Indian Journal of Rheumatology

EDITORIAL
Year
: 2018  |  Volume : 13  |  Issue : 4  |  Page : 217--219

Improving knowledge and awareness regarding rheumatology at the undergraduate level in Indian medical colleges


Ghan Shyam Pangtey1, Sameer Gulati2, Anu Maheshwari3,  
1 Department of Medicine, LHMC and Associated Hospitals, New Delhi, India
2 Department of Medicine, VMMC and Safdurjung Hospital, New Delhi, India
3 Department of Paediatrics, LHMC and Associated Hospitals, New Delhi, India

Correspondence Address:
Dr. Ghan Shyam Pangtey
Professor, Department of Medicine, Lady Hardinge Medical College and Associated Hospital, Room No 1002, MICU Complex, Department of Medicine, Lady Hardinge Medical College, Shaheed Bhagat Singh Marg, New Delhi - 110 001
India




How to cite this article:
Pangtey GS, Gulati S, Maheshwari A. Improving knowledge and awareness regarding rheumatology at the undergraduate level in Indian medical colleges.Indian J Rheumatol 2018;13:217-219


How to cite this URL:
Pangtey GS, Gulati S, Maheshwari A. Improving knowledge and awareness regarding rheumatology at the undergraduate level in Indian medical colleges. Indian J Rheumatol [serial online] 2018 [cited 2019 Mar 20 ];13:217-219
Available from: http://www.indianjrheumatol.com/text.asp?2018/13/4/217/244176


Full Text



The medical education and training has its presence in India since ancient times and believed to be 2000–3000 BC old. An elaborate system of training and assessment of medical students existed in those primitive eras which is well described in Samhitas of Charak and Sushruta. The medical education during that early period was imparted through Braminical or Gurukul system.[1] Pre-independence, Britisher's contributed by establishing first medical college in Kolkata and later on by constituting Medical Council of India (MCI) in 1933 on the line of Medical Council of the UK for establishing uniform standards of medical education. Medical education in India has expanded over so many years; and at present, our country has the highest number of medical colleges in the world. In the year 2017, the combined capacity of undergraduate (MBBS) student's enrolment in India reached 63,985; there were a total of 460 MCI recognized medical colleges, with the majority in the private sector domain.[2] The sale of undergraduate, as well as postgraduate seats in some private medical colleges in India for a huge sum of money, is a big blot in the face of present Indian medical system. The massive corruption in private medical seat selling, giving clearance to new medical colleges for monetary benefit and regularization of dysfunctional private medical colleges led the present government to take the extreme step of banning MCI on September 26, 2018, and replace it with the Indian Medical Council (Amendment) Ordinance, 2018.[3]

The medical colleges in India traditionally follow an MBBS curriculum which consists of a large body of knowledge about basic sciences and clinical disciplines.[4] There is no emphasis on “Core Concepts of essential learning,” the differentiation between “must learn,” “useful to learn,” and “nice to learn” leading to overburdening of students with excessive exposure of medical information. There are major deficiencies in the present curriculum, as there is minimal attention to the field of medical ethics, communication skills, psychosocial science, and managerial skills during graduation.[4] As per MCI guideline, medical colleges in India have adopted a pattern with 9 semesters of 6 months each. The Phase 1 consist of initial two semesters of preclinical subjects (anatomy, biochemistry, and physiology), followed by 3rd to 5th semester of Phase 2 or paraclinical subjects, and finally, four final semesters consisting of clinical subjects. Hitherto MCI's vision statement 2015 for MBBS recommended curricular reforms stressing on early clinical exposure and amalgamation of basic sciences with clinical medicine.[5] It is recommended that each institute makes his own curriculum committee, consisting of senior teachers of college and provide up-to-date curriculum including integrative teaching of basic sciences with clinical disciplines, but in most colleges, such committee is nonexistent or rarely updated with time. Horizontal (anatomy-physiology-biochemistry) and vertical (physiology-pathology-medicine) integration in teaching is very useful for the meaningful understanding of medical conditions and disease, but this is being followed in very few institutes only.

Rheumatology in India and Indian medical education system is a neglected branch with little-to-no emphasis on it during MBBS teaching. Musculoskeletal problems, namely low backache, neck pain, and pain due to osteoarthritis (OA), are some of the major causes of global burden of disease and a frequent reason for hospital/emergency room visits, in spite of this rheumatology is being ignored for years. Community-oriented program for control of rheumatic disease, under the aegis of the WHO-ILAR, had revealed that the most frequent “self-reported” complaint in a community is musculoskeletal pain, being prevalent in 6%–24% of Indian population.[6],[7] Inflammatory rheumatic diseases are found in < 1% of the population, but with a total Indian population being more than 1.2 billion, even 1% will amount to a significant number of patients.

Rheumatologic disease teaching during MBBS consists of few hours of theoretical didactic lectures, during 6th to 9th semesters. The students as well as teachers are least interested in rheumatology as the teaching and learning are examination oriented instead of concept making learning. During final year medicine or orthopedic examination, it is rare to get a case of common musculoskeletal disease, namely low backache or OA knee. Instead, students are allotted rare diseases such as motor neuron disease or muscular dystrophy, which they will rarely encounter or treat in future. The 1-year rotatory internship posting in clinical specialties is compulsory for all fresh passed out medical graduates. The successful internship completion requires performance of specific numbers of successful medical procedures. The procedures which need to be performed include highly technical, difficult, and risky procedures, namely liver biopsy and lumbar puncture. In contrast, none of the rheumatology procedures are required as a must for successful completion of the internship. Simple and very useful procedures such as joint aspirations, synovial fluid analysis, or intra-articular injections do not get a mention in intern's logbook, or even in MD medicine curriculum of most of the universities.[8] Even the rheumatology allied specialty postings in pediatrics and orthopedics, there is no weightage to joint aspiration or caring for a patient with arthritis during examination or internship.

There are only 2–3 reputed rheumatology centers offering subspecialty (doctorate of medicine-DM) training in India. Thus, it will not be surprising to anticipate a severe shortage of physicians/rheumatologists caring for persons suffering from musculoskeletal disorders in our country. A recent article estimates that there is one member of the Indian Rheumatology Association available for every 40,352-rheumatoid arthritis (RA) patients in our country, as against one rheumatologist for every 425 RA patients in the USA.[9],[10] Hence, another 5–6 centers have been developed to offer rheumatology training (Diplomate of National Board/Fellowship) to take care of deficit in specialists.[11] Considering a population of >1.2 billion and <10 centers of rheumatology training in our country, there is an immediate need to promote rheumatology in every medical college. Capacity building exercises should aim to make available “short term” as well as “long term” training of medical college teachers in institutes of excellence for rheumatology teaching. Once medical teachers are trained in basic rheumatology, they can better teach undergraduate students and also take good care of common rheumatological disorders at local levels. Rheumatology trained medical college teachers can also improve the referral system for better management of difficult to treat patients by taking timely consultation and transfer.

Such a “holistically” trained undergraduate will become the “first contact physician” and thus will assume an important position in India's medical services.[12] Such an endeavor will truly ensure “Health for all.”

Curricular deficits and their possible remedies have already been pointed out above. Even though MCI has suggested some reforms, rheumatology has not got a fair share of the deal. Elective courses have been proposed, but rheumatology has been left out.[5] Needless to say, that considering the magnitude of musculoskeletal problems in our communities, rheumatology should get it is due in the undergraduate curriculum. The curriculum should clearly lay down the minimum skills, attitude, and knowledge required by an undergraduate in the field of rheumatology.[13] These will comprise the core set of specific learning objectives. Global recommendations in rheumatology curriculum have been proposed, which may be adapted to Indian needs and local expertise.[13],[14]

Major emphasis should be laid to develop a curriculum which is strong enough to impart clinical skills and knowledge of commonly encountered musculoskeletal conditions.[14] A robust rheumatology undergraduate curriculum, without factual overload, should be coupled with standard and innovative teaching methods. Curricular development should be a dynamic process depending on changing scenarios and with the active participation of academicians. Some of the suggested measures to improve knowledge and awareness in rheumatology have been enumerated in [Table 1].{Table 1}

Awareness of rheumatology among undergraduate students may be promoted by celebrating “World Arthritis Day” on October 12, every year in the medical colleges all over India. Such events may incorporate interactive lectures by faculties from medicine, pediatrics, orthopedics as well as physical medical rehabilitation, thus sensitizing students to common rheumatological conditions. Poster sessions and counseling sessions may be arranged to increase awareness and interest in the subject. These occasions may also be utilized to promote rheumatology as career options among the students.

To conclude, musculoskeletal diseases are one of the major causes of morbidity in our communities. So far, rheumatology has not been given appropriate attention in the undergraduate curriculum. Thus, there is an urgent need for undergraduate curricular reforms and capacity building with respect to undergraduate medical curriculum and especially to rheumatic diseases. The failure of MCI for past so many years and the present Indian government's decision to bring National Medical Commission ordinance 2018 as well as the recent launch of “Ayushman Bharat” has brought the spotlight back to Indian health-care system and “Modicare.” Let's hope and also contribute our part to the success of this initiative for healthy prosperous India.

References

1Brief History of Medical Education in India and Karnataka. Available from: http://www.shodhganga.inflibnet.ac.in/bitstream/10603/90814/8/08_chapter4.pdf. [Last accessed on 2018 Oct 14].
2List of Medical Colleges in India – Wikipedia. Available from: https://www.en.wikipedia.org/wiki/List_of_medical_colleges_in_India. [Last accessed on 2018 Oct 14].
3Available from: https://www.thewire.in/health/the-mci-ordinance-is-stop-gap-surgery-not-the-long-term-policy-measure-the-industry-needs. [Last accessed on 2018 Oct 14].
4Sood R, Adkoli BV. Medical education in India. Probl Prospects J Indian Acad Clin Med 2000;1:210-2.
5Medical Council of India. Amended Upto; July, 2017. Available from: https://www.mciindia.org/documents/rulesAndRegulations/GME_REGULATIONS.pdf. [Last accessed on 2018 Oct 10].
6Chopra A. Disease burden of rheumatic diseases in India: COPCORD perspective. Indian J Rheumatol 2015;10:70-7.
7Chopra A. The COPCORD world of musculoskeletal pain and arthritis. Rheumatology (Oxford) 2013;52:1925-8.
8Handa R. Rheumatology in postgraduate curriculum. Indian J Rheumatol 2014;9:127-30.
9Joshi VR, Poojary VB. Cost-effective management of rheumatoid arthritis in India. Indian J Rheumatol 2013;8:179-82.
10Hogan RF, Bouchery E; The Lewin Group. Final Report on Workshop Study of Rheumatologist Prepared for the American College of Rheumatology; May, 2006.
11Misra DP, Agarwal V, Negi VS. Rheumatology in India: A bird's eye view on organization, epidemiology, training programs and publications. J Korean Med Sci 2016;31:1013-9.
12Das B. Rheumatology in undergraduate curriculum. Indian J Rheumatol 2014;9:69-72.
13Doherty M, Woolf A. Guidelines for rheumatology undergraduate core curriculum. EULAR standing committee on education and training. Ann Rheum Dis 1999;58:133-5.
14Woolf AD, Walsh NE, Akesson K. Global core recommendations for a musculoskeletal undergraduate curriculum. Ann Rheum Dis 2004;63:517-24.