Rheumatology in India and beyond (USA)

Chanakya Kodishala DNB (General Medicine), DM (Rheumatology)
Resident in Internal Medicine, Canton Medical Education Foundation, Aultman Hospital and Cleveland Clinic Mercy Hospital, Canton, Ohio, USA.

What are the main differences and similarities in rheumatology practice between India and the USA, and how do these affect patient care? 

US Focus on Inpatient Care: In the US, rheumatology, like other subspecialties, emphasizes consulting services, particularly in the inpatient setting due to the presence of hospitalist services.

Primary Care Referrals: Referrals to rheumatologists in the US come through primary care physicians, enhancing outpatient focus as they address preventive health screening and comorbidities.

General Awareness: There’s widespread awareness about rheumatological disorders and the specialty’s role in treating such diseases among the general population.

Urban Concentration: Both the US and India face a concentration of rheumatologist services in major cities, leaving gaps in other regions.

Treatment Consistency: Treatment patterns for rheumatological conditions are largely similar, incorporating personalized elements in both countries.

Cost Burden: Despite insurance-based healthcare in the US, there’s a significant out-of-pocket expense, especially with biologics prescriptions.

How has transitioning from India to the USA impacted your practice, and what challenges and opportunities have arisen as a result?

Transitioning to the USA for a research fellowship in rheumatology at the Mayo Clinic, I faced challenges, notably in research foundations and grant acquisition due to immigration constraints. A focused area of research laid out by my research guide (cognitive function in rheumatoid arthritis) streamlined my thoughts and made me discover new avenues, ideas, and laid foundation for future research plans. Ample time for literature review, understanding research methods and encouragement to come up with new research ideas made me nickname my time here as ‘research retreat’.

Interacting with global rheumatologists broadened my clinical and research perspectives. Recognizing the importance of clinical practice, I pursued licensing in medicine and rheumatology in the US, solidifying my commitment to a combined clinical and research career.

What disparities have you noticed in research and technology advancements in rheumatology between India and the USA, and how do they affect patient outcomes?

In my experience working as a research fellow in the US, I constantly felt that the institution recognized medical research and technological advancement as the strongest pillar that will advance our understanding of medical conditions and improve the way we manage them. At the beginning of medical school, a distinctive research career pathway is offered and a medical student graduates with an MD PhD with a strong foundation in research. Researchers are provided with appointments that offer protected and paid time to conduct research. Availability of ample funding opportunities that are highly competitive keeps the researchers striving to pursue high quality research. Patient outcomes have improved beyond rheumatic diseases: One example from my area of research, epidemiological studies have shown that rheumatoid arthritis increases the risk of a devastating disease that has no curative treatment, dementia. Further research has led us to understand that treating rheumatoid arthritis better with tight control of disease activity for several decades reduces the risk of dementia.

How do cultural and socioeconomic factors shape your approach to rheumatology practice in both countries, and how do you address these in patient care?

By the virtue of my training in India, the cultural practice led the physician to take lead in the patient care and suggest the best recommended treatment for a particular condition. The cultural scenario in medical practice in the US is more banked on shared decision making. The physician diagnoses the condition and discusses all the treatment options with the patient including the possibility of not treating the condition. Patient is the decision maker after considering the risks and benefits of given medication. I have applied this into my medical practice efficiently and honestly, I like the idea. It is indeed a shared responsibility of the physician and the patient to get the health goals right.

In terms of continuity of care, what differences exist in patient relationships between India and the USA, and how do you establish lasting patient-provider connections in both places?

Due to the different health care systems in the US and India, the continuity of care is maintained in different ways. In an Indian outpatient practice, patient is seen by the physician, gets labs done then comes back for a review and prescription. In the US office practice, physician’s office calls the patient and informs the lab results and sends the prescription to the patient’s pharmacy. The volumes of patients seen in both settings is entirely different resulting in the differences. As a provider, I have over the years understood that a lasting patient-provider connections form with keen and intent listening, clear efficient and honest communication. This must be true in any health setting.