Rheumatology

Competency-Based Curriculum

Educational Rationale

Musculoskeletal/rheumatic disorders represent the leading cause of chronic health problems, long-term disability, and health care utilization for patients in the US, UK, and Canada in recent surveys and rank near the top of the list of reasons for restricted activity and use of prescription a and nonprescription drugs. These disorders bring patients to physicians more often than any other. These disorders often involve multiple organ systems and their recognition requires broad based familiarity with all of internal medicine and discerning judgments. Those patients hospitalized with rheumatic diseases are often seriously ill and demand sophisticated skills for optimal care.

Rheumatologists cannot care for all of these patients at all times. Increasingly expectations are that primary care physicians/internists will manage patients with musculoskeletal/rheumatic disorders.

Goals
It is the goal of this rheumatology curriculum that our internal medicine residents acquire sufficient knowledge, skills, and attitudes to care for these patients.

A. Knowledge:
Upon completion of training, we expect our residents to:

  1. Acquire sufficient knowledge and experience to recognize rheumatologic disorders.
  2. Accurately diagnose rheumatologic diseases.
  3. Provide satisfactory care for patients with common and uncomplicated rheumatologic diseases.
  4. Identify those circumstances when consultation and/or referral are appropriate.
  5. Learn to use diagnostic imaging and laboratory and immunologic studies in a selective, efficient, and proper cost effective manner.
  6. Learn the indications and contraindications and benefits and risks of anti inflammatory, anti-rheumatic, and "immunosuppressive" (immunomodulatory) therapies.
  7. Understand the normal and disordered immune system and its role in the pathogenesis of certain rheumatic diseases.
  8. Learn those aspects of intermediate metabolism, bone/cartilage biology, and biomechanics to understand their roles in crystal induced disorders, bone disease, cartilage disease, osteoporosis, and biomechanical/traumatic/sports medicine related disorders.
  9. Learn to use effectively the services of occupational and physical therapists.
  10. Learn to direct or participate in a team effort to provide care for certain rheumatic disease patients.

B. Skills
Upon completion of training, we expect our residents to:

  1. Know the musculoskeletal/rheumatologic evaluation.
  2. Be able to lead and function as part of a team providing rheumatologic care.
  3. Know the indications, contraindications, procedural techniques, result interpretation, and complications of arthrocentesis.
  4. Know the indications, contraindications, procedural techniques, result interpretation, and complications soft tissue injections.
  5. Recognize monosodium urate and pyrophosphate crystals in synovial fluid.
  6. Understand appropriate circumstances for cost effective diagnostic imaging and laboratory studies and their interpretation.
  7. Know the indications, contraindications, risks, and benefits of antirheumatic therapies.
  8. Identify those circumstances when consultation or referral is appropriate.
  9. Appreciate the value of functional evaluations and assessments.

C. Attitudes:
Upon completion of training, we expect our residents to appreciate those attitudes valued and nurtured by rheumatologists, including:

  1. Viewing medicine as humane science.
  2. Balancing art with science.
  3. Recognizing the limitations of technology and the value of clinical insight.
  4. Making difficult judgments when certainty is elusive.
  5. Understanding that testing, no matter how advanced or sophisticated, rarely substitutes for thorough, thoughtful evaluation by an informed clinician.
  6. Balancing intervention with patience.
  7. Recognizing limitations of our interventions.
  8. Appreciating the unique circumstances of caring for patients with chronic, usually incurable diseases.
  9. Learning the importance of functional considerations.

Experiences

In order to achieve the goals and objectives for the residency program the following experiences have been established for the purpose of teaching Rheumatology to residents.

1. The Inpatient Experience (IP)
The residents assigned to this rotation will be responsible for supervising evaluation of inpatient consultations and continued follow up of these patients during their hospitalization. Essential in this role is the development and refinement of clinical evaluation skills. These skills include the development of appropriate differential diagnosis, assessing the need for hospitalization, diagnostic evaluation strategies and treatment plans. Essential in this rotation will be developing skills in providing consultation services, to include communicating with the referring physicians and ensuring support for continuing care of the patients' rheumatologic condition. A resident will be called upon to perform literature research on topics appropriate to the case at hand.

2. The Ambulatory Experience (AM)
All residents will participate in rheumatology outpatient activities appropriately supervised by dedicated attending faculty members. The goals of this experience will be for the residents to gain expertise in the outpatient evaluation and management of digestive problems. The experience provides an opportunity to develop an understanding for the natural history of these conditions over an extended period of time.

3. Didactic Conferences (DC)
Numerous monthly conferences are held for the residents throughout the month. They cover a variety of topics in all the major medical subspecialties. Residents will be required to attend each of the conferences that do not conflict with their clinical duties

EVALUATIONS

Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

  • Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
  • Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
  • Self-evaluation by In-service training examination scores
  • MKSAP study plan (MKSAP)
  • Participation and presentations at didactic conferences (DC)
  • Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Competency Based Goals & Objectives:

1) Medical Knowledge

Goals and Objectives-PGY1 Learning Activities* Assessment
Describe the epidemiology, genetics, natural history, clinical expression of the rheumatologic illness encountered in the inpatient setting. IP, AM, DC AE, DC, MKSAP
Summarize an approach to the evaluation of the common presentations of arthritides and connective tissue disorders IP, AM, DC AE, DC, MKSAP
Describe structure and function of the synovial fluid, soft tissues, and bony structures of the joints IP, AM, DC AE, DC, MKSAP
Generate and prioritize differential diagnoses for patients with rheumatologic disease IP, AM, DC AE, DC, MKSAP
Develop rational, evidence-based management strategies for patients with digestive
disease
IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Summarize an approach to the evaluation of common rheumatologic presentations IP, AM, DC AE, DC, MKSAP
Interpret diagnostic tests used in the evaluation of outpatients with suspected rheumatologic Illness IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of outpatients and inpatients with rheumatologic disorders. IP, AM, DC AE, DC, MKSAP

2) Patient Care

Goals and Objectives-PGY1 Learning Activities* Assessment
Effectively perform a comprehensive history and complete physical examination in patients with rheumatologic symptoms IP, AM, DC AE, DC, MKSAP
Appropriately select and interpret laboratory, imaging, and pathologic studies used in
the evaluation of rheumatologic disorders
IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Construct a comprehensive treatment plan and assess response to therapy. IP, AM, DC AE, DC, MKSAP
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended therapies. IP, AM, DC AE, DC, MKSAP
Utilize validated instruments in the assessment of function and quality of life to monitor and adjust therapy. IP, AM, DC AE, DC, MKSAP

3) Practice-Based Learning and Improvement

Goals and Objectives-PGY1 Learning Activities* Assessment
Identify and acknowledge gaps in personal knowledge and skills in the care of hospitalized and ambulatory patients with related diseases IP, AM, DC AE, DC, MKSAP
Develop and implement strategies for filling gaps in knowledge and skills of patients related diseases IP, AM, DC AE, DC, MKSAP
Integrate and apply knowledge obtained from multiple sources to the care of inpatients and outpatients IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Effectively use technology to manage information, support patient care decisions, and enhance both patient and physician education. IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC AE, DC, MKSAP
Set and assess individualized learning goals IP, AM, DC AE, DC, MKSAP
Analyze clinical experience and employ a systematic methodology for improvement IP, AM, DC AE, DC, MKSAP
Develop and maintain a willingness to learn from errors, and use errors to improve the system or processes of care IP, AM, DC AE, DC, MKSAP

4) Interpersonal Skills and Communication

Goals and Objectives-PGY1 Learning Activities* Assessment
Apply empathy in all patient encounters IP, AM, DC AE, DC, MKSAP
Demonstrate effective skills of listening and speaking with patients, families and other members of the health care team IP, AM, DC AE, DC, MKSAP
Present patient information concisely and clearly, verbally and in writing IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Reliably and accurately communicate the patient's and his/her family's views and concerns to the attending IP, AM, DC AE, DC, MKSAP
Compose clear and timely admission and progress notes and consultations IP, AM, DC AE, DC, MKSAP
Counsel patients, families and colleagues regarding side effects and appropriate use of specific medications, providing written documentation when appropriate IP, AM, DC AE, DC, MKSAP
Teach colleagues effectively IP, AM, DC AE, DC, MKSAP

5) Professionalism

Goals and Objectives-PGY1 Learning Activities* Assessment
Be prompt and prepared for all clinical duties IP, AM, DC AE, DC, MKSAP
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and equitable respect and care to all IP, AM, DC AE, DC, MKSAP
Respect patients and their families, staff and colleagues IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Model ethical behavior by reporting back to the attending and referring providers any key clinical findings IP, AM, DC AE, DC, MKSAP
Demonstrate integrity IP, AM, DC AE, DC, MKSAP
Respond to phone calls and pages promptly IP, AM, DC AE, DC, MKSAP

6) Systems-Based Practice

Goals and Objectives-PGY1 Learning Activities* Assessment
Demonstrate effective collaboration with other health care providers, including nursing staff, ancillary staff, therapists, primary care physicians, and consultants in the care of patients with related diseases IP, AM, DC AE, DC, MKSAP
Develop an understanding of the hospital resources available to the evaluation and management of patients with problems encountered by the subspecialty. IP, AM, DC AE, DC, MKSAP
Demonstrate a knowledge of and commitment to the rules governing confidentiality of patient information. IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Discuss how the health care system affects the management of inpatients with related diseases. IP, AM, DC AE, DC, MKSAP
Determine cost-effectiveness of alternative proposed interventions. IP, AM, DC AE, DC, MKSAP
Design cost-effective plans based on knowledge of best practices IP, AM, DC AE, DC, MKSAP
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care system, cost of the procedure, insurance coverage, and resources utilized IP, AM, DC AE, DC, MKSAP

Teaching Methods
All residents participate in patient care duties, didactic conferences and independent reading. They will learn at the bedside from attendings, nurses and physician extenders, pharmacists, social workers, case managers, peers, and patients.

Level of Supervision
Interns are supervised in their care of patients by more senior medical house staff (PGY- 2/3 and Chief Residents) and faculty.

PGY2/3 residents have direct and indirect supervision by Chief Resident and Faculty

REFERENCES

Primer On the Rheumatic Diseases current edition. Arthritis Foundation, Atlanta.

MKSAP: Rheumatology Section. American College of Physicians.

Koopman WJ, editor: Arthritis and Allied Conditions. Lea and Febiger, Philadelphia.

Ruddy S, Harris ED, Sledge CB, Budd RC, Sergent JS: Textbook of Rheumatology.
Saunders, Philadelphia, 2001

Useful rheumatology journals

a. Arthritis and Rheumatism
b. Journal of Rheumatology
C. Rheumatic Disease Clinics

Landmark Articles:

Lupus:
Antiphospholipid Syndrome. Lancet 2010

Systemic Lupus Erythematous: Clinical Presentations. Autoimmunity Review 2010

Interferon Induced Lupus in a Patient With Chronic Hepatitis C Virus. JCR 2011

Updates on the Treatment of Lupus Nephritis. JASN 2010

Rheumatoid Arthritis

New therapies in the management of rheumatoid arthritis. Current Opin Rheumatology 2011

Recent advances in the management of rheumatoid arthritis. BMJ 2010

Anti-TNF-a agents in the treatment of immune-mediated inflammatory diseases: mechanisms of action and pitfalls. Imm ther 2010

Advances in rheumatology: new targeted therapeutics. Arthritis Research and Therapy 2011

Recent Advances in the Management of Rheumatoid Arthritis. BMJ 2010 Glucocorticoid-Induced Osteoporosis Therapy, ACR 2010 Recommendations. Arth Care
& Res 2010

Other Rheumatologic Disorders
Gout. NEJM 2011

Managing Your Patient with Gout: A Review of Treatment Options. Postgrad Med 2011

Synovial Fluid Analysis for Crystals. Curr Opin Rheum 2011

Psoriatic arthritis: update on pathophysiology, assessment and management. Ann Rheum Dis 2011

Nomenclature and classification of vasculitis: lessons learned from granulomatosis with polyangiitis (Wegener's granulomatosis). Clin & Exp Immunology 2011

FACULTY

Andrew Weinberger, M.D., Educational Coordinator
Rheumatology Curriculum Updated 2015
Yelena Chuzhin, M.D.
William Mesnard, M.D.
James Paolino, M.D.
Jill Ritter, M.D.