Expert rheumatologist Dr. Rohini Handa’s webinar on M3 India was very well-received. Not only did it appeal to General Physicians and Rheumatology specialists, but also a number of medical students. Here we share the transcript of a part of the Q&A session from the webinar, where he answered questions on career options in rheumatology and the future of the specialty.

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Our recent webinar by Dr. Rohini Handa was enlightening for doctors and students alike. He provided his perspective on the scope of rheumatology as a career and shed light on the developments in rheumatology from the last decade. He also gave his take on the future of rheumatology.

Given below are the questions and answers on a career and future of rheumatology and Dr. Handa’s advice.

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Question 1. What is the future of rheumatology? When will Artificial Intelligence (AI) predict the outcome of progeny or cohorts?

Dr. Rohini Handa: The future of rheumatology is bright. As I mentioned earlier, the game-changers have been biologics and rheumatology is high-touch, not high-tech. Many feel there is nothing you can do for patients with rheumatic diseases, who always complain about pain – this approach is not valid anymore. Biologics make a difference between existing and living and you have to use them to know what modern medicine can do.

With AI, we may be able to better predict these, using metabolomics, proteomics, genomics, and even microbiomes to see which drug will work for whom, what is the risk to the progeny, what kind of environmental influences you can counteract. Rheumatology, immunology are happening specialties these days.

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Question 2. Any insights on rheumatology for a general practitioner to keep in mind?

Dr. Rohini Handa: Do not rely on lab panels, they can be fallacious. I would like to give you two examples; RA could exist without rheumatoid factor and you could have rheumatoid factor and conditions like tuberculosis without RA. So learn to examine the joints and learn to look at the patient in totality. The same goes for uric acid; uric acid is used as a prop to give a diagnosis of gout to most people. So examine your patients, be economical with your investigations, interpret investigations in light of the clinical context, and you will not go wrong. Do not make a diagnosis based on an antibody, which may change over time.

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Question 3. What kind of research can be done at an MBBS level for rheumatology?

Dr. Rohini Handa: We really need more number of younger doctors to come forward. The research that can be done at an undergraduate level can be questionnaire-based. You have many questionnaires available, for example, there are questionnaires on quality of life and you can use it in different subsets of people with RA and lupus. There are questionnaires that look at satisfaction with treatment, those which look at the sleep patterns, pill burden, and GI upset among others, so use questionnaire-based studies that help you look at cross-sectional studies.

Questionnaires are low-cost and many patients in India, so these should be encouraged. Many of the disease-assessments are questionnaire-based. You can correlate simplified disease activity index with rapid questionnaires, so this you can do at your level and initiate yourself into the field of research.

If you want to make research as a career, you need to be in one of the academic institutions. Once there, you can then grow and join as a faculty. If you don’t have a rheumatology department in the institute, then join the department of medicine. However, there are plenty of opportunities for clinical research in our country, where you are doing research and seeing patients at the same time. 

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Question 4. What is the scope for DM Rheumatology for future DM aspirants?

Dr. Rohini Handa: There is tremendous scope in rheumatology. There is a problem of plenty in some specialties like cardiology and in some cases, saturation. With musculo-skeletal diseases, the problems are common and there is a gap in the awareness that needs to be covered. Also, there are still many towns that are devoid of any rheumatologist, so there is a lot of scope for people opting for a career in rheumatology.

Most importantly, the arrogance of your knowledge has to be tempered by the humility of your wisdom. Your patients are sensitive and sharp and can see through you, so do not take your patient for granted. If you show empathy towards your patients, rheumatology can be very rewarding, but if you show your arrogance to them, browbeat them, you would be in for a surprise. Not everyone can afford biologics, so you need to factor in the medicine and the socio-cultural reality. Once you learn this art of balancing both, your career would be rewarding.

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Question 5. Any word of advice for GPs?

Dr. Rohini Handa: As an undergraduate student, till I moved to AIIMS, I trained in a small medical college at Patiala. My exposure there was very limited, but my tenure at AIIMS opened my eyes. So get exposure to rheumatology. It is a delightful clinical specialty. Learn to integrate the labs with your clinical judgement. Second is, get into the habit of using disease-modifying drugs upfront. Painkillers should be used on a limited basis and corticosteroids, if you are not sure about your diagnosis. It is better to have a team approach by getting the diagnosis verified by a rheumatologist. As a family physician or GP, you have a wealth of experience gained by handling the entire family, no other specialist could have given a family so much time, so it works synergistically.

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Question 6. Under what circumstances should a postgraduate doctor in medicine refer a patient to a superspecialist?

Dr. Rohini Handa: There can be times when you are unsure of your diagnosis. You can get the diagnosis straight if you have the patient’s history and the serologic investigations are matching up. Now, where could you become unsure? It could be about whether you are dealing with rheumatoid or a connective tissue disease component. Here you need the treatment strategy to be outlined, or if there is major organ involvement like interstitial lung disease, bad eye disease, kidney disease or you are dealing with a life-threatening disease like ANCA-associated vasculitis. In such scenarios, you could pair up with a rheumatologist and take a team approach.

For example, my skillset in dealing with diabetes is limited but physicians are comfortable with diabetes while handling other problems. So in cases like that of an organ-threatening disease, refractory disease, recalcitrant disease, the diagnosis can be doubtful and you could be unsure about the treatment approach. Here you can seek a referral to a rheumatologist.

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Question 7. What are the chances of getting infections for a medical student using biologics in these times of the pandemic?

Dr. Rohini Handa: Yes, with biologics, the propensity of you getting infected goes up. As per guidelines, if you have a rheumatic disease and if your disease needs those biologics, please do not discontinue. Instead use social distancing, hand hygiene, mask and try to continue with biologics.

When it comes to a medical student, especially if they are posted in wards, the exposure is obviously much higher in comparison. You have grid charts available that give you the percentage of risks you carry but here I would have a discussion with the person in question and individualise my treatment recommendation.

If the student has a disease, which has alternatives, there is no point in throwing caution to winds. The exposure of medical personnel is much higher than an average community person, particularly in an ICU set-up. So if it is someone in the frontline position handling Corona patients, I would like to step back and use alternatives. If the disease is very aggressive, I would like to discuss the risk-benefit ratio with the person. If it is a non-medical person, a patient and the patient is told that his disease requires it, he will need to continue taking it but with a medical person, you need to take the person on-board and then try and see if alternatives are possible. And if they are possible, you must try and explore the alternatives.

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If you found Dr. Handa’s answers useful, please share the article with your friends in the field of medicine. Stay with us for more informative webinars only on M3 India!

Disclaimer-

This document is a transcription of the video, produced for audience with bandwidth limitations that could possibly restrict them from viewing it. While it is believed to be accurate, it is not warranted to be so. Divergence in format is to be expected.

The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.