- Indian Rheumatology association
While doing MD in medicine, I wanted to do something different than the already established super specialty programs in cardiology, neurology and gastroenterology. I was awarded the Talent Search Fellowship (ICMR) which gave me an opportunity to pursue a career in medical research in Clinical Immunology at AIIMS, New Delhi under Prof A N Malaviya. I joined there in the middle of 1982 and in 1985 I received a Overseas Fellowship by the ARC, UK to pursue training in Clinical Immunology under Sir Prof Ravinder Nath Maini (who discovered Anti-TNF drugs) at the Kennedy Institute of Rheumatology, London. Those years of training shaped me as a rheumatologist.
Rheumatology had a humble beginning under the department of Immunology with twice a week outpatient services and 6 indoor beds. There were 6 faculty at that time: Late Prof SS Agarwal, Prof Sita Naik, Dr RR Singh, me and 2 other basic scientists. Ramraj, who was inducted before me at the institute, and I started the clinical services and Madam Naik established the laboratory services. The DM program was started in 1988 with just one fellow. I remember seeing patients, most of which were degenerative diseases or long-standing RA and AS. Major focus of the department was its academic program and establishing immunological laboratory services. Therefore, the residents had the opportunity to be exposed to all aspects of rheumatology.
Establishing the clinical and laboratory department was a problem. Our Institute was located far away from the city center in Lucknow, with limited public transportation. Patients were charged for both OPD and investigations and we used to see only referred patients. Nomenclature was another issue; our department was called Immunology which was a source of confusion among the medical fraternity. Many struggled to come to terms that we managed patients with rheumatic diseases also and this expression could be seen on their faces, if not expressed directly. The Medical Council of India (now the National Medical Commission) did not have rheumatology or clinical immunology as a subject for superspecialists. But the department pursued its goal and crafted its own path relentlessly to be regarded as a premium department in the country. As a teacher, I don’t even think of these early problems, as most of our alumni have brought glory to the department through their professional achievements. On some occasions I earn respect through their achievements.
Rheumatology has now expanded and is expanding even to tier 2 cities. With the advent of widely available investigational facilities (both biomarkers and imaging including MRI and ultrasound) there is a paradigm shift in the management of patients. The smartphone is a barrier between patients and physicians during consultation. Affordable biosimilars have prompted extensive use of these agents, sometimes inappropriately resulting in increased occurrence of adverse events. Sadly, sometimes I feel that all these advances have ultimately resulted in less reliance on physical examination and there is always a danger of drowning our clinical judgement and missing the bigger picture of the patient.
