Preamble:
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 and www.copcord.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 disorders .

The Need and Core Proposal:
There is dire need to train young internists for clinical rheumatology in a feasible and socioeconomically attractive training program.

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 required.

Core training and evaluation and Other Administrative Issues:
This essay will now address some specific training issues in a question answer format.

1) Who is eligible to apply for the 'Clinical Rheumatology Fellowship'?
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 the fellowship?
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 training.

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 document (Appendix 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 program?
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 below:

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 arthritis).

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, CRD.

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. Five 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)
5. Dr Amit Jain-Aurangabad (2018)

For further queries, write to:
ARVIND CHOPRA, MD, DNB, International Fellow ACR (USA)
Director & Chief Rheumatologist,
CENTER FOR RHEUMATIC DISEASES,
Hermes Elegance, 1988 Convent Street, Camp
PUNE 411001 India.
Tele:2026344099/26345624/26332973; Fax: 2026334756
Email: crdp5624@gmail.com; WEB: www.rheumatologyindia.org