Rheumatologist Fellow Works in India Via ACR Exchange Program

India does have several issues hindering rheumatology care. From the medication standpoint: Although generics are inexpensive, a substantial proportion of patients cannot afford them. Biologics are also cheaper than in the U.S., but a substantial proportion of patients cannot afford them, either. I was distressed to see several patients with spondyloarthropathy unable to afford even cheaper biosimilars and ending up being on NSAIDs chronically, with no options, in spite of concomitant heart or kidney disease. Those conditions would have contraindicated such treatment here in the U.S.

From the provider standpoint: There are only 30 rheumatology training positions in India for a population that is four times the size of the U.S. At SGPIMS itself, 50 students apply annually for four positions. As a result, many doctors do not qualify for training spots, although they might be completely capable of providing excellent care. Due to economics and an inability to hire labor, the fellows spend unnecessary time performing administrative duties instead of clinical, such as calling patients when beds are free or physically performing routine lab tests.

From the patient standpoint: Patients may take alternative medicines for many years and suffer progressive joint deformities before seeing a rheumatologist in person. With no clear enforcement of regulations, anyone can practice quackery. Patients may encounter a physician (who may not be a rheumatologist) prescribing long-term steroids or a “snake oil salesman” who never graduated from high school.

Rheumatologists do not have an advocacy committee, and politics plays a major role in deciding institutional and rheumatology care (more so than in the U.S.). Political attitudes can change on a whim; as a result, you have constructions and medical projects that were started with good intentions but have been stalled.

Back Home in the U.S.

I came home from India with lasting friendships and memories, in addition to a unique educational, cultural and personal experience. I saw rare rheumatologic diseases that I otherwise would probably have seen only once in a lifetime. It is fascinating to explore the practice of medicine in a completely different environment.