Rizwan Rajak | Clinical Lead for Osteoporosis & Metabolic Bone Health and Rheumatology Musculoskeletal Ultrasound, Croydon Health Services NHS Trust, UK.
Citation: EMJ Rheumatol. 2024; https://doi.org/10.33590/emjrheumatol/GSXK2442.
What motivated you to specialise in rheumatology, and how did your training at the University Hospital of Wales, Cardiff, UK, and the Royal National Hospital for Rheumatic Diseases, Bath, UK, shape your expertise?
Ever since medical school, I was always interested in musculoskeletal medicine and found this one of the most compelling subjects. During training in general medicine, I undertook a clinical experience week in rheumatology, and felt this was the right specialty of interest for me. I completed my specialist training at the University Hospital of Wales, and subsequently became a consultant at the Royal National Hospital for Rheumatic Diseases. At both sites, I managed to develop my specialisation in osteoporosis as well as musculoskeletal ultrasonography. Furthermore, I had the opportunity to see many common, as well as rare conditions, which further consolidated my general rheumatology expertise. The multidisciplinary clinics, in particular, were especially helpful at these two training centres.
As the Clinical Lead for Osteoporosis & Metabolic Bone Health and Rheumatology Musculoskeletal Ultrasound at Croydon Health Service NHS Trust, UK, could you elaborate on the initiatives you’ve spearheaded in developing local integrated bone health services and diagnostic services?
In terms of the musculoskeletal ultrasound diagnostic service, I essentially set up a diagnostic service for early inflammatory arthritis (EIA) to complement and enhance the diagnostic capability of the EIA service. I established imaging protocols (including early rheumatoid screening, psoriatic arthritis screening, and giant cell arteritis), linking of images to the picture archiving and communication system, formal rheumatology-focused image reporting, and formal training of interested specialists.
With regard to the osteoporosis service, I started by identifying the multidisciplinary stakeholders, and formed a formal integrated bone health service within the trust (including geriatricians, fracture liaison service nurses, dual-energy X-ray absorptiometry technicians, pharmacists, endocrinologists, orthopaedics, dietitians, gastroenterology, renal medicine, primary care, patient experts, and others). I then developed a term of reference for this service, and then went on to help build the actual clinic and bone health multidisciplinary team. Through the service stakeholders, I led the development of multiple osteoporosis care pathways, including treatment algorithms, monitoring pathways, and management of complications.
Through both specialist services, I have undertaken several research projects with a focus on ultrasonography in early arthritis and psoriatic arthritis, with the musculoskeletal ultrasonography service and osteoporosis risk factors, responses to treatment, and osteoporosis imaging diagnostics with the bone health service.
As the Course Director and Tutor for Rheumatology at South Wales University, what are your primary goals in shaping the curriculum, and guiding the next generation of rheumatologists?
In this role, which I have been doing since 2016, my aim has been to ensure a robust diploma and Master’s programme in rheumatology, encompassing the broad range of rheumatology conditions, scientific knowledge and understanding, and therapeutics. The objective of the qualification is to ensure that students are equipped to apply for rheumatology-based jobs, as well as use their knowledge to develop rheumatology specialist services. Given that students are from around the world, I have had to ensure that the course is relevant on an international level. In 2022, working alongside the university’s administrative and management team, I led the revalidation process for the course, to ensure that the learning curriculum and objectives were closely aligned with the UK rheumatology specialist training programme. Some of the key elements and successes of the course format have been providing a range of teaching and assessment modalities that are befitting real-world clinical practice.
As a co-lead on the development of an Early Inflammatory Arthritis service, please share some insights into the challenges and successes you’ve encountered in diagnosing and treating inflammatory arthritis early?
When I joined the current trust, my first task was to develop the early arthritis service. I started this process by developing a streamlined EIA referral form for general practitioners to use, to ensure rapid access to the rheumatology services. I also developed a referral pathway and a 1-year rheumatoid arthritis management pathway as part of the development of this service. Furthermore, to enhance rapid diagnostics I developed the musculoskeletal ultrasound service, ensuring that patients with EIA had a swift diagnosis to ensure early therapeutics. I undertook several education sessions with primary care colleagues, as well as patients, in public forums to increase awareness of the service and to ensure that the appropriate patients were identified and referred.
What motivated you to pursue a Master’s in Medical Law, and how has this additional expertise enhanced your practice as a consultant rheumatologist?
I first took an interest in medical law following a lecture I attended as a registrar as part of our generic training. Following this, I discovered an unknown passion for legal interpretation and interrogation, and how this closely fitted with the practice of clinical interrogation in rheumatology. Subsequently, I undertook a Master of Laws at Cardiff Law School, UK. Using this qualification, I have worked as an expert witness in rheumatology litigation cases since 2018. I have also provided medical legal lectures to medical colleagues and lawyers, and helped develop a diploma in medical law at the University of South Wales, UK.
Are there any innovations on the horizon in the field of rheumatology that are of particular interest to you?
Having seen the change in osteoporosis practice, where the focus has been on defining fracture risk in determining the most appropriate treatment has been refreshing, and I think it is a significant forward step in the management of osteoporosis. Furthermore, there have been developments in diagnostic possibilities in osteoporosis assessment, which has been very interesting, including CT densitometry, trabecular bone assessment, ultrasound densitometry, and biomarkers.
Another important innovation that has been of particular interest is the increased number of cytokine targets in the management of psoriatic arthritis. I have generally found this condition more challenging than managing patients with rheumatoid arthritis, and the increase in the number of therapeutic targets has been very encouraging to see.
