The number of rheumatologists practicing in India is
too less and strikingly inadequate to meet the health
and medical care requirements of the community.
Millions of population suffers from musculoskeletal
(MSK) pain and rheumatic disorders. MSK is the leading
cause of disability, loss of productivity and poor quality
of life. MSK issues have become more important in view
of increased longevity. Several MSK disorders need highly
specialized rheumatology attention and care. Inflammatory
rheumatism (arthritis) is a leading cause of premature
atherosclerosis, cardiovascular disease (including ischemic
heart disease) and osteoporosis. Rheumatoid arthritis
is an important cause of premature death.
These disorders remain woefully neglected both by the
medical and health care fraternity and community at
large. Though a universal phenomenon, the situation
in the developing World is terrible. And India is no
exception. Though the Indian Government has launched
major national health care programs for non-communicable
diseases, rural health mission and women and elderly
health, there is no inclusion of rheumatic disorders.
Rheumatic disorders dominate community ailments. Women
and elderly suffer the most. Rheumatic and MSK pains
have a profound effect on quality of life and productivity.
All this has been nicely demonstrated by the WHO COPCORD
(community oriented program for control of rheumatic
diseases) for over 4 decades. India has completed one
of the most extensive COPCORD population programs in
the World and details are available at www.rheumatologyindia.org
Rheumatology is a sub served and poorly recognized
specialty in the Indian context. The exposure to MSK
medicine and rheumatology is unsatisfactory both at
the undergraduate and postgraduate (medicine) level.
Prime Government organizations and departments like
ICMR, MCI, Medical Colleges, and Universities provide
scant recognition or an opportunity to train in rheumatology.
MCI does not provide enough recognition to rheumatology
as a stand-alone specialty and there is often an overlap
with immunology and allergy medicine in its policies.
None of the medical universities in India serve national
rheumatology interest. Several premier clinical institutions
and medical colleges do not have a full fledged department
of rheumatology and have not been able to prevail over
the Government to obtain recognition for rheumatology.
There are no rheumatologists in the Central Government
or State Government health care and research sector.
It is easy to spot the few well known and recognized
rheumatology centers with long track records of clinical
service and training-Lucknow, Chandigarh, Mumbai, Chennai,
Delhi, Kolkatta, Hyderabad and Vellore. There are a
few more in Bangalore, Coimbatore and Pune that have
achieved some seniority and merit. Several centers in
public and Government setup have been recently set up
in Jaipur, Pondicherry, Bangalore, Ahmedabad, Trivandrum,
Ludhiana, Guwahati, Dibrugarh, Jammu, Patna and few
more places by newly trained rheumatologists.
The Indian Rheumatology Association (IRA)is in the forefront
to promote rheumatology and meet the challenges of rheumatology
practice in India. However, it has no policy on training
rheumatologists. The truth is that amongst the several
hundred in the association, there are less than 350
dedicated full time rheumatologists. A prime function
of the IRA is to obtain better recognition of the specialty
and accord suitable training and education but not much
has been achieved in this regard over the years.
There are far too few MCI recognized seats (DM and DNB)
available to train rheumatologists for this one billion
plus population. Recent shared experience of several
senior rheumatologists has shown that there is an increasing
interest amongst young post graduates to train in rheumatology.
Hundreds of bright inspired young post graduates apply
for the few rheumatology seats and when rejected (extremely
likely in the current scenario) are frustrated and resort
to other PG avenues. In several instances, immunology
has been loaded onto rheumatology which though clinically
useful to a certain extent is awfully burdensome from
a theory and training perspective, and also in the long
run has limited application in the community practice
of rheumatology. In addition, the rheumatology training
period of three years is much prolonged and may suffice
for academia and or research. A lesser period may suffice
for clinical rheumatology practice.
It may be important to remember that unlike many other
medical specialties rheumatology essentially depends
upon intensive clinical approach and tools to diagnose
and monitor serious disorders. Any internist keen to
pursue rheumatology would be expected to be have acquired
adequate basic clinical knowledge during the post graduate
training and should be able to seamlessly further clinical
skills required for practice of rheumatology and in
particular management of serious multisystem rheumatology
The Need and Core Proposal:
There is dire need to train young internists for clinical
rheumatology in a feasible and socioeconomically attractive
The aim should be to position at least 2-3 rheumatologists
in every district. The emphasis will be on clinical
practice rheumatology and in particular in the community
setting. However, the trained rheumatologist will be
able to tackle emergencies effectively, both in the
community and hospital (ICU) setting, using an interdisciplinary
approach. He/she will be trained to provide the newly
emerging and acclaimed decisive biologic based therapeutic
management of difficult to treat rheumatic disorders.
Further, a clinical rheumatologist will be well versed
and experiences to participate in teaching programs
for the general practitioners and other stakeholders
and carry out clinical research (epidemiology and drug
trials, post marketing surveys) if so motivated and
Core training and evaluation and Other Administrative
This essay will now address some specific training issues
in a question answer format.
1) Who is eligible to apply for the 'Clinical Rheumatology
Ans : A post-graduate with a MD or a DNB qualification
in 'internal medicine'.
2) How long is the fellowship training period?
Ans : 24 months.
3) What is the basic structure and monitoring of
Ans: The training program of the fellowship will be
structured and divided into three phases:
a) An initial 6 month period of intensive theory and
practical clinical training.
b) 12 month period of clinical residency/registrar ship.
c) A final 6 month internship period of independent
practice in close co-ordination with a mentor preferably
of the candidate's choice. An application for this internship
should be sent in advance to the mentor and the acceptance
letter (mentor) should be submitted to the Director
(CRD). The trainee can continue the internship period
in CRD Pune as per discretion of the Director.
After obtaining a satisfactory completion certificate
from the mentor and passing fellowship board examination,
each candidate will be issued a certificate of proficiency
in clinical rheumatology duly signed by the chair and
board of examiners and chief supervisor and mentor.
During the training period, the fellow will complete
several training modules (Appendix
A) of allied subjects. He/She will have 12 hours
of structured teaching every week which will include
Clinical Case presentation & discussions, Review
& Update sessions, Journal Club and didactic sessions
of teaching. By the end of the training he/she will
have to have 2 publications (1 review article or original
full-length article and 1 case report) in peer reviewed
journals either published or submitted for publication.
It is mandatory that the fellow will also complete a
short specific clinical data based dissertation as decided
by the supervisor and make at least one presentation
on the topic during the national annual meeting of Indian
Rheumatology Association (IRACON) and 4 presentations
at regional or local meetings during the course of the
The fellow will also be required to complete the popular
and well established on line EULAR (European League
of Association for Rheumatology) certification course
and encouraged to attend short duration workshops/courses
in rheumatology in other reputed institutions (e.g.
the ANA immunology workshop in SGPGIMS Lucknow). A special
effort will be made to provide training in core practical
issues in pediatric rheumatology.
4) Who will impart training?
Ans: Dr Arvind Chopra, Director and Chief Rheumatologist,
CRD is the chief supervisor and mentor for this program.
However, there are several rheumatologists and other
specialist doctors in CRD who will also teach and supervise.
Some super specialists and experts from allied subjects
will also participate in training as shown in the modules
A). Several senior staff (non medical) from CRD
will also address some important subjects and in particular
patient centric issues (e.g. quality of life assessment).
5) What will be the finance management of the fellowship
Ans : A consolidated fee of Rs 8.5 lakhs will be paid.
Fellows will be required to pay Rs 2.5 lakhs, upfront
on the day of joining, further amount to be paid in
3 equal installments each of Rs 2 lakhs beginning 6
months post fellowship start. These installments will
be paid every 4 months. This includes Rs 30,000/- as
security fees that will be refunded without interest
within 2 months of completion of the fellowship and
conditional to no outstanding dues and as per discretion
of the Director, CRD.
The fellow will be paid a consolidated salary of Rs
30,000/- per month after completion of the first six
months of training. If accommodation is provided (twin
bed single room with attached shower/WC) a monthly rent
of Rs 5000/- will be deducted (in case of sharing it
will be Rs 3000/-).
6) What will be the status of the fellow on completing
the fellowship training?
Ans: The fellowship on completion will confer a specialization
in clinical rheumatology and facilitate to practice
as 'clinical rheumatologist'. The current fellowship
is not yet recognized (though proposed) by the Indian
Rheumatology Association or Medical Council of India
or any other professional organization. However, post
completion of fellowship, Indian Rheumatology Association
(IRA) will consider application for membership as a
rheumatologist. Till date, 4 successful fellows after
completion of training in CRD have been enrolled as
'rheumatologist' by the IRA and are in clinical practice.
7) What is status and attribute of Center for Rheumatic
Diseases (CRD), Pune?
Ans: Center for Rheumatic Diseases is centrally located
in the Pune cantonment Camp area which is about 2 kms
from the railway station and about 7 kms from Pune airport.
CRD is a private non aided rheumatology clinical, academic
and research center. ARCF (Arthritis Research Care Foundation)
is a registered public charitable research society and
trust and supervises community and education programs
of CRD. CRD is recognized as a research institute by
University of Pune and Symbiosis International University
and 'scientific and industrial research organization'
by Govt of India. CRD is a nodal center for several
national and international research projects. It is
also recognized for PhD and several students have completed
their PhD successfully in the last 15 years or so. Patients
from all over Maharashtra are referred to CRD Pune and
the daily attendance is an average of ~75-80 patients
(minimum 60 to maximum of 110). A free of cost rheumatology
outpatient is also conducted in village Bhigwan (100
kms from Pune en route to Sholapur), once every 6-8
weeks, as part of an ongoing WHO ILAR COPCORD (community
program for control of rheumatic diseases) since 1996.
More details can be obtained from the CRD website: www.rheumatologyindia.org
FACILITIES AVAILABLE IN CRD
The CRD Clinic has 8 clinical examination rooms and
1 procedure room. Each examination rool has access to
the central patient referral database with over 70,000
patients entered and followed up. The diagnostic wing
includes X-ray, ultrasound and laboratory. Facilities
for digital radiography and advanced ultrasonography
(including musculoskeletal) are available. CRD has a
state of art laboratory to carry out routine and specialized
rheumatological investigations in clinical care. The
lab is equipped with several equipment such as fully
and semi-automated biochemistry and hematology analyzers,
light &compensated polarized microscope, ELISA plate
reader and washer, electrolyte analyzer, Laminar Flow
&Thermal cycler for molecular biology, refrigerated
& high speed centrifuges, 4 deep freezers for long-term
storage of samples and several other support systems
to conduct various research activities (including immunogenetic
analysis for cytokines and HLA markers).. CRD probably
has the largest repository of sera and DNA in rheumatology
in India. A well-equipped Physiotherapy clinic and Diet
Clinic is also conducted in the premises of the center.
CRD has a well-equipped library in with a large collection
of medical books including several rheumatology reference
books of latest editions. Several other books on general
medicine, pathology & immunology, pharmacology,
anatomy & physiology, epidemiology and statistics
are also available. A special section on Ayurvedic texts
is also maintained as CRD has a special interest in
research in Ayurvedic medicines in arthritis. As on
date the library has around 280+ books and several journals/periodicals
with reference to rheumatology. Medical journals with
special reference to rheumatology & general medicine
since 1996 are also available. Some of the peer reviewed
medical journals available in the CRD Library are mentioned
Research & Care
Clinics of North America
of Rheumatic Diseases
England Journal of Medicine
Journal of Rheumatology
of Association of Physicians of India
Medical Journal of India
Computers with internet facility and printers are also
available in the library.
The center has a conference hall with a seating capacity
of 80 with modern audio-visual facility. Rooms for self-study
are also available.
A dining hall for meals and social recreation is also
available. For temporary accommodation, a fully furnished
guest room with basic cooking facility, microwave and
refrigerator is available.
A data entry unit equipped with 6-8 computers connected
by LAN to a Server for e-database in which records since
1997 are being maintained. CRD has probably the largest
rheumatology patients database in India and is the only
center in Asia to participates in the Meteor database
(a prestigious international database dedicated to rheumatoid
When required, patients are admitted in Jehangir Apollo
Hospital for in-patient, ICU and day care multidisciplinary
facilities and Usha Nursing Home for day-care infusion.
Both hospitals are located within 1.5 km from CRD.
The staff includes several rheumatologists (including
pediatric), radiologist, pathologist, microbiologist,
physiotherapist etc. Visit the CRD website www.rheumatologyindia.org
for organization and further details.
8) Are there any examinations during the fellowship?
Ans:Yes. There is a continuous assessment by the supervisor.
Fellows are encouraged to attend and compete in the
national rheumatology knowledge and quiz competitions.
Assignments in theory are given throughout the fellowship.
Anytime after completion of 18 months training, a theory
cum practical examination (one day long) will be carried
out by a senior rheumatologist elsewhere in the country.
Three such examiners will independently evaluate the
candidate. Finally, based on the results of these three
examinations and an interview, the chairman of the board
of examiners (senior rheumatologist) will announce the
result. If successful, the fellow will proceed for a
six month internship / mentorship period under the supervision
of a senior rheumatologist. After receiving a "satisfactory
completion" of internship period from the mentor,
ARCF - CRD Pune will issue a declaration of "Fitness
to practice Clinical Rheumatology". Any extension
of the fellowship period of two years to improve the
knowledge and experience and/or re-examination of the
fellow will be recommended by the chairman of the board
of examiners and finalized by Dr A Chopra, Director,
9) How does one apply for the fellowship?
Applications will be requested through an advertisement
in a national daily (Pune Edition) and the CRD website
in the first week of May and Nov. Applications will
be screened in June and Dec each year and final selection
made at the sole discretion of Director (CRD). The fellowship
will begin in January and July subject to availability
of suitably qualified candidates.
Application may be submitted (registered post or email)
at any time during the year through a personal letter
with a detail CV. Suitable candidates will be interviewed
on phone or called for an interview (under own arrangement).
Post Script Comment:
Center for Rheumatic Diseases, Pune introduced a clinical
rheumatology training fellowship program along the lines
of this proposal in Feb 2012 under an Indo-US collaborative
project (completed in 2014). This program continues
till date. Four fellows have successfully completed
training in CRD and are now working in corporate hospitals,
private sectors and teaching institutes.
1. Dr Nachiket Kulkarni - Pune (2013)
2. Dr Naisar Nahar - Nasik (2015)
3. Dr Abraham Mohan - Kochi (2016)
4. Dr Nagnath Khadke - Goa (2017)
For further queries, write to:
ARVIND CHOPRA, MD, DNB, International Fellow
Director & Chief Rheumatologist,
CENTER FOR RHEUMATIC DISEASES,
Hermes Elegance, 1988 Convent Street, Camp
PUNE 411001 India.
Tele:2026344099/26345624/26332973; Fax: 2026334756