Training in Paediatric Rheumatology

Currently there is an extreme shortage of paediatricians with rheumatology training. The British Society of Rheumatology and the Royal College of Paediatrics and Child Health are in agreement that the historical situation of rheumatologists with no paediatric training looking after children with rheumatological conditions cannot continue, even in collaboration with a paediatrician. The aspiration is that every DGH employ a paediatrician with paediatric rheumatology training to look after such children, sharing care with a tertiary paediatric rheumatology centre, and working with an adult rheumatologist to ensure smooth transition to adult services. The numbers of appropriately trained paediatricians are very low.There is scope for development in the east of England  as we are particularly poorly served. In addition the sub-specialist posts in tertiary paediatric rheumatology are expanding and there are very few trained clinicians to take up these posts. Grid training in paediatric rheumatology is available but there are few applicants to these positions, possibly through lack of exposure to the discipline since it is an out-patient based specialty. Paediatric trainees need exposure to rheumatology to be enthused to take up further training opportunities.

Training in Paediatric Rheumatology - Jenny Lind Children's department

The training post based in the department allows competent practice to be undertaken by the trainee as a General Paediatrician with a Special Interest in Paediatric Rheumatology. Such an individual would be expected to provide care for children at a local level, with shared care arrangements with a tertiary service for those children with more complex needs.

The conditions cared for would include:

• Juvenile idiopathic arthritis
• Arthritis associated with infection
• Septic arthritis, osteomyelitis
• Reactive arthritis
• Irritable hip
• Connective tissue disorders
• SLE, dermatomyositis etc.
• Primary vasculitis – Kawasaki, HSP etc
• Idiopathic pain syndromes
• Localised pain syndromes, reflex sympathetic dystrophy
• Idiopathic night pain
• Overuse syndromes – chondromalacia patellae, tenosynovitis etc.
• Skeletal dysplasias – osteochondroses, epiphyseal dysplasia etc.

Dr Kate Armon provides a tertiary level paediatric rheumatology service in Norwich. The service is well developed and caters for approximately 150 children with active rheumatology conditions, almost 70 of whom are currently on methotrexate as second line therapy, and 20 receiving biologic therapies. There is a weekly single clinic list expanding to a double list fortnightly with one of the adult rheumatologists. Professor David Scott and Dr Karl Gaffney have considerable experience of paediatric rheumatology and there is an active transition programme. Multidisciplinary team meetings are held weekly for the team, consisting of the consultants, a paediatric rheumatology nurse specialist, specialist paediatric physiotherapists and occupational therapist, any trainees. There is close liaison with the paediatric orthopaedic team (two consultants and a nurse specialist) and access to orthotics, ophthalmology, and other specialties when needed. There are specialist musculoskeletal radiologists and an interested paediatric radiologist and an X-Ray meeting is held once a month.

There is a general anaesthetic list for joint injections once a fortnight and access to the day ward for injections under sedation/local anaesthesia. Multi-disciplinary teamwork is the cornerstone of our philosophy of care. There is ready access to in-patient beds as necessary, and an adolescent clinic is in development.

Children with rheumatological conditions are primarily managed on an out-patient basis. Education about their condition is critical to their compliance with medication and their self-image and well-being. Similarly children with pain syndromes are unlikely to improve unless they are given time to understand the nature of their condition. The trainee will have ample opportunity to develop communication skills related to this group of children. There are a number of regional, national and international meetings each year, and trainees will be encouraged and funded to attend appropriate meetings.

The department is active in research, taking part in a number of multi-centre studies. Research in paediatric Rheumatology is generally on a multi-centre basis because of the relative rarity of the conditions. The trainee would be expected to take part in data-collection and the development of local research interests and audit in conjunction with Dr Armon, the adult rheumatology department and the Birmingham rheumatology team. To facilitate this there are excellent IT facilities with full Internet access and an excellent medical library, in the hospital's Education Centre.

Tertiary level Training

At present there are no training posts specifically for Tertiary Paediatric Rheumatology in the east of England and there is no tertiary centre currently serving the region. The Norfolk and Norwich University Hospital provides a tertiary level service to its local children and receives referrals of complex cases from neighbouring hospitals. Dr Armon attends inreach clinics in Birmingham on a bi-monthly basis, so there is ongoing tertiary level discussion over complex patients. The development of a more formal clinical network is in process.

Specific Responsibilities of the Post

• To share in ward cover and on call arrangements for general paediatrics.
• Attendance at specific Rheumatology training clinics or other attachments as planned.
• Organisation of Rheumatology investigations and interventions in conjunction with children's day ward
• Specialist Rheumatology discharge summaries
• Research project (to be agreed with supervising consultants)
• Audit and other clinical governance responsibilities  for example guideline development
• Presentations to local, regional and national meetings

Nationally there are very few formal paediatric rheumatology training placements. In the east of England we are fortunate in  that a number of consultant paediatricians run high quality local paediatric rheumatology services in conjunction with specialist centres across the country. We are in the process of trying to develop formal rotations that would allow trainees to gain expertise to have a special interest in paediatric rheumatology. This is likely to involve rotations to Norwich to work with Dr Kate Armon and to Peterborough to work with Dr Venkat Reddy.  In addition there are services in Cambridge and Colchester.  In the longer term, there may be an opportunity to develop a National Grid training programme involving rotations to other specialist centres. 

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