DISCLAIMER: This document is meant for guidance and the reader may address any queries to the undersigned. This document cannot be routinely used for any legal purpose. All content is at the sole discretion of the Director, Center for Rheumatic Disease (CRD), Pune, who may change/modify the same to suit any particular purpose and in time without assigning any reason. Though all efforts have been made towards the accuracy and veracity of this document, nobody can challenge this document for any error found whether inadvertent or otherwise. It is the responsibility of the potential candidate to clarify all doubts regarding the current subject of rheumatology fellowship training with the undersigned or any other nominated CRD staff prior to sending application and selection of the same. The decision of the Director, CRD Pune in regard to any kind of query/dispute arising from this document will be as per his/her discretion and final and binding without assigning any reason.

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.

Musculoskeletal (MSK) pain and rheumatic disorders are the commonest ailment in the community and are the leading cause of disability, loss of productivity, poor quality of life and reduced lifespan. 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.

Arthritis and rheumatism remain woefully by the health care providers and the community. The burden of disease is immense. This is well demonstrated by the WHO COPCORD (community oriented program for control of rheumatic diseases) for over 4 decades. Launched in 1996 in village Bhigwan (Pune) India has completed one of the most extensive COPCORD population programs and details are available at www.rheumatologyindia.org and www.copcord.org.Though the Indian Government has launched major national health care programs for non-communicable diseases, there is no inclusion of rheumatic disorders.

Rheumatology is a sub served and poorly recognized specialty in the Indian context. The exposure to rheumatology is unsatisfactory in the graduate and post-graduate medical curriculum. 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. 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 except for Armed Forces Medical Services.

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 few well known and recognized rheumatology centres with long history of rheumatology services-Lucknow, Chandigarh, Mumbai, Chennai, Delhi, Kolkata, Hyderabad, Vellore, Bangalore and Pune. In the recent times several more are emerging such as Jaipur, Pondicherry, Ahmedabad, Trivandrum, Bhubaneshwar, Dibrugarh, Manipur, Cochin, Guwahati,

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 and practise perspective. 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. It is predominantly an outpatient speciality. Most of the systemic emergencies, albeit uncommon compared to other mainstream super specialities , are best dealt with an interdisciplinary approach along with other specialists. 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.

At a national level, the should be to position at least 2-3 rheumatologists in every district. The emphasis will be on clinical practice rheumatology and in particular a 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 experienced to participate in teaching programs for the general practitioners and other stakeholders. He/she will be able to carry out clinical research (epidemiology and drug trials, post marketing surveys).

Against this perspective Center For Rheumatic Diseases, Pune (India) has begun a structured 'Clinical Rheumatology Fellowship Training' program in 2012.

Center For Rheumatic Diseases, (CRD): This 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 (since 2000) 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' (SIRO) 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 60 patients (45-90 daily, Monday to Friday)). 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.

The working hours are 8.00 am to 7.00pm daily, Monday to Saturday. Saturday is mostly devoted to training, research and clinical meeting.

More details can be obtained from the CRD website: www.rheumatologyindia.org.

FACILITIES AVAILABLE IN CRD:

The CRD is about a 6000 sq feet plus facility in a multistorey building with the Clinic/outpatient services on the ground floor. The clinic has 8 clinical examination rooms and 1 procedure room. Each examination room has access to the central patient referral CRD database with now over 1.0 lakh patients. 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 Diagnostic center 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. Online access to standard medical literature is available.

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 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 paediatric), radiologist, pathologist, microbiologist, physiotherapist etc. 30-40 staff are generally employed in the centre. Visit the CRD website www.rheumatologyindia.org for organization and further details.

A dining hall for meals and social recreation is also available.

Guest Room: For temporary accommodation, a fully furnished guest room (bed room+ living room+ private bathroom+ kitchenette (microwave, cooking gas, refrigerator, basic utensils and crockery) is available.

CORE TRAINING AND EVALUATION AND OTHER ADMINISTRATIVE ISSUES:

This essay will now address some specific training issues in a question answer format.
Note: The contents of this document are applicable to potential candidates from India and with accredited Indian medical qualifications. The requirements, conditions, fees etc may differ for foreign candidates and will be clarified by the undersigned on a case to case basis.

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'; or registered FCPS (Medicine) from a recognised medical institute.

2) How long is the fellowship training period?
Ans : 24 months.

3) What is the basic structure of the fellowship?
The essential target will be adult rheumatology training. However, basic and routine rheumatology practise approach to childhood onset rheumatic diseases will also be provided.
(a) The training program of the fellowship will be structured and divided as follows:
i) An initial 6 month period of intensive theory and practical clinical training.
ii) Subsequent 12 month period of clinical residency/registrar ship.
iii) 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.
iv) Probation period: This will be an initial period of 3 months. The supervisor will judge suitability of the candidate fellow to continue fellowship training as per his/her discretion
(b) General: During the training period, the fellow will complete several training modules 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).

(c) Special Basic training modules:
    i) Anatomy (6 weekly sessions of 2 hours each)
    ii) Musculoskeletal Imaging (8 weekly session of 1 hour each)
    iii) Laboratory (4 weeks, daily 2 hours)
    iv) Physiotherapy (12 weeks, daily 1 hour)
    v) Patient centric measures including functional assessment (6 weeks, daily 1 hour)
    vi) Database, epidemiology, biostatistics, clinical research, orthopaedics (relevant to rheumatology), paediatric rheumatology as per mentor discretion

(d) Additional: The fellow will also be required to complete the popular and well established on line EULAR (European League of Association for Rheumatology) certification course.

4) 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 if required will be recommended by the chairman of the board of examiners and finalized by Dr A Chopra, Director, CRD.

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.

5) 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 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).

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 as per its policy Till date, 8 successful fellows after completion of training in CRD have been enrolled as 'rheumatologist' by the IRA and are in clinical practice

7) What will be the fees and other expenditure?
(i) Annual fees: Rs 2.5 Lakhs (Total Rupees five lakhs) and paid in 2 equal instalments -on joining and after one year completion.
(ii) Security Deposit: Rs 40,000/-on joining fellowship and will be refunded interest free within 2 months of fellowship completion. Any kind of damage incurred by the fellow will be finalized as per discretion of Director, CRD will be adjusted against the security deposit, and extra payment will be levied if applicable. This will be settled prior to issuing the fellowship completion certificate.
(iii) Limited sponsorship/concession on fees may be considered based on merit and financial constraints of the candidate fellow.
(iv) Examination fees: Rs 10,000/= honorarium per examiner (maximum 3 examiners)

8) Fellowship Monthly Stipend:
    i) For Initial 6 months 40,000/-plus Rs 5000/- (Allowance)
    ii) Remaining 18 months Rs 45000/ plus Rs 5000/- (Allowance)

9) Miscellaneous / Other Requirements:
(i)Personal Behaviour and Conduct: The selected candidate fellow will be expected to follow the highest standards of behaviour and other personal conduct, and discipline, during the course of this fellowship training and while attending to the patients. They will observe the highest standards of professional conduct as learn during the medical graduate training (MBBS). They will fully cooperate with the other faculty and staff and participate in the smooth and efficient functioning of CRD Pune. They will follow the various operative policies and guidelines set by the Director, CRD Pune. They will be expected to follow all instructions relevant to this fellowship training and to carry out their medical responsibilities and duties as issued by the Director, CRD, Pune in word and spirit. All complaints and grievances will be addressed by the Director, CRD, Pune or a person nominated for this person. All final decisions on the latter will be taken by the Director CRD Pune and conveyed as per his/her discretion and be binding on the rheumatology fellow.
(ii) Health/Medical Insurance: The selected candidate fellow will necessarily deposit a copy of the (a) personal health insurance to cover the period of fellowship (b) personal medical professional indemnity insurance beginning with the month of joining the fellowship. The insurance copies will be submitted to the Director CRD Pune within one month of joining the fellowship. Failure to do so (latter requirement) may disqualify the candidate to continue the training as per the discretion of the Director, CRD.
(iii) Accommodation: No accommodation/transportation will be provided to the selected candidate by CRD, Pune, during the training period. However, if available, the CRD guest room may be provided on request on a single/ double occupancy basis for a maximum period of 3 months. The rental will be Rs 10,000/= pm paid in the beginning of a month. A fully refunded interest free security deposit of Rs 30,000/= will be taken prior to occupying the guest room.

10) Exit Clause:
30% of the annual fees will be deducted and rest refunded if the candidate quits the training program during the probation period or is declared unfit to continue fellowship training by the mentor/Director CRD. After the probation period is over, no fees of any kind (including security deposit) will be refunded if the candidate quits training at any point of time. However, in case of serious lapse or misconduct (behaviour) or gross negligence of duties, the candidate may be expelled at any time during the fellowship training period by the Director CRD/ Supervisor & Mentor as per his/her discretion without refund of any kind of fess (including security deposit). In the latter case, depending upon the nature of the offence, a warning in writing and a special observation period of not more than 4 weeks duration to judge correction/rectification may be issued to the fellow by the Director CRD Pune. All decisions of the Director CRD Pune on this subject will be final and binding upon the fellow and need not carry any written explanation other than verbal communications.

11) How does one apply for the fellowship?
Applications may 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. However, the latter process may be altered as per the convenience of the Director CRD/Supervisor .
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).

12) 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. 8 fellows have successfully completed training in CRD and are now working in corporate hospitals, private sectors and teaching institutes at various places- Pune, Goa, Kochi/Kottayam, Aurangabad, Nasik, Nagpur, Kurukshetra, Ahmedabad

Signed by and for 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, 9822009140
Email: crdp5624@gmail.com; WEB: www.rheumatologyindia.org