical Immunology, Ganga Ram Institute for Postgraduate Medical Education and Research, Sir Ganga Ram Hospital, New Delhi, India
Durga Prasanna Misra,
Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: We surveyed rheumatology consultants regarding their perceptions about rheumatology practice and training in India.
Materials and Methods: A structured questionnaire was administered during two national rheumatology meetings to evaluate practice settings and demographic characteristics of patients seen. We also assessed perceptions regarding junior doctors, auxiliary health professionals (AHPs), ancillary facilities (daycare, intra-articular injections, musculoskeletal ultrasound [MSKUS]), and possible government-driven strategies for improving rheumatology care delivery.
Results: The response rate was 56% (70/125); 68 complete responses were further analyzed. Most respondents were in the private sector (56/68), had been in practice for a mean of 11.5 (±8.4) years, attended to a mean of 150 (±91) patients every week, a majority of whom were educated upto intermediate level and belonged to the middle class. About 60% had junior doctors to assist them in care delivery; 82.5% (52/63) felt that junior doctors had limited competence in managing rheumatic diseases. More than 90% felt the need for AHPs in the clinic, although less than one-half had access to such personnel. Most utilized ancillary services like intra-articular injections (97%), daycare facilities for infusions (92%), and MSKUS (71%). More than 90% respondents felt that government-funded programs for the management of rheumatic diseases, coupled with a structured referral system, would be useful.
Conclusion: Rheumatology practice in India may improve by better training junior doctors in skills related to rheumatology at the undergraduate and postgraduate internal medicine levels. The development of specialist AHPs may help enhance service delivery. Government programs for community management of rheumatic diseases and management guidelines suited to the needs of a developing economy majorly reliant on out-of-pocket expenditure for healthcare are significant areas for development.
Keywords: Auxiliary health professionals, nurses, physical therapists, rheumatology education, rheumatology organization and administration, rheumatology practice
|How to cite this URL:|
Misra DP, Ravindran V, Sharma A, Wakhlu A, Negi VS, Chaturvedi V, Agarwal V. Rheumatology practice and training in India – A perspective from rheumatology consultants. Indian J Rheumatol [Epub ahead of print] [cited 2020 Jun 2]. Available from: http://www.indianjrheumatol.com/preprintarticle.asp?id=284249
| Introduction|| |
Musculoskeletal disorders are prevalent in 15%–20% of the Indian population. These are a cause of significant morbidity and mortality. As emphasized from the subanalysis of data from India available from the recent Global Burden of Diseases survey, low back and neck pain (ranked 12th) and other musculoskeletal complaints (ranked 19th) are major causes of disability-adjusted life years (DALYs) in India. From 1990 to 2016, there has been a two-thirds increase in the DALYs due to low back and neck pain. Correspondingly, DALYs due to other musculoskeletal complaints have registered an 80% increment during this period in India. Formal training courses in the specialty did not begin until the late 1980s. Of late, the number of sub-specialists as well as training posts in this specialty, has registered a significant increase. However, little information is available regarding the ground realities governing the practice of rheumatology in India.
The number of rheumatologists available in India is limited. As per estimates, there are 209,000 patients with rheumatic complaints per rheumatologist in the country. In the Western world, rheumatology practice relies not only on the treating doctor but also on a team of auxiliary health professionals (AHP). Such AHPs include specialist nurses, physiotherapists, occupational therapists (OT), psychologists, and others. Such a multidisciplinary approach often helps in imparting comprehensive patient care, rather than just providing a medication dispensing service. In general, the concept of AHPs is not well developed in most medical specialties in India, where the role of personnel such as nurse specialists is just being understood. Considering the aforementioned burden of rheumatic diseases in the community, AHPs represent a untapped source of workforce that can share the healthcare responsibilities of Rheumatologists in India. Apart from routine outpatient and indoor facilities, rheumatology care also requires supporting services, such as daycare facilities and intra-articular injections. To assess the practical considerations in rheumatology practice in India, we conducted a survey of rheumatology consultants to identify their perceptions regarding the practice settings and supporting facilities available to them, including various AHPs. The results of such a survey might serve as a baseline assessment to help guide future policies with regards to the improvement of existing and development of future rheumatology healthcare facilities in the country.
| Materials and Methods|| |
We surveyed rheumatology consultants at two national rheumatology meetings in July 2018 and March 2019, held at Kochi and New Delhi, respectively. A questionnaire was devised; face and content validity of this questionnaire were assessed by the investigators who are also subject experts. The questionnaire attempted to assess practice settings, number of patients seen weekly, the perceived educational status and socioeconomic strata of the patients seen in the clinic, and the average amount of time required to assess patients in the clinic, separately for the first visit and subsequent follow-up visits. We also enquired regarding junior doctors (if any) assisting the rheumatology consultant in the clinic and their felt competence in dealing with rheumatic diseases. Information was also gathered regarding the utilization and perceived need of AHPs (nurse specialists, physiotherapists, OT, psychologists) in the rheumatology clinic. We also attempted to gauge the utilization and perceptions regarding clinic facilities such as daycare for infusions, intra-articular injections, and musculoskeletal ultrasound (MSKUS), as well as their perceptions regarding a structured referral system and government-funded health-care programs for rheumatic diseases. Open-ended questions also assessed the opinion regarding the improvement of existing rheumatology training in India and the various ways nurse specialists could be optimally utilized in the Indian scenario. The full questionnaire is provided as [Supplementary Table 1].
Survey results were anonymized before data entry and further analysis. Wherever complete responses were not available, this has been mentioned while presenting the results. The results are presented in a descriptive manner. Intergroup comparisons were not considered a suitable strategy due to the small number of subjects. Considering that this was a survey of educational practices, exemption from full ethics committee review was obtained from the Institute Ethics Committee, SGPGIMS, Lucknow (2018-62-IP-EXP). The survey was administered by paper forms.
| Results|| |
One hundred and twenty-five questionnaires were distributed, of which we received 70 responses (56% response rate). Of these, two were excluded, one due to incomplete responses to most questions, and the other because the respondent was a rheumatology assistant doctor rather than a consultant. The remaining 68 responses were analyzed.
The respondents had been in practice for a mean (± standard deviation or SD) of 11.5 (±8.4) years (range 1–-35 years; 65 responses). Twenty-one practiced in government settings and 56 in private setups; 9 practiced in both settings. They attended a mean (± SD) of 150 (±91) patients every week (64 responses). Patients attending the rheumatology clinic were most commonly educated up to intermediate (34/68) or graduate level (24/68). Most of the patients belonged to the middle class (46/68) [Figure 1]. Nearly one-half spent 10–20 min during a first encounter with the rheumatology patient in the clinic. A follow-up visit required 5–10 min for 60.3% of the surveyees [Figure 2].
|Figure 1: Average educational status (a) and socio-economic status (b) of patients seen in the Rheumatology clinic (68 total responses for each)|
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|Figure 2: Average time required per patient encounter for new and follow-up patients (68 responses for each category)|
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Forty-one respondents did not have junior doctors to assist them in the clinic. Of the remaining 27, 13 had junior doctors who had only a basic undergraduate medical degree, 17 were assisted by junior doctors who were internal medicine postgraduate degree holders, and two were assisted by junior doctors who had already completed specialty training in rheumatology. There were 63 responses to the question regarding the felt competence of junior doctors in managing rheumatic diseases. A majority felt that such competence was either minimal (30/63) or enough to distinguish different diseases (22/63). Only a minority felt that junior doctors were able to manage rheumatic diseases either confidently (6/63) or not at all (5/63) [Figure 3]. The surveyees felt that existing rheumatology training (apart from formal 3-year specialty training) could be supported by short term training courses, enhancement of coverage of rheumatology in the undergraduate and postgraduate internal medicine curricula, focused workshops and continuing medical education programs [Table 1].
|Figure 3: Felt competence of junior doctors in managing patients with rheumatic diseases (63 responses)|
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|Table 1: Improvement of existing rheumatology training apart from the prevalent 3-year DM/DNB programs as perceived by the surveyed consultants|
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More than 90% of respondents felt the need for nurse specialists, physiotherapists, and OTs in the rheumatology clinic, and 84% perceived the need for a psychologist. However, less than one-half actually had specialist nurses, 71% had a physiotherapist, a third had access to an OT, and only one-fourth had access to a psychologist [Figure 4]. More than 90% of respondents felt the need for and had access to facilities for intra-articular injections and daycare facilities for infusions. Nearly 71% had access to MSKUS facilities, whereas 82% felt the need for such a service in the rheumatology clinic [Figure 5]. The surveyed consultants felt that nurse specialists could be utilized to help with counseling, disease assessment, record keeping, and supplement patient care in the rheumatology clinic [Table 2].
|Figure 4: Utilization and perceived need for auxiliary healthcare professionals in the Rheumatology clinic. Numbers above each bar reflect the number of responses|
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|Figure 5: Utilization and perceived need for specialized facilities in the Rheumatology clinic. Numbers above each bar reflect the number of responses|
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|Table 2: Roles that can be fulfilled by nurse specialists in the rheumatology clinic as perceived by the surveyed consultants|
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A majority of respondents (61/67) felt that a referral system for patients from primary to secondary and then tertiary care would be helpful. However, some of them noted that the prevalent health-care system in India, where patients can walk into the clinic of a healthcare provider at any level of care, might hinder the functioning of such a system. Most of the surveyed consultants (62/67) felt that government-funded programs for rheumatic diseases would be useful in the Indian scenario. Only fourteen of the 68 respondents professed that they had a structured program for the rehabilitation of patients with rheumatic diseases with deformities. Of the remaining 54, 50 (92.6%) perceived the need for such a rehabilitation program.
| Discussion|| |
Our survey of rheumatology consultants provided a glimpse of the ground realities of rheumatology practice in India. The information from this survey complements that provided by another survey of internal medicine specialists regarding their perceptions of rheumatology practice and training in India. The present survey provided insights into practice settings, AHPs in rheumatology practice in India, the felt need for structured community management and government-funded programs for the management of rheumatic diseases, and knowledge dissemination and training in rheumatology. We shall individually discuss these four themes.
Most of the surveyed rheumatology consultants practiced in the private sector. Most of their patients belonged to the middle class. More than a third practiced without junior doctors to assist them. These findings are in line with the general situation of the healthcare sector in India. The private sector is the major provider of healthcare as of today to most Indians, and a majority of the consumers of healthcare comprise a middle-class population. Issues such as accessibility to healthcare remain significant. The use of health insurance is sparse in Indian settings, and out-of-pocket expenditure remains a major source of funds utilized for imparting healthcare.,,, This is particularly important with respect to rheumatic diseases, many of which are chronic, lifelong illnesses. Thus, sustaining one's treatment for long simply based on out-of-pocket expenditure remains a challenge, even for those with a steady source of income. This problem is amplified when costlier drugs such as biologic disease-modifying antirheumatic drugs (DMARDs) or small molecules are indicated for the treatment of the individual patient. Sustenance on such drugs or treatment as per prescribed protocols based on international norms becomes difficult. Thus, there remains an unmet need to institute evidence-based guidelines for the management of rheumatic diseases in a cost-effective manner for the Indian scenario. Greater input from the government regarding healthcare is also needed, as shall be discussed in detail subsequently.
Our survey also revealed that most of the respondents utilized ancillary facilities such as intra-articular injections and daycare facilities for administering infusions in their practice. More than three-fourth of respondents also felt the need for dedicated facilities for MSKUS in their practice. MSKUS is rapidly gaining traction among rheumatologists, predominantly as an extension of clinical examination, as well as a guide for intra-articular injections., Speaking from personal knowledge, the national rheumatology society has been conducting workshops for MSKUS at the annual conference for a few years now, and this might have enabled the growth in popularity of this useful tool among Indian Rheumatologists.
Auxiliary health professionals
An important finding from our survey was that while most of the surveyees felt the need for AHPs such as nurse specialists, physiotherapists, OTs, and psychologists, a vast majority did not have access to such AHPs. Conventionally, the healthcare system in India has been driven by doctors. This is quite in contrast to systems operational in the West, where AHPs share a significant proportion of patient care responsibilities. This is even more true in the case of rheumatology.
We tried to assess the perspectives of practicing rheumatology consultants regarding roles that could be handled by a nurse specialist. Guidelines already exist for the various roles a nurse specialist could perform in the management of an inflammatory arthritis such as rheumatoid arthritis. Apart from those roles brought out by our survey, nurse specialists could also help in counseling about psychosocial issues in the management of chronic diseases, as well as impart self-management skills to the patients. In countries such as the United Kingdom, nurse specialists often lead rheumatology clinics, and such nurse-led clinics have been found to be cost-effective in imparting comprehensive rheumatology care.,, An important issue identified by the European League against Rheumatism (EULAR) guidelines relates to adequate training for specialist nurses, as well as the imparting of ongoing training to help them keep up to date with contemporary practices. While such training is available at places where specialist nurses are the norm in healthcare, such as the United States of America, these facilities are not widely prevalent in India presently. The lack of such training facilities would represent a challenge to bring in nurse specialists into the existing rheumatology care system in India. The national association may like to consider training a few interested nurses from facilities outside India to become Rheumatology specialist nurses, who can then possibly impart such skills to eventually develop a wider network of specialist nurses in India.
Physiotherapy refers to the prescription of appropriate exercises to the affected joint or muscle groups, keeping in mind the functional abilities of the patient and the disease activity state. Too much or too little exercise are equally deleterious, hence the need for a physiotherapist who can take into cognizance the nuances of appropriate physiotherapy for a particular patient in the existing clinical context. Some ways in which such prescription could be imparted is through specific exercises, heat or cold application, mobilization, and energy conservation. Occupational therapy refers to the evaluation of the home and works environment of the patient and the dispensation of advice or orthotic devices such as splints to enable the patient to resume either independent functioning at home, or enable them to continue working and remaining productive.,, A large randomized controlled trial evaluated the role of occupational therapy in patients with rheumatoid arthritis within 2 ½ years of diagnosis in more than 300 subjects, and found that while the intervention of occupational therapy enabled better self-management, overall health status did not significantly improve. The latter might have been due to the fact that these patients had early disease, and were not necessarily significantly disabled, as one would expect with a longer disease duration. Systematic reviews have suggested the possible benefit of occupational therapeutic interventions in preserving the ability of patients with rheumatoid arthritis to continue working. Our survey identified the felt need for physiotherapists and OTs able to deal with musculoskeletal problems in the rheumatology clinic. While physiotherapists and OTs are widely available in the community, it is unclear how many of them may be appropriately trained to deal with musculoskeletal problems. Although such literature is not available from India, a study from the United Kingdom revealed lacunae in the training of physiotherapists, OTs, and specialist nurses in dealing with rheumatic problems. This may be another area where appropriate training programs need to be established in India so that OTs and physiotherapists are adequately trained to deal with musculoskeletal problems. Soft tissue rheumatism comprises a major proportion of musculoskeletal complaints in the community; trained physiotherapists and OTs could easily manage most such patients. Psychologists were another felt need by a majority of respondents. The psychological burden associated with rheumatic diseases bears similarities with other chronic illnesses; hence, training workforce in this regard specifically for the challenges related to rheumatic diseases may not be as much as in the case of specialist nurses, OTs, and physiotherapists.
Structured programs for community-based management of rheumatic diseases
More than 90% of the surveyed Rheumatology consultants felt that a structured referral system, from primary to secondary and then tertiary care might be useful. A similar proportion also recognized the potential utility of government-sponsored programs for the community-based management of rheumatic diseases. As of today, such government programs exist for non-communicable diseases such as cardiovascular diseases and mental health. Considering the fact that rheumatic diseases affect nearly one-fifth of the populace, such a program for rheumatic diseases may also have public health relevance.
For the success of such community outreach for the management of rheumatic diseases, probably a strengthening of the teaching of Rheumatology during undergraduate medical training, and a greater emphasis on joint examination and rehabilitation for postgraduate internal medicine trainees may be necessary. This may be more useful in enabling access to basic rheumatology services for common diseases such as osteoarthritis, soft-tissue rheumatism, gout, rheumatoid arthritis and spondyloarthritis to the most remote corners of the country. Establishment of government programs may enable wider access to commonly used drugs in Rheumatology for a majority of patients, akin to the National List of Essential Medicines in Thailand which also contains certain DMARDs. Community-based management of rheumatic diseases could also utilize trained nurse specialists to impart basic rheumatology care, rather than relying on medical doctors alone. Rheumatology may learn from systems that are already in place for imparting basic community maternal and child health services through Anganwadi workers, auxiliary nurse midwives, and accredited social health activists. Lessons already documented from experience in delivering healthcare via community workers, such as associated costs and the need for appropriate training as well as dedicated management protocols, may help guide better the community-based management of rheumatic diseases., Our survey also identified a perceived need for structured programs for rehabilitation of patients with deformities. Such programs may utilize appropriately trained physiotherapists and OT, suitably sensitized to the unique considerations while managing patients with rheumatic diseases, as discussed subsequently. Another unexplored resource to enhance community outreach for the management of rheumatic diseases may be to train specialists in Ayurveda, Homeopathy, and other complementary and alternative forms of medicine to diagnose common rheumatic diseases, since a wide network of such specialists already exists in the country.
Perspectives on rheumatology training
Nearly two-thirds of the respondents had junior physicians to assist them; most felt a lacuna in the abilities of junior doctors to diagnose and treat rheumatic diseases. This is in line with another related survey of internists regarding Rheumatology education in India that we had recently conducted, where a majority of respondents felt a deficit in existing Rheumatology exposure at the undergraduate and postgraduate internal medicine training levels. Limited outreach of Rheumatology services in India has already been documented in recent publications., The existing system of training DM and DNB subspecialists in Rheumatology is constrained by its ability to add only few Rheumatology sub-specialists every year, insufficient to manage the increasing quantum of patients with musculoskeletal complaints in the community. Another practical problem that the authors could identify while discussing the findings of the survey with other experts in the specialty was that such sub-specialists are likely to pool at existing cities or large townships where there may already be a significant number of Rheumatologists available, rather than spread out into the community. Therefore, a more pragmatic solution might be to train internists from established internal medicine departments at medical colleges and district hospitals, or for internists practicing in private sector settings with teaching capabilities. This may enable the internists to teach about Rheumatology to pass on this information and skill to their trainees. These may be short term 3–6 monthly courses, or longer-term 1–2-year ones, imparted at centers already imparting DM/DNB training courses in Rheumatology. Similar short-term bridge training for Rheumatology already exist in other countries such as Ukraine, possible only because of the greater emphasis towards Rheumatology during undergraduate and postgraduate internal medicine training. This shall enable such trained internists to establish Rheumatology clinics at their medical colleges or hospitals, manage common rheumatic problems such as soft-tissue rheumatism, uncomplicated rheumatoid arthritis, osteoarthritis, gout and spondyloarthritis, while referring more complicated cases, multisystem connective tissue disorders or vasculitis to specialist centers already existing in the country. This may aid the decongestion of already overburdened Rheumatology training centers, and help better utilize their skill in managing complex diseases. To-and-fro referral shall enhance overall competence in managing complex rheumatic diseases over time.
Other suggestions received from our surveyees identified that existing Rheumatology consultants might benefit from focused skill-development workshops, such as those related to MSKUS and advanced imaging techniques. Some respondents also suggested the development of exchange programs amongst existing Rheumatology training centers to increase the diversity of exposure to different rheumatic conditions across the country. Similar exchange programs already exist elsewhere, such as the American College of Rheumatology – EULAR exchange program, enabling fellows from these two continents to obtain a wider range of exposure in Rheumatology. The Indian Rheumatology community may consider developing such exchange programs across the country, or across other Asian countries under the aegis of the Asia-Pacific League of Nations for Rheumatology.
Strengths and limitations
Our survey had limitations. The response rate was a little lesser than 60%; however, this is considered as a reasonable response rate. The sample size of 68 respondents was relatively small; however, Rheumatology is an emerging specialty in India, and the surveyed respondents represented about 5% of the country's Rheumatology workforce. The strengths of our survey lie in the paucity of prior published information regarding Rheumatology practice settings in the country.
| Conclusion|| |
Our survey provided an overview of Rheumatology service delivery in the country today. There is a significant contribution toward such service delivery from the private sector. Public-private partnerships, as well as training of internists at medical colleges and teaching hospitals across the country (whether government or private), augmented by the improvement of Rheumatology curriculum in the undergraduate and postgraduate medical studies, may help enhance the access to Rheumatology care across the country. There is a great potential for enhancing existing Rheumatology services by imparting appropriate training to develop specialist nurses, physiotherapists, OT and psychologists dedicated to the specialty. Community-based musculoskeletal medical care and rehabilitation services may be enhanced by government-funded programs for the control of rheumatic diseases, as already exist for other non-communicable diseases. The results of our survey may provide a fertile soil to enable the further maturation of Rheumatology service delivery in the country.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]